The challenges of thoracic surgery on a COVID-19 ward

Vlad Alexe, Mădălina Iliescu, Adriana Zgăvîrdici, Mădălin Ţeţu, Bogdan Tănase, Alin Burlacu, Natalia Motaş, Laura Popovici, Mihnea Davidescu, Mihai Mugescu
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

The SARS-CoV-2 pandemic has brought great challenges in all areas of human society and especially in the healthcare system, where major changes in organization, practices and behavior have been imposed in a short time over a long period, for the protection of uninfected patients and medical staff while treating contagious patients. In this presentation, we will cover the way in which the Thoracic Surgery Department of the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology from Bucharest had to face and overcome these challenges together with the patients.

Keywords: COVID-19, challenges, thoracic surgery, contagious patients

Benefit of intraoperative electrophysiology in cerebral glioblastoma

Dorin Bica, Ionuţ Gobej, Irina Orban, Antonia Lefter, Nicoleta Arhire
NeuroHope, Monza Oncology Hospital, Bucharest, Romania

Electrophysiology is an intraoperative technique that monitors various brain tracts by direct stimulation of brain tissue, both cortical and subcortical, monitoring mainly the motor area and speech area, but also areas such as occipital or parietal, with complex intraoperative tests. This paper presents the decision-making implications on surgery in a series of 20 patients, both the intraoperative and the preoperative implications. The data were collected prospectively and a statistic of the surgical results with intraoperative electrophysiology is presented, and the cases in which the availability of electrophysiology changed the course of the patient’s treatment will be discussed, both through preoperative and intraoperative decisions.

Keywords: lioblastoma, electrophysiology, brain stimulation

Sublobar lung resections by minimally invasive approach – indications and challenges

Alin Burlacu, Bogdan Tănase, Violeta Deaconescu, Mihai Mugescu, Teodor Horvat
Thoracic Surgery Clinical Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Although lobar resection is considered the standard for the surgical treatment of bronchopulmonary cancer, there are more and more discussions about sublobar resection. This paper focuses on anatomical sublobar lung resections – various types of segmental resections (solitary or associated) with minimally invasive approach. We present the allowed indications for this type of resection, as well as the technique used, with examples from our cases. Nonanatomical resections are excluded from the presentation, which, in our clinic, respecting certain criteria, are performed with a minimally invasive approach, using EndoStapler or laser technology. In our presentation, we will run video images from the personal collection with sublobar resections by minimally invasive approach, the paper leaving room for discussion about the type of approach, suturing or vascular sealing devices used, ways to delimit and create the intersegmental plane, discussions that can have a positive outcome for all conference participants. Our communication will also include a case with an extremely useful anatomical feature for performing a sublobar resection. At the end of the presentation, we draw some useful conclusions about the use of this type of approach in the case of sublobar resections.

Keywords: sublobar lung resections, segmentectomy, bronchopulmonary cancer, VATS

Types of surgical approach in pleuro-pulmonary pathologies – advantages and disadvantages

Alin Burlacu, Bogdan Tănase, Violeta Deaconescu, Mihai Mugescu, Teodor Horvat
Thoracic Surgery Clinical Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

The types of minimally invasive approach used in the treatment of bronchopulmonary cancer can be classified, besides the number of ports used, according to the location of the ports, as well as according to the size (thickness) of the instruments used, therefore the size of the chest ports. Thus, depending on the number of VATS ports, it is classified into: multiportal, biportal, uniportal. Regarding the location of the access ports, the pleural cavity can be accessed through the intercostal, subxiphoid or “mixed” approaches. The access ports can also be positioned at the level of the anterior thorax or at the level of the posterior thorax. Types of VATS approaches, such as microlobectomy or needlescopic lobectomy, have emerged using access ports of different thicknesses; these approaches are characterized by the use of instruments up to 5 mm thick. There can be many combinations between the types of approaches listed before that lead to new mixed or hybrid approaches. All types of approaches must follow the principles of minimally invasive surgery – not to use a rib retractor, and the principles of oncological surgery – to obtain oncological radicalism. Any minimally invasive approach is subject to conversion to classical surgery (direct or staged), without this being a surgical failure, but rather a proof of wisdom and surgical maturity. This paper presents the advantages and disadvantages of the main types of surgical approach used in the treatment of pleuro-pulmonary pathologies.

Keywords: VATS, uniportal, multiportal, microlobectomy

Radiation-induced secondary cancers in oncopediatry and the responsibility of the community

Ion Christian Chiricuţă
Amethyst Radiotherapy Center, Otopeni, Ilfov, Romania

In oncopediatry, the radiotherapy treatment should be delivered only with proton radiotherapy. The major advantages result from the very precise treatment, lower side effects and less normal tissue irradiated with unnecessary low doses around the tumor. Using proton radiotherapy, a reduction of the secondary induced cancers was noted. The incidence of the secondary induced cancers if linear accelerator photon therapy is used could be up to 20% in long-term survival patients. The secondary induced cancers are more aggressive as the initial treated primary cancer. Masashi Mizumoto from Japan reported only four treatment induced cancers in 62 long-term survival children irradiated with proton radiation. Two of these secondary cancers were located in the regions with low dose from proton therapy. The other two tumors were located outside of the treated area. It is the responsibility of the community and the government to build a National Proton Cancer Center, along with the responsibility to promote and make possible the education of the young generation in schools and universities.

Keywords: oncopediatry, proton radiotherapy, secondary induced cancer

The spring within you – a tale about guidelines and malignant pleural effusions

Adrian Ciuche1,2, Anca-Pati Cucu1, Camelia Găvan1, Claudiu Eduard Nistor1,2
1. Thoracic Surgery Clinical Department, “Dr. Carol Davila” Central Emergeny University Military Hospital, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Objectives. Malignant pleural effusions (MPE) constitute 20% of all pleural effusions and 37.5% of them are secondary to lung cancer. They are usually an indicator of poor prognosis, the survival period after the occurrence of the effusion being less than six months. This paper presents a comparative view of current guidelines regarding the management of MPE from the point of view of survival rate and quality of life. Materials and method. A systematic search was conducted on the websites of respiratory diseases, thoracic surgery and oncology medical associations, as well as the major databases Web of Science and PubMed. We analyzed differences in imaging (ultrasound – yes or no), interventional (chemical pleurodesis/talc poudrage or talc slurry/chest tube size, indwelling pleural catheters) and surgical management (VATS pleurodesis – mechanical or chemical/pleurectomy), oncology treatment, and treatment options for loculated or bilateral MPE or trapped lung. Conclusions. A considerable heterogeneity was observed in the current guidelines mainly due to lack of evidence-based data and to the prevalence of empirical local practices. When confronted with a MPE, whether recurrent or not, the physician (surgeon, pneumologist or oncologist) is constantly in search for the appropriate care to extend the patients’ survival and improve their quality of life. But local regional disparities from the point of view of epidemiology, logistics and national medical care system seem to render impossible a universal management of MPE. Nevertheless, when we take a look at the guidelines’ “chart”, we can take the best possible decision for our patients.

