Delay in Breast Cancer Treatments During the First COVID-19 Lockdown. A Multicentric Analysis of 432 Patients

BACKGROUND/AIM

Extraordinary restrictions aimed to limit Sars-CoV-2 spreading; they imposed a total reorganization of the health-system. Oncological treatments experienced a significant slowdown. The aim of our multicentric retrospective study was to evaluate screening suspension and surgical treatment delay during COVID-19 and the impact on breast cancer presentation.

PATIENTS AND METHODS

All patients who underwent breast surgery from March 11, 2020 to May 30, 2020 were evaluated and considered as the Lockdown group. These patients were compared with similar patients of the previous year, the Pre-Lockdown group.

RESULTS

A total of 432 patients were evaluated; n=223 and n=209 in the Lockdown and Pre-lockdown-groups, respectively. At univariate analysis, waiting times, lymph-nodes involvement and cancer grading, showed a statistically significant difference (p<0.05). Multivariate analysis identified waiting-time on list (OR=1.07) as a statistically significant predictive factor of lymph node involvement.

CONCLUSION

Although we did not observe a clinically evident difference in breast cancer presentation, we reported an increase in lymph node involvement.

Exploratory evaluation of an obese population seeking bariatric surgery in an Italian public service

Obesity is a difficult to treat multi-problematic disease. Bariatric surgery (BS) has been regarded as the most effective therapeutic option, however the outcomes strongly depend on baseline conditions and further behavioural modifications. Our aim was to assess the characteristics of severely obese patients seeking BS in a Public Health Service in Italy. Socio-demographic characteristics, eating habits and the presence of stressful situations associated to weight increase, as well as psychiatric disorders of 111 outpatients attending our BS Program were assessed. Twenty-seven percent of patients have familiar history of obesity (FHO). Differences between patients having or not having a FHO were found for several psychiatric conditions, including lower Bulimic symptoms (p=0.025) and lower use of Alcohol (p=0.045). A total of 28.8% of the participants reported a BED; those patients do not differ in BMI (p=0.437) from non-BED patients but had higher psychological disorders associated to eating disorder, as for example Bulimic symptoms (p=0.000), higher BES scores (p=0.000) and psychological distress, such as Depression (p=0.000). Nearly 50% of patients had any psychiatric disorders and depression was the most common disturbance (32.4%); anxiety disorder was present in 15.3% of patients. Moreover, patients who have disclosed traumatic episodes (11.7%) presented higher distress associated to eating disorder variables, such as BES (p=0.001) and EDI-2 BU scores (p=0.000) and presence of BED (p=0.001), and women are more likely to be in this group (p=0.043). Our report proposes that multiple causative factors play a role in obesity, and we need to take them all into account to plan a comprehensive pre- and post-surgical treatment plan.

[Colorectal cancer: 74 patients treated by laparoscopic resection with a mean follow-up of 5 years]

OBJECTIVE

The aims of this study were to analyse the results and long term outcome in a prospective non randomised trial of 74 patients treated by laparoscopic colo-rectal resection for cancer, and to determine wether survival and recurrence are or are not compromised by an initial laparoscopic approach.

PATIENTS AND METHODS

Seventy-four patients with colo-rectal carcinoma were included in a prospective trial and treated by laparoscopic resection. All patients were reviewed at 1, 3, and 6 months interval. A median of 5 years follow up was available. Forty-eight patients (65%) had more than 3 years of follow up.

RESULTS

Six conversions (8.1%) were necessary: 2 for tumor invasion of adjacent organs, 2 for limited margin resection in lower rectal tumors, 1 for small bowel injury and 1 for obesity. After surgery, passing flatus occurred at 34.3 +/- 16.7 h and oral intake could be reinstaured at 42.6 +/- 22 h. Mean postoperative stay was 8.2 +/- 3.4 days. No death occurred. The overall morbidity was about 13.5%. The rate of late complications was 5.4%. Two port site metastasis (2.6%) were seen in locally advanced carcinoma. Recurrence rate at 5 years was 0% for Dukes A, 20% for Dukes B, 39.2% for Dukes C. Survival rate at 5 years was 100% for Dukes A, 80% for Dukes B, and 60.7% for Dukes C. These results are similar to those of conventional open surgery.

CONCLUSION

Laparoscopic colorectal resection for cancer can be performed safely, with a low morbidity and rare late complications. Long term follow up (5 years) assessment shows similar outcome compared with conventional surgery.

