Search

Introduction:Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery.Materials and Methods:Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021.Result:There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastec-tomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR.Conclusion:Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.

Introduction Hyperthermic Ιsolated Limb Perfusion using melphalan and TNFα (TM-HILP) is a regional chemotherapy method for advanced melanoma. Purpose To explore the feasibility of the study of Circulating Melanoma Cells (CMCs) in the context of acute physiological changes induced by TM-HILP and their association with oncological outcomes. Methods The study included 20 patients undergoing TM-HILP for unresectable in-transit melanoma of the limbs, stage III(B/C/D). CMCs in the peripheral blood were analyzed at 5-time points from the preoperative day until day 7 from surgery using the following biomarkers: MITF, Tyrosinase mRNA, Melan-A and S100b, through quantitative RT-PCR. Results No CMCs according to Tyrosinase and Melan-A biomarkers were found in any sample. Friedman test showed significant alterations perioperatively for MITF (p

One of the most intriguing eras in the evolution of hernia surgery is the second half of the 18th century, when surgeons interested, also, in anatomy, started to publish studies on the abdominal wall and the inguinal canal. Petrus Camper (1722–1789), a well-known “praelector anatomiae” of the Amsterdam Guild of Surgeons and Professor of Anatomy and Surgery at the Universities of Franeker, Amsterdam, and Groningen, performed dissections on corpses of children and adults to study the anatomy and aetiology of inguinal hernias. He rejected the prevailing concept of that time that a hernia was caused by “a rupture of the peritoneum” and provided a clear description of the aetiology of hernias in both children and adults. His geometrical measurement of the pelvis and his acquired craftsmanship provided the basis for the development of an effective and reliable truss to treat inguinal hernia conservatively. His artistic and drawing talent rendered him great facility in presenting his anatomical observations of the inguinal canal in a marvelous way. Campers “Icones herniarum” include exceptional anatomical illustrations of inguinal hernias. His anatomic studies allowed the development of hernia surgery based on anatomy rather than barbaric castration by ancient “herniotomists”. Petrus Camper should be considered as a pioneer in anatomy and aetiology of inguinal hernias.

Despite, the strong rationale and evidence of the benefit of postoperative intraperitoneal chemotherapy in advanced ovarian cancer, it has not been widely adopted, mainly due to its high morbidity and logistical difficulties. Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) is a more tolerable and technically feasible method of intraperitoneal chemotherapy, whereas other potential advantages include homogenous drug distribution, application before tumor regrowth and combination with hyperthermia, which is directly cytotoxic and enhances the efficacy of many drugs.In this review, the authors explain the rationale and indications for cytoreductive surgery (CRS) and HIPEC in advanced ovarian cancer. Data of major clinical studies, meta-analyses, and recent randomized trials are discussed.After many encouraging clinical studies and meta-analyses, a recent randomized study demonstrated survival benefit for HIPEC during interval CRS in primary ovarian cancer, without increased morbidity, whereas another implied its benefit in recurrent ovarian cancer. Results of recently completed and numerous ongoing randomized studies will further determine the benefit of HIPEC in ovarian cancer at different time points. Patient selection and appraisal of the best protocols are crucial. The field of gynecological oncology will most likely evolve to include HIPEC eventually as a routine treatment for ovarian cancer.

MCC is a rare but highly aggressive skin cancer. The identification of the driving role of Merkel cell polyomavirus (MCPyV) and ultraviolet-induced DNA damage in the oncogenesis of MCC allowed a better understanding of its biological behavior. The presence of MCPyV-specific T cells and lymphocytes exhibiting an ‘exhausted’ phenotype in the tumor microenvironment along with the high prevalence of immunosuppression among affected patients are strong indicators of the immunogenic properties of MCC. The use of immunotherapy has revolutionized the management of patients with advanced MCC with anti-PD-1/PD L1 blockade, providing objective responses in as much as 50–70% of cases when used in first-line treatment. However, acquired resistance or contraindication to immune checkpoint inhibitors can be an issue for a non-negligible number of patients and novel therapeutic strategies are warranted. This review will focus on current management guidelines for MCC and future therapeutic perspectives for advanced disease with an emphasis on molecular pathways, targeted therapies, and immune-based strategies. These new therapies alone or in combination with anti-PD-1/PD-L1 inhibitors could enhance immune responses against tumor cells and overcome acquired resistance to immunotherapy.