Keywords: malignant pleural effusions, respiratory diseases, guidelines

Pulmonary metastasectomy – indications, limitations and alternatives

Mihnea Davidescu, Alin Burlacu, Bogdan Tănase, Natalia Motaş, Corina Bluoss, Mădălina Iliescu, Vlad Alexe, Teodor Horvat
Thoracic Surgery Clinical Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Because the whole blood circulation passes through it, the lung is the main target for multiple neoplasias, which take root at this level, generating pulmonary metastases. The treatment should be multidisciplinary, surgery having an important role: from histological diagnosis to curative treatment. Laser technology has earned a well-established role in pulmonary resections, the most common application being pulmonary metastasectomy, with maximum preservation of lung parenchyma. There is a worldwide orientation towards minimally invasive surgery, owning to its advantages: for the health system – lower hospital stay, with reduced costs, and for the patient – lower postoperatory pain, lower morbidity, faster recovery and esthetic advantages. This paper aims to review the various therapeutic possibilities for pulmonary metastases and to present our experience by analyzing the medical records of all patients operated in our clinic for pulmonary metastases during the last year.

Keywords: pulmonary metastasectomy, laser, surgery, thermal ablation

Bioinformatic approach to cancer defeat. Part I: Data resources

Iolanda Dumitrescu
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Objective. We examined the most important publicly available data resources containing genomic and proteomic information. Materials and method. International collaborations exist between the National Center for Biotechnology Information (NCBI) – NLM – NIH, from USA, the National Cancer Institute (NCI), from USA, the European Molecular Biology Laboratory (EMBL), the European Bioinformatics Institute (EBI), and the National Institute of Genetics (NIG) from Japan. The goal should be to understand the features, function, structure or evolution of the analyzed entities. Results. Nucleotide and genomes resources contain vast amounts of data, part of the International Nucleotide Sequence Database Collaboration (INSDC): NCBI, EMBL – EBI, and the DNA Database of Japan. Protein databases and international collaborations, such as the Swiss Institute of Bioinformatics (SIB), the Protein Identification Resource and the EBI, include functional and structural knowledge. As molecular structure resources, there is a collaboration between EBI and the RCSB Protein Database in the USA on the following issues: 3D structure information, secondary structure and fold classification resources, and access to small molecules. Public resources in gene expression are concentrated mainly on two databases: at NCBI and at EBI. Molecular interactions data resources are represented by a database of annotated biological models and a curated database of biological processes in humans. Some resources on protein families use domains identified in sequences using regular expressions or profiles, while others use 3D-structure relationships, inferred by advanced sequence or 3D structural alignments. Conclusions. The “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology from Bucharest has the advantage to have a good know-how on working with publicly available genomic and proteomic data resources.

Keywords: bioinformatics, data resources, genomics, proteomics

Bioinformatic approach to cancer defeat. Part ll: Computational tools

Iolanda Dumitrescu
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Objective. We analyzed publicly available computerized tools requested to access and use safely genomic and proteomic information, mainly in the context of high-throughput analyses. Materials and method. The considered computerized tools are issued by the most important international collaborations between the National Center for Biotechnology Information (NCBI) – NLM – NIH, from USA, the National Cancer Institute (NCI), from USA, the European Molecular Biology Laboratory (EMBL), the European Bioinformatics Institute (EBI), and the National Institute of Genetics (NIG) in Japan. Results. The area we considered is very broad and diverse. Data retrieval tools means computerized techniques getting information present in data resources. Protein functional analysis tools are used to assign biological or biochemical roles to proteins. Sequence similarity search tools mean searching sequence databanks by using alignment to a query sequence. Statistically, homology can be inferred. Pairwise/multiple sequence alignment tools are used to identify regions of similarity that may indicate functional, structural and/or evolutionary relationships between biological sequences – proteins or nucleic acids. RNA analysis tools refers to any of a variety of techniques involved in gathering data about a sequence of RNA. Sequence statistics tools evaluate a wide variety of protein sequence properties using statistics. Conclusions. Accessing and exploiting genomic and proteomic data in repositories help in screening, prevention, early diagnosis, prognosis prediction, precision/personalized care in cancer, in the context of high-throughput analyses. The “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology from Bucharest has the advantage to have a good know-how on working with publicly available computational tools for genomics and proteomics.

Keywords: bioinformatics, computational tools, genomics, proteomics

Paraganglioma – an anesthetic-surgical challenge

Nicolae Gheorghiu, Mădălina Iliescu, Ioan Timaru, Mircea Robu, Monica Olaru, Jeanina Vâlcea, Carmen Zamfir, Ştefania Neicu, Alina Deacu, Dan Popa, Natalia Motaş
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Paraganglioma is a rare type of catecholamine-secreting tumor that arises from neural crest cells of the sympathetic and parasympathetic paraganglia. It usually presents with symptoms of catecholamine excess that include hypertension and sympathetic hyperactivity. Paraganglioma is a diagnostic and surgical challenge. We present a case of paraganglioma in a 38-year-old female, with symptoms (high blood pressure) that began in 2014. A CT scan showed a mass in the left pulmonary-mediastinal area. The surgical resection was performed and a malignant tendency was revealed. In 2021, we reported a recurrence of the tumor, with the same symptoms in the same area. The treatment was represented by the complete resection of the tumor and the metastasis (lower inferior right lobe) with local lymphadenectomy. Conclusions. We report this late recurrence of paraganglioma in a young patient, 10 years later after the first symptoms and 7 years after the first surgical attempt.

Keywords: paraganglioma, anesthesia, surgery, catecholamine-secreting tumor

Two cases of melanoma metastases in the brainstem. Technical aspects and evolution

Ionuţ Gobej, Dorin Bica, Nicoleta Arhire, Irina Orban, Antonia Lefter
NeuroHope Clinic, Bucharest, Romania

Brainstem metastatic lesions are often considered inoperable and usually have a poor prognosis. In this paper, we present the cases of two patients with brainstem metastases, who underwent neurological microsurgery in our clinic. This article revises the clinical presentation at onset, the technical microsurgical aspects, as well as the postsurgical clinical evolution. Conclusions. Microsurgical approach to brainstem metastases may have excellent outcomes, resulting in long-term cancer-free patients.