Laparoscopic Versus Open Surgery For Colorectal Carcinoma

The role of laparoscopic resection in the management of colorectal cancer is still unclear. It has been shown that laparoscopic colectomies can be accomplished with acceptable morbidity. Major concerns are port-site recurrences and neoplastic dissemination. The aims of this study were to compare perioperative results and long-term outcomes in a prospective, nonrandomized study of patients treated by laparoscopic versus open colorectal resection for cancer. In particular, the effects of an initial laparoscopic approach on survival and recurrence were examined. One hundred fifty-seven patients with colorectal carcinoma were included in the prospective trial: 74 underwent laparoscopic resection and 83 underwent conventional open surgery. The two groups were comparable in terms of characteristics, demographic data, stage of disease, and use of adjuvant or palliative chemoradiotherapy. All patients were observed at 1.3- and 6-month intervals. The median duration of follow-up was 60 months (range, 10-125 months). The mean operating time was significantly longer in the laparoscopic group. Six conversions (8.1%) were necessary. The passage of flatus and the restarting of oral intake (P = 0.0001) occurred earlier in the laparoscopic surgery group than in the open conventional surgery group. The mean postoperative stay was significantly shorter in the former group (P = 0.005), as was the length of the scar (P = 0.001). There were no deaths in either group. The overall morbidity was significantly lower (13% versus 33.7%; P = 0.001) in patients treated laparoscopically. No significant differences were observed between the groups in the length of specimens, the size of the tumor, or the number of nodes removed. Late complications were more frequent after open resection (12% versus 5.4%; P = 0.01). Two port-site metastases (2.6%) were seen in stage III and IV locally advanced carcinoma. There was no significant difference in recurrent disease between the groups (24.3% versus 25%) during the 60-month follow-up. Stage-for-stage comparisons showed that disease recurrence rates and crude death rates were comparable.

Effect of TT virus infection on hepatocellular carcinoma development: results of a Euro-Asian survey

A small percentage of persons with hepatocellular carcinoma (HCC) lack identifiable causes of liver pathology. The single-stranded DNA virus, TT virus (TTV), has been found in persons with acute and chronic liver injury. Nested polymerase chain reaction was used to search for both TTV and parvoviruses in 293 HCC samples from Asia and Europe. TTV was found in >30% of Chinese and Italian samples but in only 13% of French samples. No clinicopathologic differences were found between TTV-positive and -negative populations. A significant association was found between TTV infection and hepatitis B virus (P<.01) and herpesviruses (P<.02) in HCC patients, suggesting that factors promoting these infections are associated with enhanced TTV positivity. Parvovirus B19 and adeno-associated virus were found in only 7.5% of the tumors. Taken together, these data suggest that TTV infection is unlikely to be associated with the induction or acceleration of the hepatocarcinogenic process in humans.

Importance of the level of axillary involvement in relation to traditional variables in the prognosis of breast cancer

Survival in breast cancer correlates with the presence of metastatic lymph nodes, so that removal and pathological examination of the axillary nodes provides the most important prognostic information and basis for planning subsequent therapy. However as the size of primary tumours at diagnosis is decreasing, the likelihood of axillary involvement is also declining, so that the indications for axillary dissection are undergoing radical revision. To definitively establish the value of removing all three axillary lymph node levels (as defined by Berg) in node positive breast cancer, retrospective analysis of a large series receiving complete dissection was carried out. consecutive breast cancer patients (n=1003) with positive axillary nodes were analyzed: all received identical axillary treatment and the three levels were tagged with metal disks to facilitate recognition and pathological examination. Follow-up (mean 97 months) was exceptionally complete. The length of disease-free and overall survival were taken as the primary endpoints. The variables considered in the statistical analysis were tumour size, number of metastatic nodes, axillary invasion by level (the three classic levels), perilymphnodal invasion and age. By univariate analysis, overall and disease-free survival decreased significantly as tumour diameter, number of involved lymph nodes, and involvement by axillary level increased. Multivariate analysis assessing the relative importance of these variables when all were considered together found that they were all important independent predictive factors for survival. This study confirms the importance of tumour size and number of metastatic axillary nodes as predictors of outcome in breast cancer. In addition, the level of axillary invasion as a third independent factor of equal importance to the established indicators was identified. When axillary dissection is performed it should be complete, and all three Berg levels tagged separately, so that involvement by level can be ascertained. This provides additional important prognostic information on which to base subsequent treatment decisions.