In breast cancer, expression of Cluster of Differentiation 24 (CD24), a small GPI-anchored glycoprotein at the cell periphery, is associated with metastasis and immune escape, while its absence is associated with tumor-initiating capacity. Since the mechanism of CD24 sorting is unknown, we investigated the role of glycosylation in the subcellular localization of CD24. Expression and localization of wild type N36- and/or N52-mutated CD24 were analyzed using immunofluorescence in luminal (MCF-7) and basal B (MDA-MB-231 and Hs578T) breast cancer cells lines, as well as HEK293T cells. Endogenous and exogenously expressed wild type and mutated CD24 were found localized at the plasma membrane and the cytoplasm, but not the nucleoplasm. The cell lines showed different kinetics for the sorting of CD24 through the secretory/endocytic pathway. N-glycosylation, especially at N52, and its processing in the Golgi were critical for the sorting and expression of CD24 at the plasma membrane of HEK293T and basal B type cells, but not of MCF-7 cells. In conclusion, our study highlights the contribution of N-glycosylation for the subcellular localization of CD24. Aberrant N-glycosylation at N52 of CD24 could account for the lack of CD24 expression at the cell surface of basal B breast cancer cells.

The goals of treatment for soft tissue sarcoma (STS) of the extremities are local tumor control, preservation of limb function and reduction of the risk of distant metastasis. The standard treatment for STS of the limbs is wide local excision with histologically negative margins and, in the majority of cases, adjuvant radiotherapy. In the case of locally advanced tumors, this might not be feasible, especially when the tumor is located at the periphery of the limb, or tumor infiltration, encasement or fixation of motor nerves, major vessels or bones has occurred, in which case, amputation may be necessary. The aim of neoadjuvant treatment is to minimize the need for amputation or surgery that leads to major functional impairment with an acceptable level of toxicity and without a negative impact on survival. This is a comprehensive review of the various neoadjuvant treatment strategies applied in an attempt to salvage the limb and to preserve its function in patients with locally advanced STS. Systemic chemotherapy with regional hyperthermia and isolated limb infusion (ILI) are promising. Novel treatment option such as, isolated limb perfusion (ILP) with tumor necrosis factor-α (TNF-α) and melphalan appears to be the most effective neoadjuvant treatment modality for these cases. ILP provides the highest likelihood of local tumor eradication with preservation of the limb and its function for patients with limb-threatening locally advanced STS. Approximately one quarter of the patients experience complete pathological response and half of the patients a partial response, together resulting in limb salvage in three quarters of the patients. Because of the high pathological response rates, the high limb salvage rate, the improved surgical margins after ILP with TNF-α and melphalan, and its low toxicity, the indications for performing this treatment should be evaluated for primary and recurrent tumors when infiltration, encasement and/or fixation of motor nerves, major vessels, or bones are present. When ILP is indicated, the limited availability of the technique, which is provided at present by only one center in Greece, should not be a reason to withhold from a patient the opportunity of salvage of the limb and its function.

Discovery of the lymphatic system is documented in numerous sources and can be attributed to a variety of persons. Like many other important developments in medicine, the recognition of the lymphatic system starts with Hippocrates (ca. 460–370 BC), who described a disease course consistent with metastasis to lymph nodes. Until the 17th century, knowledge about the anatomy and pathophysiology of the lymphatic system was limited, probably because of the difficulty of visualizing lymph vessels in animals and humans. Frederik Ruysch (1638-1731), a “praelector anatomiae” of the Amsterdam Guild of Surgeons, must be considered one of the pioneers in lymphatic research. His contribution relied on meticulous anatomical dissection of lymph vessels, and with his innovative preservation techniques, he was the first to visualize lymphatic valves. This major step provided a better understanding of lymphatic anatomy and the circulation of lymph. The German pathologist Rudolf Virchow (1821–1902) suggested that lymph nodes function as filters in the lymphatic system and could therefore contain cancer. He was the first to propose that lymph fluid from any given area of the body drains through lymphatics to a specific lymph node and subsequently to other lymph nodes. Consequently, clinicians began to recommend that local therapy of cancer should be supplemented with regional lymph node treatment to improve the cure rate. Subsequently, lymph node surgery became an essential element of surgical oncology. Lymphatic mapping and sentinel lymph node biopsy were developed several decades ago by Donald Morton (1934–2014) to stage melanoma accurately and to avoid unnecessary lymph node dissection. In a way, history is now repeating itself, as today there is renewed interest in imaging lymph vessels and lymph nodes from an oncological perspective, more than 300 years since Ruysch committed himself to visualizing the lymphatic system. From this perspective, it is important to acknowledge early contributions of Ruysch in providing the foundations to our knowledge of lymphatic anatomy.

Osteosarcoma shows a high propensity to metastasize to the lung. Pulmonary metastases occur in approximately 40% of patients with osteosarcoma during the course of their disease, and the lung is the only site of metastatic disease in the majority of these cases. Chemotherapy continues to be the standard treatment for metastatic sarcoma, but when it is the only treatment modality, it still results in poor survival rates. In order to improve the outcome, a combination of chemotherapy followed by surgical resection of the metastases has been advocated for selected cases. Substantial evidence documents the potential benefit of pulmonary metastasectomy in osteosarcoma, resulting, in various series, in a 5-year overall survival of 30-40%. Aggressive surgery in combination with chemotherapy appears to be justified for metastatic osteosarcoma in selected patients, and it is associated with acceptable morbidity. Synchronous metastases, a short interval from diagnosis to presentation of pulmonary metastasis, a higher number (>4) of metastases, bilateral and central location, pleural infiltration, poor response to preoperative chemotherapy and concurrent (resectable) extra-pulmonary disease have all been associated with a less favorable outcome. Complete surgical resection is essential for giving a chance of long-term survival. Lateral thoracotomy with salvage of as much lung parenchyma as possible is the procedure of choice. Repeat surgery for re-recurrences is feasible and beneficial, resulting in prolonged survival in a number of cases.