Keywords: keyhole neurosurgery, melanoma, brain stem, metastasis

New insights into HR-positive, HER-2 negative breast cancer

Dana Grecea
“Prof. Dr. Ioan Chiricuţă” Institute of Oncology, Cluj-Napoca, Romania

Currently available CDK4/6 inhibitors for patients with HR-positive/HER-2 negative breast cancer consist of ribociclib, abemaciclib and palbociclib. The addition of CDK4/6i to aromatase inhibitors (AI) leads to the doubling of the progression-free survival(PFS). Both pre- and postmenopausal women were included in the first-line trials. Using a CDK4/6i in an endocrine sensitive cohort is associated with a PFS benefit (PL-3, ML-2, MO-3). Also, using a CDK4/6i in an endocrine resistant cohort is associated with a progression of PFS (PL-3, MO-2, ML-3). Most trials included postmenopausal patients. ML-7 is the only trial to exclusively enroll premenopausal patients. ML-7 and PL-3 are the only trials to allow prior chemotherapy for ABC. First-line phase III trials CDK4/6i arms showed benefit regarding PFS – ML-2: 25.3 months versus 16 months (HR=0.57; 95% CI), PL-2: 24.8 months versus 14.5 months (HR=56; 95% CI), MO-3: 28.2 months versus 14.8 months (HR=0.54; 95% CI). Also, in second-line phase III trials, PFS was superior for CDK4/6i – ML-3: 14.6 versus 9.1 (HR=0.565; 95% CI), PL-3: 9.5 versus 4.6 (HR=0.46; 95% CI), MO-2:16.9 versus 9.3 (HR=0.553; 95% CI). Final protocol-specified overall survival (OS) results in patients treated with CDK4/6i showed benefit regarding mOS – ML-2: 63.9 months versus 51.4 months (HR=0.76; 95% CI), MO-2: 46.7 months versus 37.3 months (HR=0.76; 95% CI), PL-3: 34.9 months versus 28 months (HR=0.81; 95% CI). CDK4/6i have demonstrated OS benefits in patients with liver/lung or visceral metastases. The three CDK4/6i maintained health-related quality of life (QoL), and ribociclib (ML-7) and palbociclib (Pl-3) improved health-related QoL. Several novel oral SERDs are under investigation in combination with CDK4/6i.

Keywords: breast cancer, immunohistochemistry, clinical trials

Introductory elements in clinical research in medical oncology and palliative care

Alexandru C. Grigorescu
“Dr. Carol Davila” Clinical Hospital of Nephrology, Bucharest, Romania

Introduction. According to the National Medicines Agency, the term clinical trial, synonymous with clinical study, defines any investigation performed on a human subject with the intention of discovering or verifying the clinical, pharmacological and/or pharmacodynamic effects of a product to be investigated and/or ascertain the adverse reactions of such a product and/or to study the absorption, distribution, metabolism and excretion of the product to be investigated in order to ascertain its safety and/or efficacy. Materials and method. We presented in the form of a review the main types of studies used in the clinic. Thus, in a chronological classification, there are: phase 0, phase I, phase II, phase III and phase IV studies. Results. The following research objectives were also relevant: in the early phase studies, the objective is the tolerability of the new medicinal product under study, the maximum tolerated dose (phase I study). The therapeutic results and overall survival represent the “end points” of phase III studies. The results obtained in real practice (real word) are obtained in phase IV studies. In some cases, a study in the form of a survey is useful because it can reveal relatively quickly certain particularities of the use of drugs or their combinations. Data analysis is performed according to epidemiological procedures. We conclude the presentation with the particularities of clinical trials in palliative care (PC). Thus, in PC we must take into account the particular ethical principles in the case of patients in the advanced stage of the disease or in the terminal phase. The ethical principles in PC studies are as follows: research must be beneficial to the patient and to intermediaries – verified and approved by the Ethics Commission; elimination of inefficiency – elimination of confusion between the perception of the patient, his intermediaries and the multidisciplinary team; the autonomy of patients and their relatives, including their right to decide; justice or fairness means equal treatment of all patients regardless of their social or material condition. Conclusions. The conclusions of the presentation are related to evidence-based medicine. Thus, the evidence on which this approach to medicine that we practice today is based is obtained from the clinical studies presented in this review. The interpretation of the results of the studies must take into account the finite human diversity that implies a diversity in terms of response to various therapeutic agents.

Keywords: clinical research, clinical trial, palliative care, ethical principles

The importance of therapeutic colonoscopy

Estera Jeledinţan
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

I present the technique of complex polypectomy in three patients who were diagnosed with large colonic polyps and the management of complications. 1) A 62-year-old patient, with family history of rectal adenocarcinoma, personal history of cardiac disease and one year of rectal bleeding. The initial colonoscopy revealed several polyps, including three large pedunculated polyps located in the sigmoid, which were extracted in consecutive sessions. The first (2 cm, JNET 2A) and third polyps (3 cm, JNET 2B) had long, thin pedicles and were extracted using adrenaline injection and hemostatic clips. The second polyp (cylindrical, 4 cm long, JNET 2B), with a short and thick pedicle, was extracted using adrenaline injection and endo-loop. The histopathological examination showed in situ adenocarcinoma for the second and third polyps (3 mm and 7 mm free resection margins, respectively). 2) A 79-year-old patient with history of cecum adenocarcinoma, atrial fibrillation on anticoagulant therapy, diabetes, high blood pressure and mild thrombocytopenia. The last colonoscopy was performed three years ago and found no significant polyps. The initial colonoscopy found four sessile 8-10 mm polyps which were removed and a fifth 3-cm rectal polyp with wide base implantation, JNET 2B, which was removed in a subsequent session. The LMWH treatment was resumed after 24 hours and the patient developed late bleeding at 72 hours, for which colonoscopic reintervention and hemostasis were achieved using hemostatic clips. Minimal rebleeding after a new attempt of anticoagulation with lower doses, and it was decided to stop the anticoagulation completely for five days. The histopathological examination revealed villous adenoma with high grade dysplasia. 3) A 73-year-old patient with a history of ischemic stroke, antiplatelet drugs, presenting with rectal bleeding and perianal pain. The initial colonoscopy diagnosed two polyps of 12 and 15 mm in ascending and splenic angle, in situ, and a 6-7 cm semicircumferential LST at the rectosigmoid junction, JNET 2B, which was resected in several fragments, after which five hemostatic clips were applied. The patient bled diffusely after 24 hours, and seven more hemostatic clips were added, as well with i.v. hemostatics and a local Gelaspon® over the clips, and the bleeding stopped. The histopathological examination revealed tubulovillous adenoma with high-grade dysplasia.

