Minerva chirurgica
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Recent studies have demonstrated that the extent of surgical treatment in both breast and axilla can be minimized through a multimodal and personalized management, based on assessment of breast cancer (BC) molecular subtypes, genetics and on the prevailing relevance of systemic therapies. Axillary lymph-nodes dissection (ALND) represents the older surgical modality for appropriate staging and for adjuvant systemic and radiation therapies planning. Thanks to findings from extensive and crucial clinical trials, sentinel lymph node biopsy (SLNB) replaced this approach, obviating the need for ALND in node-negative disease patients, both in mastectomy and conservative surgery, and becoming a crucial turning point in BC managing. ⋯ Several studies also proved that neoadjuvant chemotherapy (NAC) increases the BCS rates, as well reducing the extent of axillary surgery. The potential oncological safety of axillary observation choice in early BC patients undergoing BCS, in the recent perspective of the prevailing value of BC biology, is also under scientific evaluation. This study explores the current role of SLNB in BC patients eligible for BCS, providing a view into future directions in BC care.
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The novel SARS-CoV-2 pandemic arose in China in the late 2019 and soon after spread in the rest of the world. The management of SARS-CoV-2 is a serious challenge for all the healthcare professionals. The management of this disease has caused an epochal change in all of the hospitals. ⋯ The surgeons too had to quickly adapt their skills, in order to recognize and treat this life-threatening problem. In the meantime, the surgeons had to ensure continuity of the oncall availability for the emergency procedures, meanwhile the regular scheduled surgical activities were suspended. We present here our experience in a neighborhood hospital located in Milan, Italy.
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The spread of COVID-19 pandemic has determined a huge imbalance between real clinical needs of the population and effective resources availability. The aim of this study was to report how this situation forces surgeons to consider a non-operative management as an alternative. This is a retrospective monocentric study and we collected data from 60 patients, split in two groups: info from Group A, 28 patients (11 March to 11 April 2020) were compared with info from group B, 32 patients (11 March to 11 April 2019). ⋯ Otherwise, non-operative approach occurred in 10 cases (35,7%) in group A and only in 4 patients (12,5%) in group B. These data suggest that the drastic reduction of means narrows the range of therapeutic choices. Indeed, in this emergency scenario, the rationing of healthcare resources was the propelling for surgeons to consider alternative therapeutic pathways.
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Within the last 50 years the management of patients with breast cancer has changed dramatically with a significant de-escalation of the role and magnitude of surgery, both for the management of the primary tumor and for the management of the axilla. In the management of the axilla of patients with early stage breast cancer (EBC) and clinically uninvolved axilla (cN0), axillary lymph node dissection (ALND) was gradually replaced by sentinel lymph node biopsy (SLNB) saving more than 60-70% of patients from an unnecessary dissection. Further studies confirmed that isolated tumor cells or micrometastases found on the SLN had no further benefit from ALND sparing even more patients from an unnecessary ALND. Eventually, the Z0011 and other studies showed that even patients with 1-2 positive SLN can be spared from ALND provided they fulfill certain criteria. Still though there were many flaws in these studies and further research was necessary to generalize the results of these studies to a wider target group. Meanwhile, there is a clear view that many low risk patients if they have their axilla evaluated via US and are not found to have suspicious nodes, it is highly unlikely to have involved axilla. This let to studies evaluating the non-surgical management of the axilla. Finally, in the post neoadjuvant setting 3 randomized controlled trials showed that under certain circumstances SLNB can be done after the NAC even in patients who initially had involved axilla and was converted to clinically uninvolved (cN1→cN0). ⋯ Although we have covered a long way in the journey of eliminating axillary surgery, there are still lots of questions to be answered and trials to be conducted. We anticipate the results of the ongoing trials to provide the necessary evidence to safely de-escalate more the axillary surgery, both in the non-neoadjuvant as well as in the neoadjuvant setting, hoping that in the not so far future the axillary surgery will eventually perish.
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During Coronavirus disease (COVID-19) pandemic entire countries rapidly ran out of intensive care beds, occupied by critically ill infected patients. Elective surgery was initially halted and acute non-deferrable surgical care drastically limited. The presence of COVID-19 patients into intensive care units (ICU) is currently decreasing but their congestion have restricted our therapeutic strategies during the last months. ⋯ On the basis of our experience awake laparotomy under LA resulted feasible, safe, painless and, in specific cases, the only viable option. For patients presenting fragile cardiovascular and respiratory, reserves and in whom general anesthesia (GA) would presumably increase morbidity and mortality we encourage LA as an alternative to GA. In the COVID-19 era, it has become part of our ICU-preserving strategy allowing us to carry out undeferrable surgeries.