Renal angiomyolipoma (AML) is a relatively rare tumor that is generally considered as merely benign. However, epithelioid AML (EAML), an uncommon subtype, is associated with potentially malignant behavior. We herein present the case of a 60-year old male patient who had undergone left nephrectomy with left adrenalectomy and lymphadenectomy for a renal tumor 12 years earlier, and presented to our hospital with dull abdominal pain. The histology report after the previous surgery had revealed an AML of the left kidney with a maximal diameter of 17 cm. Imaging studies demonstrated a large tumor of 13 cm in diameter in the area of the resected kidney, as well as hepatic and peritoneal metastases. Computed tomography-guided core needle biopsy of the mass and revision of the histology of the nephrectomy revealed an EAML. Four years after a two-stage resection of the recurrences the patient is in excellent condition and free of disease. From this case report and the literature review on EAML, it appears that correct histological diagnosis of this subtype of renal AML is crucial. Erroneous diagnosis of simple renal AML instead of EAML may lead to insufficient postoperative management. Clinicians should be aware of the malignant potential of EAML and the need for long-term follow-up. As effective surgical and emerging medical treatment options are available, timely detection of recurrent disease may lead to improved outcome.

Colorectal cancer presents relatively often as acute bowel obstruction, which requires immediate intervention. Operative morbidity and mortality are increased by deterioration of the patient and the commonly poor condition of the proximal bowel. The optimal curative approach for obstructing colorectal carcinoma continues to be a topic of discussion and is the subject of this literature review. The pros and cons of the various strategies based on data provided by clinical studies are discussed. Primary decompression of the bowel with a colostomy or stent and delayed colectomy has the advantage of providing time for improvement of the patient’s general condition, recovery of the initially dilated large bowel, accurate disease staging, planning of preoperative treatment and resection by an experienced surgeon. In the absence of significantly dilated bowel the definitive surgical procedure may be performed laparoscopically. Since placement of a self-expanding metallic stent as a bridge to elective surgery is associated with a high complication rate, and probably with impaired oncological outcome, it should be considered only as an alternative to emergency surgery in those patients who have an increased surgical risk, or as a palliative procedure. Local availability and expertise, and high costs are further issues that need to be considered. The creation of diverting colostomy as a bridge to elective surgery is a safe and valid alternative. Although a second operation is required, the overall morbidity and mortality are no higher than for primary resection, while the rate of permanent colostomy is significantly lower, and there is evidence that the two-stage approach is associated with a better oncological outcome.

Training, examination and quality standards of surgeons are topics of interest for the present international surgical community. In this review, surgical training and examination are discussed from the historical perspective on the basis of the regulations of the Amsterdam Guild of Surgeons (1461-1736). In Amsterdam, in that period, surgeons usually underwent a 5-year training in a master-mate relationship under the guidance of a master surgeon in a “surgeon's store”. The trainee was expected to acquire additional knowledge from weekly anatomy lessons on the body of a deceased person, given by the “praelector anatomiae” in the anatomy theater. After successful completion, the master handed over to his apprentice a so-called “education letter”, in which the master stated that the trainee had worked to his satisfaction with diligence and devotion in his “surgeon’s store” throughout the 5 years. This letter was required for participation of the trainee in the examination to become a surgeon. The learning period ended with a 'master’s examination', in which the manufacture of lancets, bloodletting and a trepanning of a skull were indispensable elements. The master’s examination as the ultimate test of competence at the end of surgical training is currently absent from the surgical specialty program in many countries, including Greece. The introduction of a modern master’s examination could be considered in the interest of enforcing explicit quality standards and ensuring adequate examination of candidate surgeons.