Keywords: polyp, in situ adenocarcinoma, endoscopic polypectomy, hemorrhagic complications

Survival benefit of adjuvant treatment for complete resected stages II and III of cutaneous melanoma

D.C. Jinga1, Ioana Lazăr1, Andrea Crăciunescu1, Corina Toader1, Maria-Ruxandra Jinga2
1. Department of Medical Oncology, NEOLIFE Bucharest Clinic, Romania
2. School of Medicine, Newcastle University, UK

Cutaneous melanoma is one of the deadliest cancers, with a dramatically increasing incidence in the last 20 years; a slight decrease in mortality has been observed in the past 10 years, especially due to new approaches such as sentinel node biopsy and new systemic treatments. For over 15 years, adjuvant therapy for stages IIB, IIC and III was limited to interferon-alpha-2b (IFN-ᾳ2b), with good disease-free survival rates, but with clinically significant adverse events, and with questionable overall survival improvements. Recently, adjuvant immune therapy with PD-1 inhibitors was approved for stage III treatment independently of mutation of BRAF and adjuvant immune therapy or targeted therapy with BRAF inhibitors in combination with MEK inhibitors for BRAF mutated stage III cutaneous melanoma treatment. Unfortunately, the adjuvant treatment for stages IIB and IIC of cutaneous melanomas remains unresolved; the national guidelines recommend observation and treatment in case of recurrence of the disease. Materials and method. We performed a retrospective clinical study on 84 cases of stages IIB, IIC and III of cutaneous melanomas diagnosed between 2003 and 2019. After the wide excision of the primary tumor and sentinel lymph node biopsy for stages IIB, IIC and wide excision and complete lymph node dissection for clinically node positive stage III melanoma, the patients received adjuvant treatment. Forty percent of the patients received adjuvant IFN-ᾳ2b, 6% of the patients received innovative adjuvant treatment (targeted or immune therapy), 6% of the patients received other therapies and 48% did not receive any adjuvant treatment due to the poor compliance to the treatment in the interferon era or due to the lack of approval of innovative adjuvant treatment for stages IIB and IIC. The main endpoint of the retrospective study was to determine median disease-free survival (DFS) and 1-year, 2-year and 3-year DFS and OS rates. Results. Fifty-four out of 84 patients (57.44%) had a recurrence. The median DFS was 24.8 months for the entire cohort, with 28.84 months for stages IIB and IIC, and with 20.76 months for stage III cutaneous melanoma. The Kaplan-Meier disease-free survival curves by adjuvant treatment demonstrates a slight difference for stages IIB, IIC and stage III at 3 years from diagnosis (9.1%). The 1-year, 2-year and 3-year rates for DFS were 87.41%, 75.49% and respectively 69.53%, and the 1-year, 2-year and 3-year rates for OS were 95.36%, 86.75% and, respectively, 73.75%. Discussion. The results of our study indicate the same pattern of recurrence for stages IIB, IIC and III of cutaneous melanoma, regardless of whether the adjuvant treatment was administered or not. Our results are similar with those from meta-analyses of the adjuvant treatment in the interferon era. We present the improvements of the prognosis of stage III cutaneous melanoma after the approvals of innovative therapy and we present the new data for adjuvant treatment of stages IIB and IIC from international clinical studies. Conclusions. Our study demonstrates the same pattern of recurrence and the same outcomes for stages IIB and IIC, compared with stage III, and recommends amending the national guidelines for adjuvant treatment of stages IIB and IIC of cutaneous melanoma.

Keywords: cutaneous melanoma, adjuvant interferon alpha-2b therapy, BRAF mutation, targeted therapy (BRAF inhibitors and MEK inhibitors), immune therapy (PD-1 inhibitors)

Optimal management of immune-mediated adverse events

Raluca Ioana Mihăilă1,2, Liliana Cristina Popescu2, Adelina Silvana Gheorghe1,2, Elena Dumitrescu1,2, Mihai Bălaşa2, Crina Siminiceanu2, Iolanda Georgiana Augustin2, Daniela Luminiţa Zob1,2, Dana Lucia Stănculeanu1,2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Department of Medical Oncology I, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Immunotherapies include immune checkpoint inhibitors, targeted therapies like anti-VEGF, adoptive cell transfer and therapeutic cancer vaccines, with specific adverse events that need to be considered before initiating the treatment. Therapies based on immune checkpoint inhibitors (ICIs) are transforming the treatment landscape of oncology, but can be associated with immune-related adverse events. The types and severity of adverse events vary with immune checkpoint inhibitors (ICPis). Multiple mechanisms of pathogenesis have been identified: direct effects of the checkpoint inhibitor, emergence of autoantibodies or autoreactive T cells, and destruction by toxic effects of activated T cells. Several host factors such as genotypes, preexisting autoimmune disease, inflammatory responses and others like BMI (Body Mass Index) may have predictive value. It is very important to offer guidance on the recommended management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy. Thus, it is mandatory to increase awareness and outline strategies. The most common immune-mediated adverse reactions are cutaneous, digestive, hepatic, endocrinological and pulmonary, the rarest being renal, ophthalmological, neurological and hematological. The severity is established according to the degree and a standard scale, such as the Common Terminology Criteria for Adverse Events (CTCAE v5.0), which is frequently use. There are guidelines and recommendations for specific organ system-based toxicity diagnosis and management. While the management varies according to the organ system affected, in general immunotherapy should be continued with close monitoring for grade 1 toxicities. ICPi therapy may be temporarily discontinued for most grade 2 toxicities, with consideration of resuming when symptoms revert ≤grade 1. Corticosteroids can be indicated. Grade 3 toxicities generally indicate the discontinuation of ICPis and the initiation of high doses of corticosteroids. The corticosteroids should be tapered over the course of at least 4-6 weeks and organ-specific treatment should be discussed in multidisciplinary teams. Some refractory cases may require other immunosuppressive therapy. The permanent discontinuation of ICPis is recommended in grade 4 toxicities, except for endocrinopathies that have been controlled by hormone replacement. Although immune checkpoint inhibitors have revolutionized the treatments of cancers, we need to identify ways of modulating the autoimmunity without affecting the antitumour response with agents that are specific for the autoimmune mechanisms.