Axillary dissection can be avoided in selected breast cancer patients: analysis of 401 cases

The role of axillary dissection in early breast cancer remains controversial because of its uncertain value with respect to disease free and overall survival. 401 breast cancer patients underwent breast surgery without axillary dissection from January 1986 to June 1994. 323 (81%) patients were postmenopausal whereas 78 (19%) were premenopausal status, the mean age was 62.9 years. 216 out of 401 patients (53.6%) had a pathological tumour < or = 1 cm, 133 (33.6%) were between 1 and 2 cm, whereas 38 (9.5%) had a tumour size > 2 cm. Breast conservative surgery was performed in 383 patients (95.6%), 257 patients (64.1%) received radiotherapy to the operated breast. In elderly patients adjuvant hormonotherapy was preferred considering the hormonal receptorial status. Accurate follow-up showed that 25 patients underwent delayed full axillary dissection, and pathological metastases were determined in 19 cases, so that the total rate of axillary relapses, histologically confirmed, was 4.7%. We conclude that axillary surgery can be avoided in selected breast cancer patients.

Interpretation of the risk associated with the unexpected finding of lobular carcinoma in situ

BACKGROUND

The risk of developing invasive breast cancer after finding lobular carcinoma in situ (LCIS) is controversially reported in the literature. The surgeon who finds LCIS unexpectedly may be tempted to remove the breast, or even remove both breasts.

METHODS

From 1976 to 1991, 157 consecutive women with palpable or mammographically detected breast lesions underwent surgery to resolve doubt as to the presence of invasive cancer. We report on the women in whom LCIS was found after diagnostic breast surgery and analyze the incidence of breast cancer after a mean 5 years of follow-up in comparison with that in the normal reference population.

RESULTS

Eight patients developed infiltrating breast carcinoma (four ipsilateral, four contralateral as first events), equal to a homolateral rate of 0.00625. The expected rate in the normal reference population is 0.00152; ratio 4.11 (95% confidence interval 1.1-10.5). For a contralateral event the rate ratio is 3.0 (95% confidence interval 0.8-7.6).

CONCLUSION

LCIS is one of many markers for later infiltrating cancer, so patients should be carefully followed. Ablative surgery is not justified.

Conservation surgery after primary chemotherapy in large carcinomas of the breast

OBJECTIVE

The authors evaluated the utility of preoperative chemotherapy in patients with large size breast carcinoma, with a view to rendering a conservative surgical approach possible or easier.

SUMMARY BACKGROUND DATA

Two hundred twenty-six of 227 patients with breast cancer involving a tumor larger than 3 cm at greatest dimension were candidates for mastectomy. They were treated with various primary preoperative chemotherapies and evaluated for surgery.

METHODS

After administering various chemotherapeutic regimens, the authors reevaluated the patients' conditions clinically and radiologically to plan definitive surgical treatment. If the tumor diameter was sufficiently reduced, quadrantectomy was planned; otherwise, mastectomy was performed. Complete axillary lymph node dissection was done in all cases.

RESULTS

In 90% of the cases, the size reduction was sufficient to justify breast conservation; in 10%, tumor size did not decrease enough or increased, thus mastectomy was performed. In 11.8% of the cases, the tumor was no longer identifiable at surgical inspection, and in 3.5% no tumor was found on microscopic examination. Axillary lymph nodes were free of metastases in 39% of cases. Twelve local recurrences occurred among the 203 patients treated with breast conservation (5.9%) and five among the 23 patients treated with mastectomy (21.7%).

CONCLUSIONS

Primary chemotherapy can expand the indication for breast conservation to large tumors; careful attention, however, must be paid to surgical technique. The position of the tumor should be marked with tattoo points on the skin before chemotherapy. The macroscopic extent of the tumor regression must be evaluated carefully, and multiple frozen section biopsies may be needed. The margins of the resected breast should be evaluated microscopically. All microcalcifications present before treatment must be resected. The skin incision and mammary resection must fulfill criteria of radicality as well as good cosmetic outcome.

Effect of menstrual phase on surgical treatment of breast cancer

1175 premenopausal women whose date of last menstrual period was known were followed up for up to 20 years (average 8 years) after surgery for breast cancer. 525 patients were in the follicular phase and 650 in the luteal phase. We observed 192 unfavourable events among patients operated on during the follicular phase (36.6%) and 192 among patients operated on during the luteal phase (29.6%). The effect of phase was restricted to patients with positive axillary nodes. The 5-year relapse-free survival was 75.5% in 246 node-positive patients operated on during the luteal phase and 63.3% in 190 node-positive patients who had surgery during the follicular phase. The hazard ratio at Cox multivariate analysis was 1.329 for all patients (p = 0.006) and 1.431 for node-positive patients (p = 0.03). In our study, premenopausal patients with breast cancer and positive axillary nodes operated on during the luteal phase had a significantly better prognosis than patients operated on during the follicular phase. It may be that the processes of cell metastases, such as loss of adhesiveness, may be enhanced by high concentrations of unopposed oestrogens or by reduced activity of natural killer cells during the first half of the menstrual cycle.