Small bowel adenocarcinoma (SBA) is rare despite the fact that the small bowel represents the longest part and has the largest surface of all alimentary tract sections. Its incidence is 50-fold lower than that of colorectal carcinoma. It is often diagnosed at an advanced stage due to atypical and late symptoms, its low index of suspicion, difficult endoscopic access and poor detection by radiological imaging, resulting in impaired outcome. Due to its rarity and being molecularly a unique intestinal cancer, data regarding its optimal management are relatively sparse.A PubMed search was performed to identify relevant manuscripts that were recently published. Emerging data regarding the pathogenesis, the diagnosis and the treatment of SBA that resulted from recent research are discussed in this comprehensive review.Genomic analysis has demonstrated that SBA is a molecularly unique intestinal cancer. Double balloon enteroscopy and capsule endoscopy are novel techniques which may result in earlier diagnosis and consequently in improvement of the generally poor prognosis. For clinically localized disease, the quality of surgery has recently been defined, with removal of at least 8-10 lymph nodes correlating with improved prognosis. Moreover, adjuvant chemotherapy seems to improve outcome of stage III disease. The combination of a fluoropyrimidine and oxaliplatin appears to be the most effective systemic chemotherapy for disseminated disease. Genomic profiling can identify potentially targetable genomic alterations in a significant proportion of SBA patients. The role of administration of targeted agents or immune checkpoint inhibitors is still unknown and subject of ongoing clinical trials. In the common case of peritoneal metastases, recent studies have shown that cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy may be an attractive treatment option in selected patients.SBA is a rare and unique malignancy, whose diagnostic approach and treatment are evolving, resulting in improved outcome.

Intraperitoneal chemotherapy is associated with a significant pharmacokinetic and pharmacodynamic benefit and can, alone or in combination with systemic chemotherapy (bidirectional chemotherapy), be used for treating primary and secondary peritoneal surface malignancies. Due to the peritoneal–plasma barrier, high intraperitoneal drug concentration can be achieved by intraperitoneal chemotherapy, whereas systemic concentration remains low. Bidirectional chemotherapy may provide in addition adequate drug concentrations from the side of the subperitoneal space to the peritoneal tumour nodules. Major pharmacological problems of intraperitoneal chemotherapy are limited tissue penetration and poor homogeneity of drug distribution to the entire seroperitoneal surface. Significant pharmacological determinants of intraperitoneal chemotherapy are choice of drug, drug dosage, solution volume, carrier solution, intra-abdominal pressure, temperature, duration, mode of administration, extent of peritonectomy and interindividual variability. Drugs most commonly applied for intraperitoneal chemotherapy include mitomycin C, cisplatin, carboplatin, oxaliplatin, irinotecan, 5-fluoruracil, gemcitabine, paclitaxel, docetaxel, doxorubicin, premetrexed and melphalan. The drugs and their doses that are used vary widely among centres. While the adequate drug choice for intraperitoneal and bidirectional chemotherapy is essential, randomized clinical trials to determine the most optimal drug or drug combination are lacking, and only eight retrospective comparative clinical studies are available. Further clinical pharmacological studies are required to determine the most effective drug regimen for intraperitoneal and bidirectional chemotherapy in various indications. In the future, reliable drug sensitivity testing and genetic profiling of peritoneal metastases will be needed for enabling patient-specific therapy.

Chronic stress is thought to be involved in the occurrence and progression of multiple diseases, via mechanisms that still remain largely unknown. Interestingly, key regulators of the stress response, such as members of the corticotropin-releasing-hormone (CRH) family of neuropeptides and receptors, are now known to be implicated in the regulation of chronic inflammation, one of the predisposing factors for oncogenesis and disease progression. However, an interrelationship between stress, inflammation, and malignancy, at least at the molecular level, still remains unclear. Here, we attempt to summarize the current knowledge that supports the inseparable link between chronic stress, inflammation, and colorectal cancer (CRC), by modulation of a cascade of molecular signaling pathways, which are under the regulation of CRH-family members expressed in the brain and periphery. The understanding of the molecular basis of the link among these processes may provide a step forward towards personalized medicine in terms of CRC diagnosis, prognosis and therapeutic targeting.

The effectiveness of autologous platelet-rich plasma (PRP) in chronic wounds remains controversial.The aim of this prospective study is to objectively assess the impact of PRP therapy on pressure ulcer (PU) healing utilizing digital planimetry.Eligible patients included those with PUs with a surface area ⟩ 1 cm2 and ⟩ 3 months' duration. Each ulcer initially was debrided surgically. The patient then was advised to continue conventional treatment for 4 weeks, after which time repeat debridement was performed as needed. Subsequently, PRP was applied and the patient was observed for an additional 4 weeks. During the 8-week study period, the treatment's effectiveness was assessed weekly with digital planimetry. The Wilcoxon signed-rank test was used to compare continuous variables.Thirty-six patients (22 men, 14 women) with a median age of 62 years (range, 38-88 years), who had 64 PUs with an initial median surface area of 20 cm2 (range, 1 cm2-180 cm2), a median diameter of 6.3 cm (range, 1.3 cm-18.6 cm), and a median circumference of 16.8 cm (range, 4 cm-68 cm) were included. Reduction of median surface area (63% vs. 41%), median maximal diameter (33% vs. 20%), and median circumference (38% vs. 21%) were significantly (P ⟨ .001) greater after PRP treatment compared with after conventional treatment.It appears treatment with PRP accelerates healing of PUs as objectively measured by digital planimetry. Compared with conventional treatment, a significantly higher reduction in surface area, diameter, and circumference of PUs was observed following application of PRP.