Keywords: immune checkpoint inhibitors, immune-mediated adverse, multidisciplinary teams, oncology, tumor response

Electronic cigarette – interference with lung cancer

Florin Mihălţan, Ancuţa Constantin
“Marius Nasta” Institute of Pneumophthisiology, Bucharest, Romania

The e-cigarette has recently become a fashionable topic of discussion, with important scientific and social values. On the one hand, there is a tobacco industry that sponsors scientific articles that demonstrate the non-toxicity of e-cigarette and, on the other hand, there are articles published by independent researchers identifying the dangers behind e-cigarette use and flavorings. One by one, in this presentation we will emphasize the epidemiological problems of this type of exposure, the toxicology data, the persistent confusion among oncologists, data on lung carcinogenesis, pathogenic pathways, results of experimental studies but also on population samples, and possible cancers associated to the use of electronic cigarette. Finally, we are doing recommendations for both specialists and consumers to prevent the possible effects of e-cigarettes related to the presence of lung cancer or concerning the risk of inducing other types of cancers.

Keywords: lung cancer, smoking, electronic cigarette

Video-assisted thoracic surgery and bronchoscopy in oncology

Natalia Motaş, Mădălin Tetu
“Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

The management in thoracic malignant lesions depends on the early and as complete as possible diagnosis. Furthermore, the treatment is advisable to be performed as minimally invasive as possible and in a multidisciplinary team. The authors present data on resecability in lung cancer, the diagnostic procedures, the treatment options and complex situations – with clinical examples and images from cases treated in every day practice. The solitary pulmonary nodule approach is also presented. As final conclusion of the presentation, the authors underline the importance of team work and of the technical equipment for the multidisciplinary management of the oncological patients.

Keywords: VATS, bronchoscopy, lung cancer, multidisciplinary team, minimally invasive diagnosis, minimally invasive treatment, solitary pulmonary nodule

Integrating medical genetics in breast cancer patients’ management – the Filantropia Clinical Hospital experience

Florina Mihaela Nedelea, Loredana Antuanela Tuinea, Dragoş Mircea Median, George Iancu
1. Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

The development of genetic testing and the evaluation for patients with high risks of hereditary breast cancer allow the diagnosis of BRCA and non-BRCA germline mutations, which is a helpful tool in the individualization of treatment. It is well known that approximately 5% to 10% of breast cancers are inheritable, and BRCA1 and BRCA2 germline mutations account for up to 30% of inheritable breast cancers and are the most commonly assessed mutations in patients presenting with early-onset breast cancer, triple-negative breast cancer, bilateral breast cancer, and with a family history of breast cancer or Ashkenazi Jewish descent. Also, other genes, such as PALB2, CHEK2, ATM, CDH1 (linked with hereditary diffuse gastric cancer), PTEN (linked with Cowden syndrome) and TP53 (linked with LiFraumeni syndrome), have been identified in hereditary breast cancer syndromes, each of them having a particular risk pattern, therefore necessitating an adequate management. In conclusion, identifying an increased risk for breast cancer is a chance to have the options to reduce significantly the risks with preventive surgery and monitoring, by up to 95%. Furthermore, the personalized treatment options available for BRCAm and the potential development of new targeted molecules in the future are an important step in the development of a cure for this type of cancer. The Filantropia Clinical Hospital of Obstetrics and Gynecology, Bucharest, is one of the few medical institutions that integrated a genetic unit – the genetic lab, the genetic patient counseling and advice within the multidisciplinary tumor board in the approach to breast and gynecological cancers.

Keywords: breast cancer, genetic tests, targeted therapies

Minimally invasive surgery in malignant pleuropericarditis – a 10-year retrospective study

Claudiu Eduard Nistor1, Camelia Găvan2, Anca-Pati Cucu1, Adrian Ciuche1,2
1. Thoracic Surgery Clinical Department, “Dr. Carol Davila” Central Emergency University Military Hospital, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Objectives. This paper presents a retrospective analysis for 10 years, from the experience of the Thoracic Surgery Clinic of the “Dr. Carol Davila” Central Emergency University Military Hospital, Bucharest, by using minimally invasive surgery techniques for malignant pleuropericarditis. Materials and method. A total of 338 cases were analyzed in the period 2010-2020, in which minimally invasive surgical techniques were performed under videoscopic control. A pleuropericardial window was practiced both by video-assisted thoracoscopy and by subxifoidian approach under videoscopic control. These techniques allowed multiple biopsies of the pericardium and a pleuropericardial window by hybrid method, using both electric scalpel and endoGIA with endographer (Claudiu Nistor procedure). For chemical pleurisy, we used medical talcum powder or a hybrid method (pleural abrasion associated with a chemical agent – betadine). Results. We present a comparison between the preoperative aspects (chest X-rays and computed tomography), intraoperative videoscopic aspects and the postoperative results for the pleuropericardial effusions included in our study. Conclusions. Minimally invasive thoracic surgery is the best approach to pleuropericardial effusions, having the following advantages: this procedure leads to a correct diagnosis, adequate treatment, and has lower mortality and morbidity rates compared to open surgery.

Keywords: surgical technique, videoscopic control, malignant pleuropericarditis

Development of skills in minimally invasive surgery in oncological pathology by using modern technologies

Claudiu Eduard Nistor, Camelia Găvan, Adrian Ciuche
“Dr. Carol Davila” Central Emergency University Military Hospital, Bucharest, Romania

Importance. Human patient simulators are currently used in a multidisciplinary way. The scenarios of training the team in the operating room cannot simulate surgery, as they lack the realistic surgical aspect. This is a significant barrier when minimally invasive surgery applications in oncological pathology are required. Objective. To develop and test a strategy to train the operating team based on simulation requires the development of skills and competences of working with realistic operational maneuvers. Design, declaration and participants. The type of pre-post-educational intervention is required to gain teamwork skills for surgical specialties practicing minimally invasive surgical inventions. Training at the basal, medium and advanced level is required. These needs can be acquired through exercises on virtual reality simulators. Interventions. Participation in the simulation scenario for a single doctor but also for teamwork. Results and main measures. The competence of single and team work is assessed using several tools with extensive evidence of validity, including the assessment of non-technical skills and the improvement of self-efficacy skills. Results. Course participants include surgical residents, medical specialists and primary physicians who want to perfect their skills for minimally invasive surgery. Conclusions and relevance. The inclusion of a surgical task in the formation of the dermine operation team significantly improves teamwork skills. Specialized studies have shown that simulators have been as effective as other techniques to learn on animals, casts or corpses, for promoting the skills of surgical teamwork.