Purpose To investigate and histopathologically validate the role of model selection in the design of novel parametric meta-maps towards the discrimination of low from high-grade soft tissue sarcomas (STSs) using multiple Diffusion Weighted Imaging (DWI) models. Methods DWI data of 28 patients were quantified using the mono-exponential, bi-exponential, stretched-exponential and the diffusion kurtosis model. Akaike Weights (AW) were calculated from the corrected Akaike Information Criteria (AICc) to select the most suitable model for every pixel within the tumor volume. Pseudo-colorized classification maps were then generated to depict model suitability, hypothesizing that every single model underpins different tissue properties and cannot solely characterize the whole tumor. Single model parametric maps were turned into meta-maps using the classification map and a histological validation of the model suitability results was conducted on several subregions of different tumors. Several histogram metrics were calculated from all derived maps before and after model selection, statistical analysis was conducted using the Mann-Whitney U test, p-values were adjusted for multiple comparisons and performance of all statistically significant metrics was evaluated using the Receiver Operator Characteristic (ROC) analysis. Results The histologic analysis on several tumor subregions confirmed model suitability results on these areas. Only 3 histogram metrics, all derived from the meta-maps, were found to be statistically significant in differentiating low from high-grade STSs with an AUC higher than 89 %. Conclusion Embedding model selection in the design of the diffusion parametric maps yields to histogram metrics of high discriminatory power in grading STSs.

Subcutaneous fat may have variable signal intensity on T2w images depending on the choice of imaging parameters. However, fatty components within tumors have a different degree of signal dependence on the acquisition scheme. This study examined the use of T2, T220 patients with benign lipomas or liposarcomas of variable histologic grade were examined at an 1.5 T scanner with Multi Echo Spin Echo (MESE) different echo spacing (ESP) in order to produce bright fat T2w images (ESP: 13.4 ms, 25 equidistant echoes) and dark fat images (ESP: 26.8 ms with 10 equidistant echoes). T2Significant differences of SCr were found for five different types of lipomatous tumors (Pairwise t-test with Bonferroni correction): lipomas, well differentiated liposarcomas, myxoid liposarcomas, pleomorphic liposarcomas and poorly differentiated liposarcomas. SCr surpassed the classification performance of T2 and T2A novel biomarker based on spin coupling related signal loss, SCr, is indicative of lipomatous tumor histological grading. We concluded that T2, T2

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.

Patient selection for PI3K-targeted solid cancer treatment was based on the PIK3CA/PTEN mutational status. However, it is increasingly clear that this is not a good predictor of the response of breast cancer cells to the anti-proliferative effect of PI3K inhibitors, indicating that isoform(s) other than p110α may modulate cancer cells sensitivity to PI3K inhibition. Surprisingly, we found that although no mutations in the p110δ subunit have been detected thus far in breast cancer, the expression of p110δ becomes gradually elevated during human breast cancer progression from grade I to grade III. Moreover, pharmacological inactivation of p110δ in mice abrogated the formation of tumours and the recruitment of macrophages to tumour sites and strongly affected the survival, proliferation and apoptosis of grafted tumour cells. Pharmacological inactivation of p110δ in mice with defective macrophages or in mice with normal macrophages but grafted with p110δ-lacking tumours suppressed only partly tumour growth, indicating a requisite role of p110δ in both macrophages and cancer cells in tumour progression. Adoptive transfer of δD910A/D910A macrophages into mice with defected macrophages suppressed tumour growth, eliminated the recruitment of macrophages to tumour sites and prevented metastasis compared with mice that received WT macrophages further establishing that inactivation of p110δ in macrophage prevents tumour progression. Our work provides the first in vivo evidence for a critical role of p110δ in cancer cells and macrophages during solid tumour growth and may pave the way for the use of p110δ inhibitors in breast cancer treatment.

Adrenal hemorrhage represents a relatively rare condition, usually associated with meningococcal septicemia. It is an underestimated cause of acute decompensation, multiorgan failure and death, usually diagnosed post-mortem. Depending on its etiology adrenal hemorrhage is categorized as traumatic and non-traumatic. The technical advancement of imaging modalities, has made diagnosis and management more efficient. Assessment of hemodynamic stability, exclusion of a hormonal active adrenal tumor and assessment for adrenal insuffi¬ciency, are of cardinal importance. Angiographic embolization has contributed significantly in better outcomes as emergency laparotomy is associated with high morbidity and mortality rates. Hereby we present two cases of spontaneous adrenal hemorrhage associated with extensive retroperitoneal bleeding and hemodynamic instability. Both underwent angiography with one requiring embolization with favorable outcome. Investigation for exclusion of underlying adrenal tumor, adrenal insufficiency and follow-up imaging are presented in detail for both cases.

Tumor necrosis factor alpha (TNF-α) is known to cause selective destruction of tumor neovascularisation. Perfusion changes in tumor microenvironment were studied in a young patient with a high-grade myxoid liposarcoma after isolated limb perfusion with TNF-α and melphalan, using advanced MR imaging. Quantitative and semi-quantitative evaluation of perfusion metrics included ktrans/f/T2* shift and automatic extraction of enhancement patterns. Strong agreement between different methods is consistent with response to therapy, specifically reduced perfusion (mean ktrans shifted from 0.424 to 0.099 mL/g/min, mean f from 33.5 to 7.3%), reduced hypoxia indication (mean T2* increased from 72 to 82 ms) and prevalence of necrotic areas. Abbreviations (TNF-α) : Tumor Necrosis Factor Alpha ILP : Isolated limb perfusion DCE : Dynamic Contrast Enhanced DWI : Diffusion Weighted Imaging IVIM : Intravoxel Incoherent Motion T2*r : T2* Relaxometry BOLD : Blood Oxygen Level-Dependent PK : Pharmacokinetic ktrans : Transendothelial permeability dHb : Deoxyhemoglobin IMVD : Intratumoral Microvessel Density FISH : Fluorescence In situ Hybridization PR : Pattern Recognition

Background Facial anthropometric analysis is essential for planning cosmetic and reconstructive facial surgery, but has not been available in detail for modern Greeks. In this study, multiple measurements of the face were performed on young Greek males and females to provide a complete facial anthropometric profile of this population and to compare its facial morphology with that of North American Caucasians. Materials and methods Thirty-one direct facial anthropometric measurements were obtained from 152 Greek students. Moreover, the prevalence of the various face types was determined. The resulting data were compared with those published regarding North American Caucasians. Results A complete set of average anthropometric data was obtained for each sex. Greek males, when compared to Greek females, were found to have statistically significantly longer foreheads as well as greater values in morphologic face height, mandible width, maxillary surface arc distance, and mandibular surface arc distance. In both sexes, the most common face types were mesoprosop, leptoprosop, and hyperleptoprosop. Greek males had significantly wider faces and mandibles than the North American Caucasian males, whereas Greek females had only significantly wider mandibles than their North American counterparts. Conclusions Differences of statistical significance were noted in the head and face regions among sexes as well as among Greek and North American Caucasians. With the establishment of facial norms for Greek adults, this study contributes to the preoperative planning as well as postoperative evaluation of Greek patients that are, respectively, scheduled for or are to be subjected to facial reconstructive and aesthetic surgery.

Background Although current progress in surgical instruments is oriented towards stapler devices, minimally invasive instrumentation and advanced cautery tools, it definitely seems intriguing to determine what instruments were used in antiquity and to appraise their use. Most adequate information can be retrieved from manuscripts of early medical authors, of whom Paul of Aegina (AD 625–690), also being a most important surgeon, is the most recent. The aim of this study is to present surgical instruments used in his practice. Methods Surgical instruments mentioned in the original Greek text of his monumental work named Epitome of Medicine were sought using computer software. Further, similar research was performed on other significant manuscripts of earlier Greek medical writers to determine whether some of the instruments were exclusively mentioned by Paul of Aegina. Results In total, 121 different surgical instruments were identified and described in detail in the Epitome of Medicine. Thirty-three instruments (27%) were exclusively reported by Paul of Aegina. Conclusions In antiquity a large number of surgical instruments were already being used. Paul of Aegina described in detail a large variety of fine, as well as a substantial number of, original surgical instruments, which he himself used in a wide spectrum of surgical operations.

To evaluate the role of sleeve gastrectomy (SG) in gastrointestinal motility.SG is a widely used bariatric operation leading to weight loss and early improvement of patient's metabolic profile. Current data indicate faster postoperative gastric emptying, but detailed studies on alterations in small bowel motility are missing.We evaluated 21 morbidly obese patients who underwent laparoscopic SG before and 4 months after the procedure. After consumption of a semisolid radiolabeled meal, their gastric and intestinal transit times were studied with a gamma camera. Particularly the times of 10% gastric emptying, 50% gastric emptying, maximal intestinal filling, 10% terminal ileum filling, duodenal to terminal ileum transit, cecal filling initiation, and ileocecal valve transit (T ICVt) were studied pre- and postoperatively.Ten percent gastric emptying and 50% gastric emptying were decreased postoperatively as well as maximal intestinal filling, indicating faster gastric emptying and intestinal filling. Duodenal to terminal ileum transit and 10% terminal ileum filling also decreased as small bowel transit time accelerated and the meal reached the terminal ileum more rapidly. Contrary opening of the ileocecal valve and food transit through it were delayed, with postoperative increase in cecal filling initiation and T ICVt, respectively.SG accelerates gastric emptying and small bowel transit of semisolids. In addition, it delays the initiation of cecal filling and T ICVt. This early and prolonged contact of food with the distal small bowel mucosa may explain the metabolic effects of SG occurring before substantial weight loss.