Keywords: minimally invasive surgery, operating team based on simulation, realistic operational maneuvers

Ultrasound guided management of pleural effusions

Claudiu Eduard Nistor1,2, Anca-Pati Cucu1, Adrian Ciuche1,2
1. Thoracic Surgery Clinical Department, “Dr. Carol Davila” Central Emergency University Military Hospital, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Objectives. Malignant pleural effusions (MPE) are a commonly encountered pathology in the practice of the thoracic surgeon and require interventional or surgical care. Materials and method. This paper discusses more or less fundamental ultrasound concepts that can assist the thoracic surgeon in performing safe MPE interventions. Recent studies indicated the usefulness of thoracic ultrasound in virtually eliminating the significant risk of iatrogenic complications. Thoracentesis and chest tube thoracostomy are usually indicated in patients who cannot tolerate a major surgical procedure under general anesthesia, and therefore the risk of postprocedural complications must be minimized. Conclusions. The current literature established the importance of preprocedural thoracic ultrasound in patients with malignant pleural effusions. The British Thoracic Society mandated pre-procedural ultrasonography examinations for pleural effusions. Every physician performing pleural effusion drainage should have working knowledge of thoracic ultrasound for an efficient and safe management of these patients, and the national guidelines should include mandatory thoracic ultrasound in the interventional management of pleural effusions.

Keywords: preprocedural thoracic ultrasound, thoracentesis, malignant pleural effusion

Osteosarcoma of the iliac bone secondary to radiotherapy in cervical cancer – case presentation and literature review

Claudia-Elena Pavel1, Nadejda Corobcean1, Laura Florentina Rebegea1,2,3
1. Department of Radiotherapy, “Sf. Apostol Andrei” Emergency Clinical Hospital, Galaţi, Romania
2. Medical Clinical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galaţi, Romania
3. Research Center in the Field of Medical and Pharmaceutical Sciences, ReFORM-UDJ, Galaţi, Romania

Objective. Radioinduced osteosarcoma after radiotherapy for cervical cancer is a very rare but aggressive complication, associated with a poor prognosis. The literature on radioinduced osteosarcomas provides us with limited data and the objective of this case presentation is to supplement these data and to make a comparison between the evolution and prognosis of the current case with those in the literature. Materials and method. We present the case of a 52-year-old patient with previous history of radiation treatment for cervical neoplasm who developed osteosarcoma in the right iliac bone 11 years after radiotherapy. Results. Initially, this bone injury was considered a bone metastasis. Subsequently, it has been shown histopathologically that the lesion is compatible with osteosarcoma secondary to radiotherapy, and the evaluation balance revealed lung metastases. The treatment decided in the oncology commission included: chemotherapy, internal hemipelvectomy, pulmonary metastasectomy. The evolution was favorable under multidisciplinary treatment, currently the patient being in complete remission. Conclusions. The peculiarity of this case is represented by the appearance of osteosarcoma at a distance of 11 years post-radiotherapy and by the favorable evolution of the patient, despite the aggressiveness of post-radiotherapy osteosarcomas described by the limited case studies in the literature.

Keywords: osteosarcoma, radiotherapy, cervical cancer, osteosarcoma secondary to radiotherapy

Best practices in mCRC – the best way to predict the future is to create it

Liliana-Cristina Popescu2, Adelina Silvana Gheorghe1,2, Elena Adriana Dumitrescu1,2, Crina Maria Siminiceanu2, Mihai Bălaşa2, Mihai Mungiu4, Alin Burlacu1,4, Bogdan Tănase4, Radu Valeriu Toma1,4, Dana Lucia Stănculeanu1,2, Raluca Ioana Mihăilă1,2
1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2. Department of Medical Oncology I, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
3. Department of Radiotherapy, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
4. Department of Thoracic Surgery, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Objective. Colorectal cancer is the third most common cause of cancer mortality in the world, with more than 1.85 million cases and 850,000 deaths per year. Among patients diagnosed with metastatic colorectal cancer (mCRC), approximately 70-75% of them survive beyond one year, 30-35% survive beyond three years, and less than 20% survive beyond five years from the initial moment of diagnosis. The principles of treatment are well known in protocols, but the multidisciplinary team needs to decide the purpose of the treatment: to treat the metastatic disease with the best possible quality of life or to try to covert metastatic disease into curative setting. Materials and method. In order to take the best therapeutic decision, we need to establish the right sequence of treatment.The driving factors behind the growth of CRC are various, such as family history and genetics (relatives with colorectal cancer, hereditary non-polyposis colorectal cancer [HNPCC] – Lynch syndrome; adenomatous polyposis coli [FAP], inflammatory bowel disease like Crohn’s disease, ulcerative colitis, colon polyps, diabetes mellitus, cholecystectomy), obesity, sedentary lifestyle, inappropriate dietary patterns (a diet low in fiber, fruits, vegetables, calcium, a great amount of red and processed meat), alcohol and tobacco. Also, older age influences the risk of developing colorectal cancer. The rates of both incidence and mortality are substantially higher in males than in females etc. Of new colorectal cancer diagnoses, 20% of patients have metastatic disease at first presentation and another 25% with localized disease will later develop metastases. The optimal treatment strategy for patients with mCRC should be discussed in a multidisciplinary team. In order to identify the optimal treatment strategy for patients with mCRC, the patient should be assessed with blood tests, including liver and renal function tests, tumor markers and imagistic evaluation by CT scan of the abdomen and chest (or, alternatively, MRI). The majority of patients are diagnosed with metastatic disease at first presentation and most cases are not suitable for potentially curative resection. It is, however, important to select patients in whom the metastases are suitable for resection and those with initially unresectable disease that can become suitable for resection after a major response. The aim of the treatment is, therefore, to convert initially unresectable mCRC to resectable disease. Conventional chemotherapy increases progression-free survival (PFS) and overall survival (OS) of mCRC patients versus best supportive care (BSC). However, the efficacy of chemotherapy is limited. Targeted therapy has now been incorporated into routine clinical care for mCRC. The EGFR pathway plays a critical role in CRC tumorigenesis; hence, the blockade of this pathway is an attractive therapeutic strategy, but there is one condition that needs to be accomplished: the tumor must not harbor rat sarcoma mutations (RAS); thus, the assessment of RAS mutation status from tumor samples is now mandatory prior to considering treatment with anti-EGFR inhibitors. For those patients who have left-sided all RAS wild type disease, a cytotoxic doublet plus an EGFR antibody should be the treatment of choice, and for those with right-sided all RAS wild type disease, a cytotoxic triplet plus bevacizumab or a cytotoxic doublet plus an EGFR antibody can be the treatment of choice. Its very important to consider first-line therapy in mCRC as an opportunity to help maximize outcomes. Different patients’ groups with mCRC all RAS wild type can benefit from EGFR antibody (panitumumab) treatment in the first-line therapy: liver-limited disease, non-liver-limited disease, post-progression, patients with good performance status. The anti-EGFR antibodies treatment is well tolerated and the main adverse event, acneiform rash, is common but typically manageable. Grade 2+ toxicity has been found to correlate with improved PFS and OS. With appropriate prophylaxis, the incidence and severity of these events can be reduced, while management strategies tailored to the patient and the degree of toxicity can help to ensure the continuation of anti-cancer therapy. Results. The EGFR antibody (panitumumab) has demonstrated efficacy (the extension of median PFS) and acceptable toxicity when paired with both FOLFIRI or FOLFOX chemotherapy in the first-line setting, in both phase II and III trials. We present the case of a 47-year-old male, non-smoker, with no family history of CRC, with an appendicectomy, diagnosed with metastatic colorectal adenocarcinoma, G2 (low grade), invasive, ulcerative, with stable microsatellite status (MSS), all RAS wild-type, with localized lymph-node metastases in the portal pedicle. The patient started the first-line anti-EGFR therapy (panitumumab 6 mg/kc) and chemotherapy dublet (FOLFOX) and had a partial response to therapy according to imagistic RECIST 1.1 criteria, therefore the disease converted to resectable stage. The histopathologic result after surgery was pT0 pN0 pM0 – complete response. What is the next approach after surgery? There are many options according to multiple guidelines, including to continue the treatment for about 3-6 months or just intense follow-up. Due to complete response after therapy and surgery and mild skin toxicity developed during treatment, we considered optimal to continue panitumumab + FOLFOX for another 3 to 6 months, with follow-up according to guidelines. Conclusions. For mCRC all RAS wild-type patients, choosing the optimal first-line therapy is important. All the above presented has proven that metastatic stage can be converted to resecability with the efficient association between targeted therapy and chemotherapy. Skin toxicity caused by anti-EGFR therapy is a common but a typically manageable side effect. The multidisciplinary team (oncologist, surgeon, radiotherapist, dermatologist) always represents the key to therapeutic success, but also a good communication between doctor and patient can improve the compliance to therapy.