Spindle cell lipoma is a relatively rare adipocytic neoplasm, which usually occurs in the posterior neck, shoulder or upper back of male patients aged 45-65 years. We report here an unusual coexistence of ordinary and spindle cell lipoma. The patient presented with a painless mass in the area of the right scapula. Imaging was suggestive of a lipomatous mass, possibly liposarcoma. Histological examination revealed the concurrent existence of an intramuscular spindle cell lipoma and an ordinary lipoma. In the literature there are only fourteen cases of intramuscular spindle cell lipoma and only in four cases there was a coexisting mature lipoma. As exclusion of malignancy remains clinicians main concern,diagnosis and treatment of deep seated lipomatous tumors remains challenging.

Peritoneal metastases (PM) affect approximately one third of patients with metastatic small bowel adenocarcinoma (SBA). Treatment options are (1) systemic therapy ± palliative surgery and (2) cytoreductive surgery with intraperitoneal chemotherapy (CRS + IPC). Due to scarce evidence, PM from SBA represents a therapeutic challenge. This narrative review summarised and discussed the evidence that investigated available treatment options.Studies were discussed if they investigated first line systemic therapy for advanced SBA or CRS + IPC for PM from SBA. Extracted outcomes were objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), disease-free survival (DFS), overall survival (OS), and grade III-V toxicity/morbidity.Eighteen studies (15 observational, 3 phase II) that investigated systemic therapy and six observational studies that investigated CRS + IPC were reviewed. In studies that investigated systemic therapy, ORR, DCR, median PFS, median OS, and grade III-V toxicity ranged from 6% to 50%, 50% to 90%, 3 to 11 months, 8 to 20 months, and 10% to 68%, respectively. Fluoropyrimidine-oxaliplatin revealed favourable survival outcomes compared to fluoropyrimidine-irinotecan, fluoropyrimidine-cisplatin, fluoropyrimidine monotherapy, and other regimens. In studies that investigated CRS + IPC, median DFS, median OS, and grade III-V morbidity ranged from 10 to 12 months, 16 to 47 months, and 12% to 35%, respectively.Based on available evidence, fluoropyrimidine-oxaliplatin should be regarded as optimal first line systemic treatment. In selected patients, CRS + IPC appears safe and may be more effective than systemic therapy as single treatment. Future studies should evaluate survival and morbidity of CRS + IPC in larger cohorts, as well as the value of chemotherapy with targeted agents in metastatic SBA with subgroup analysis for PM from SBA.

Pilomatrix carcinoma is a very rare malignancy, with ~130 cases reported in the literature. In the past, pilomatrix carcinoma was considered to be a low-grade malignant tumor. Currently, however, its significant recurrence and metastatic potential has been well documented. Lymph node and systemic metastases are frequently observed. Wide surgical excision of the primary lesion is the principal modality of treatment, whereas adjuvant radiotherapy may be beneficial in local tumor control. Lymph node metastases may be treated surgically or with radiotherapy. Systemic disease is not responsive to chemotherapy, and is hence associated with a poor prognosis. Since the majority of nodal and systemic metastases present after the initial diagnosis and treatment, follow-up examinations of these patients may be warranted, despite the currently inadequate treatment options. In the present study, a case of pilomatrix carcinoma of the parotid region with early local recurrence only 2 months after complete excision with negative surgical margins is reported. The local recurrence was treated by excision and radiotherapy. The associated literature is also discussed.

Controversial results regarding the efficacy and toxicity of hypoxic abdominal and pelvic stop-flow perfusion chemotherapy (SFP) have been reported in relatively small series. Hence, because adequate assessment of its benefit in large homogenous cohorts is missing, acceptable morbidity should initially be assured in a series of adequate size. Additionally, risk factors should be assessed for eventual patient selection. The morbidity of abdominal and pelvic SFP performed on a miscellaneous group of patients in our institute was analyzed and potential risk factors for adverse events were evaluated. Seventy abdominal (n = 42) and pelvic (n = 28) SFP were performed on 55 patients. In total, 28 adverse effects were observed after 30 % of the procedures. Severe (grade 3) adverse events were recorded only after 4 % of the procedures, while treatment-related life-threatening events and deaths were not present. Abdominal procedures when compared with pelvic ones were associated with increased systemic toxicity (36 vs. 7 %, p = 0.005). Advanced age, gender, prior chemotherapy and/or radiotherapy, limited experience, repeated procedure, drug choice and omission of hemofiltration after SFP completion were not associated with statistically significant increase of procedures with overall or systemic adverse events. In the present series, abdominal and pelvic SFP was associated with an acceptable morbidity, which was mostly mild or moderate. Abdominal procedures were associated with increased toxicity. This procedure seems to be repeatable and also well tolerated both by elderly patients and by patients who had undergone prior chemotherapy and/or radiotherapy, while hemofiltration does not appear to decrease the incidence of systemic toxicity.

Background Erythema can be described only through subjective evaluation, except when it is quantified by digital image analysis software. Using such software, the authors performed comparisons of the erythema produced after skin closure of clean surgical wounds. Five suture materials were compared with respect to the local skin irritation that was caused. Different quantities of erythema are produced by suture material after the skin closure of clean surgical wounds. The authors present an objective method of measuring how unreactive a suture material is in comparison with another when applied to the skin. Methods The suture materials polydioxanone, polypropylene blue, polyamide 6, metallic clips, and polyglactin were compared in the present study. Digital photographs of 100 patients were compared by means of software, evaluating red color superiority (mean value of red color) in the region surrounding the wound. Results The least to most irritation caused to the skin by different suture materials was established for paired data. The Kolmogorov-Smirnov criterion and the Wilcoxon signed rank test were used. Polydioxanone was found to have the best performance, followed in order by polyglactin, polyamide, polypropylene, and metallic clips. Immediately after suture removal, differences between the effects of suture materials were statistically significant on postoperative day 10. Conclusions Absorbable sutures can be used in skin closure of clean surgical wounds and can produce less erythematous reaction than nonabsorbable ones. Digital image analysis is a reliable method of quantitative evaluation of skin erythema resulting after skin closure of surgical wounds.

The extent of lymphadenectomy during therapeutic gastrectomy for gastric cancer remains a protracted and controversial issue. While traditionally extended lymphadenectomy is performed in Eastern Asia, limited lymphadenectomy is advocated by most western surgeons. Two large western randomized trials, meta-analyses and a recent systematic review were unable to demonstrate overall benefit from extended lymphadenectomy. In this review, the currently available data on this topic are critically evaluated, while ongoing studies and future perspective are discussed.

BACKGROUND: Rectal cancer treatment has become multimodal as a result of significant advances in imaging, staging, surgery, radiotherapy, and chemotherapy. Multidisciplinary teams can incorporate these developments into tailor-made treatment plans and offer state-of-the-art services for rectal cancer patients. METHODS: We searched the MEDLINE and PubMed databases using the following keywords: “rectal cancer,” “total mesorectal excision,” “multidisciplinary treatment/team,” “radiotherapy,” “chemotherapy,” and their combinations. There were no language or publication year restrictions. References in published articles also were reviewed. RESULTS: Total mesorectal excision surgery, high-resolution pelvic magnetic resonance imaging, preoperative chemoradiotherapy, and pathologic reports according to Quirke protocol are preconditions for the initiation of an effective multidisciplinary team. Common topics for discussion are the status of the circumferential margin, the type of radiotherapy and surgery required, and the chemotherapeutic agent to be used. CONCLUSIONS: This review focuses on this issue based on two main principles. First, the status of the circumferential margin dictates the use of preoperative chemoradiotherapy. Second, preoperative chemoradiotherapy is superior in terms of free circumferential resection margin rate, local recurrence rate, and toxicity.

Mesenteric cysts are uncommon intra-abdominal masses that can present with atypical abdominal symptoms. A rare type of mesenteric cyst is the mesenteric cystic lymphangioma (MCL), with fewer than 200 cases reported in the literature. MCLs are benign cystic masses of unknown etiology, but have the tendency to recur and invade neighboring structures. We report the case of a 47 year old male who underwent complete resection of an MCL and remained free of disease during 48 months of follow-up. The importance of early recognition and proper surgical management of this rare entity are discussed. Citation: Leventi A, Christodoulakis M, Taflampas P, Bree ED, Melissas J (2015) Prog Science 2(2):e11 | doi: 10.14721/pscience.2015.e11 Original Published: J Surg Radiol. 2010 Jul 1;1(1) | Republished: 02/18/2015 Copyright: © 2015 Leventi A et al. Published by TranScience. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. Funding: none Competing Interests: The authors have declared that no competing interests exist. E-mail: ksleventi@yahoo.com

Basal cell carcinoma (BCC) is very common and usually encountered when it is small in size. Giant BCC (i.e. greater than 5 cm in diameter) is quite rare and comprises 0.5 percent of all BCC. Extremely rarely, tumors larger than 20 cm have been reported. Herein, a case with an enormous, vegetating BCC of the abdominal wall, 30 x 20 cm in size, is described. This report demonstrates that such a case can still be observed in the civilized world of the 21st century, which remains profoundly astonishing. A literature survey was performed and revealed only 7 cases with such super giant BCC (i.e. larger than 20 cm in diameter). Generally, this tumor attains these enormous proportions due to neglect on the patient's part, and is usually located at sites covered by clothes. Treatment is mainly surgical and generally curative, resulting also in an improved quality of life. Tumor size of more than 10 cm in diameter is associated with increased risk for metastatic disease, severe morbidity and consequently impaired prognosis.