Keywords: genetics, strategy, multidisciplinary team, major response, resectable disease, targeted therapy, EGFR antibody, panitumumab, RAS, wild type, first line, acneiform rash

Clinical and dosimetric challenges in synchronous bilateral breast cancer irradiation

Ciprian Daniel Stancu1, Mihaela Dumitru1, Andreea Cosmina Ciobanu1, Laura Rebegea1,2,3
1. Department of Radiotherapy, “Sf. Apostol Andrei” Emergency Clinical Hospital, Galaţi, Romania
2. Medical Clinical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galaţi, Romania
3. Research Center in the Field of Medical and Pharmaceutical Sciences, ReFORM-UDJ, Galaţi, Romania

Introduction. Multiple studies have shown that the incidence of bilateral breast cancer varies between 1.4% and 11.8%, and the incidence of synchronous bilateral breast cancer is around 3%. The incidence of synchronous breast cancers is rising as a result of increased breast cancer awareness and improved diagnostic imaging methods. The cases of synchronous breast cancer are more aggressive compared to metachronous ones, and the five-year survival is approximately 78% for metachronous ones and 60% for synchronous ones. Methodology. We analyzed the case of a 46-year-old patient diagnosed with synchronous bilateral breast cancer treated with surgery (conservative resection) and chemotherapy, and we present the clinical and dosimetric challenges encountered in the management of this case. Results. The irradiation technique used was 3DCRT. The target volume represented by the right mammary gland and right axillary nodes areas received a total dose of DT=50 Gy/25fr/33 days and the left mammary gland received a total dose of DT=50 Gy/25fr/33 days. The difficulty of the treatment plan was to orient the radiation beams so that there are no areas of overexposure on the mid-sternal line. In the treatment plan, two different isocenters were established for the two target volumes. The evaluation of the treatment plan was performed according to ICRU62 (International Commission on Radiation Units and Measurements) and the dose constraints complied with the QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) conditions. The patient showed good adherence to treatment with optimal clinical and therapeutic tolerance and developed grade 1 radiodermatitis. Conclusions. Synchronous breast cancer irradiation raises issues in terms of establishing therapeutic behavior, developing and evaluating treatment plan, and performing treatment.

Keywords: synchronous bilateral breast cancer, radiotherapy, dosimetry

Complete mediastinal lymph node dissection (CMLND) in bronchopulmonary cancer – the impact of minimally invasive approach

Bogdan Tănase, Alin Burlacu, Violeta Deaconescu, Mihai Mugescu, Teodor Horvat
Thoracic Surgery Clinical Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

The advantages of the minimally invasive approach in the treatment of bronchopulmonary cancer are well known, but the oncological safety of this type of approach is not sufficiently analyzed. We consider it necessary to standardize the type of resection in bronchopulmonary cancer by video-assisted thoracic surgery (CTVA) – sublobar/lobar or extended, as well as the need to standardize lymphadenectomy, thus leading to a precise staging. This presentation shows the conclusions of a study that has the following working hypotheses: the minimally invasive surgery in the treatment of bronchopulmonary cancer ensures a longer survival compared to classic approach operations, and patients with minimally invasive bronchopulmonary surgery have a disease-free interval longer than those operated on through thoracotomy. This study conclusion is compared with the analyses in the literature by providing useful information on the oncological value of the minimally invasive approach to mediastinal lymphadenectomy associated with surgical treatment of bronchopulmonary cancer. In literature, it is suggested that patients operated on by minimally invasive approach adhere better to adjuvant treatment, which is why they have a better survival. Also, the minimally invasive approach allows a better exploration of the lymph nodes (magnifying effect), allowing a complete lymphadenectomy, a complete staging and, finally, a correct adjuvant treatment adapted to a correct staging, which can lead to an increase of survival.

Keywords: bronchopulmonary cancer, CTVA, mediastinal lymphadenectomy

Gastric and duodenal metastases as a progression of breast cancer – case presentations and literature review

Corina Toader1, Dan Corneliu Jinga1, Andreea Crăciunescu1, G. Constantinescu2
1. Department of Medical Oncology, NEOLIFE Bucharest Clinic, Romania
2. Clinic of Gastroenterology, Bucharest University Emergency Hospital, Romania

Breast cancer is the most frequent cancer in women and was the most common cancer overall in 2020. Metastases to the gastrointestinal tract (GIT) from breast carcinoma are rare, detected in less than 5% of all breast cancer patients. Invasive lobular carcinoma (ILC) is the most common histological type of breast cancer to metastasize to the GIT. We report two cases of breast cancer with gastrointestinal metastases. The first case is a 48-year-old woman diagnosed in 2015 with invasive breast cancer, HER-2 amplified, with liver metastasis, treated according to the guidelines, who presented three years later with a liver function test consistent with biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, a wide retrograde sphincterotomy was done, two billiary stents were mounted and a biopsy was taken, confirming breast metastasis. The second case was a 77-year-old woman diagnosed in 2016 with ILC, treated according to the guidelines, who presented four years later with bone progression and minimal gastric symptoms; a biopsy confirmed the breast origin of GIT metastasis. These two cases demonstrate the importance of considering metastatic breast cancer as a potential cause of gastrointestinal symptoms and radiological abnormalities affecting any part of the GIT of women with breast cancer, not only the lobular subtype. Gastrointestinal symptoms are usually not specific to breast origin and mimic primary intestinal disorder, and healthcare professionals beyond oncology should be aware of this possibility.

Keywords: breast cancer, gastrointestinal tract, metastases, case report

Anesthetic consideration for tracheal resection and reconstruction

Jeanina Vâlcea1, Leonard Dobre1, Sorela Rădoi1, Carmen Pantiş1, Alin Burlacu2, Bogdan Tănase2
1. Intensive Care and Anesthesia Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. Thoracic Surgery Clinical Department, “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania

Tracheal resection surgery is a field of great challenges for the anesthetic-surgical team, comprising a variety of surgical approaches and ways of ventilation. In this paper, we try to make an overview of the main clinical situations encountered in this pathology, the main challenges for the anesthesiologist, tactical solutions adaptative to specifical issues and, above all, we emphasize once more the critical importance of the collaboration between the surgical and the anesthetic team. We also present our initial experience underlying the main problems we encountered in our clinic, our solutions and future objectives.

Keywords: tracheal resection, TIVA, BIS, ventilation

Management of cutaneous malignant melanoma in Romania. Where and what are we doing wrong?

Silviu Cristian Voinea1,2, Angela Şandru1, Răzvan Ioan Andrei1
1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “Carol Davila” University of Medicine of Pharmacy, Bucharest, Romania

Surgery is the first line of treatment for cutaneous malignant melanoma (CMM) and can be performed at any stage, with better results than of any other therapeutic methods. However, the outcome is not great, perhaps primarily due to the fact that it is a disease at the border of competence of several specialties: dermatology, plastic surgery, general surgery, surgical oncology and oncology. Although things should be well established, mistakes occur from the moment of the biopsy, because a wide range of procedures are performed for diagnostic purposes: incisional biopsy (less often), excisional biopsy (most often), but also wide and very wide excision (even with skin patch), most of the time unnecessary and excessive. After the diagnosis is established, confusion appears upon the therapeutic indication and the surgical procedure. The indication should be decided by a surgical oncologist, but this happens quite rarely and, as a result, various surgeries are performed, ranging from wide excision of the scar with or without sentinel lymph node biopsy and elective lymphadenectomy. If sentinel lymph node biopsy is performed, it is not clear when exactly the procedure should be after the excision of the primary tumor or, if its positive, what should be done in this case. Completion lymphadenectomy is generally an unclear concept, the same as lymphadenectomy performed for therapeutic purpose when no sentinel lymph node biopsy is performed due to regional lymph node invasion. Follow-up after treatment is another unknown, including the methods and intervals of follow-up. Due to an obvious lack of consistency, the results cannot be good either. European and American guidelines are clear in terms of diagnosis and therapeutic indications, depending on the stage of the disease. Despite this, there is no consensus, each specialty trying to acquire as many duties in the surgical treatment of CMM, without having the necessary training and experience. It should be pointed out that only the surgical oncologist has the training and skills to correctly determine the surgical treatment indication for cutaneous malignant melanoma. The “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, is the center with the highest experience in Romania regarding the treatment of CMM, with the highest addressability for this neoplastic disease, and we are available for all those who want to learn the correct treatment of CMM.

Keywords: cutaneous malignant melanoma, oncologic surgery, mistakes

Actual status of sentinel lymph node identification and biopsy in gynecological cancers

Silviu Cristian Voinea1,2, Cristian Ioan Bordea1,2, Angela Şandru1, Lăcrămioara Borangic1, Cristina Capşa1, Alexandru Blidaru1,2
1. “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology, Bucharest, Romania
2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Sentinel lymph node (SLN) mapping has been introduced into the surgical staging of gynecologic cancers with the goal to reduce morbidity associated with comprehensive lymphadenectomy, with the same prognostic information from lymph node status. SLN mapping techniques have been developed first for the management of vulvar cancer and after that for cervical and endometrial cancers. The mapping tracers used are: radioactive tracer, blue dyes or indocyanine green. SLN biopsy is today part of care in early-stage vulvar cancer treatment. For cervical cancer, SLN biopsy can be usually used in all patients with early-stage disease. The result of SLN biopsy is reducing lower leg lymphedema. For endometrial cancer, SLN mapping is more controversial because there are no prospective trials about examination of oncologic outcomes in patients staged with this procedure. SLN mapping in ovarian cancer is currently in the experimental phase; for vaginal cancer, SLN mapping is not a usual procedure. In conclusion, the use of SLN mapping for gynecologic cancers is increasing and, with the implementation of this procedure, the incidence of the most disabling complication after lymphadenectomy, lower leg lymphedema, has decreased significantly and the result is the improvement in the functional capacity of patients. The integration of SLN mapping into the routine care for gynecologic cancers raises new questions and new debates, subjects for future studies.

Keywords: SLN mapping, gynecologic cancer, actualities