Parallel pathways:A chronicle of evolution in rectal and breast cancer surgery

In this editorial,we have analyzed the historical evolution of rectal and breast cancer surgery,focusing on the progressive reduction of demolitive approaches and the increasing use of more conservative strategies,accompanied by a growing emphasis on perioperative treatments aimed at enhancing surgical outcomes.All of these changes have been made possible due to an increased awareness and understanding of oncological diseases and improved perioperative treatments.

Retroaortic left renal vein associated to variations of liver vasculature and biliary system in a patient submitted to total pancreatectomy

Total pancreatectomy(TP) is a surgical procedure which includes the complete removal of the pancreatic gland, the spleen, the duodenum, the gallbladder, and the distal part of the stomach. TP represents the curative treatment of pancreatic cancer which simultaneously involves the head and the body/tail of the pancreas. Other possible indications for TP comprise multifocal parenchymal diseases, such as intraductal papillary mucinous neoplasms, pancreatic neuroendocrine tumors, multiple endocrine neoplasms, and chronic pancreatitis. Sometimes, TP is carried out in patients scheduled for pancreaticoduodenectomy(where only the head of the pancreas is removed) when a cancer located in the pancreatic head is intraoperatively found to also extend to the pancreatic body [1].

Hepatopancreatoduodenectomy for the treatment of extrahepatic cholangiocarcinoma

To the Editor:Extrahepatic cholangiocarcinoma(ECC)is an uncommon neoplasm associated with a poor prognosis[1-3].Surgical resection represents the only curative approach,since systemic treatments have scarce efficacy in achieving disease control.However,only 10%-40%of patients with ECC are resectable at diagnosis[1].Ma-jor hepatectomy and portal lymphadenectomy are usually required for hilar ECC,while pancreatoduodenectomy is the standard operation for distal ECC[3-5].However,ECC may spread horizon-tally along the biliary tree,causing tumor involvement of the entire extrahepatic biliary system.In these circumstances,hep-atopancreatoduodenectomy(HPD)has been proposed as a pro-cedure with curative intent[2,6,7].

Clinical Outcome of Autologous Hematopoietic Stem Cell Infusion via Hepatic Artery or Portal Vein in Patients with End-stage Liver Diseases

Objective To investigate the efficacy of hematopoietic stem cell(HSC) transplantation via the hepatic artery vs.the portal vein for end-stage liver disease(ESLD).Methods Patients with hepatic decompensation were prospectively recruited from September 2010 to September 2012 to receive HSC transplantation via the hepatic artery or the portal vein.Liver function was examined at 3,6,and 12 months after transplantation.Liver biopsy results were analyzed using the Knodell score.Results Eighty patients(58 males and 22 females) were enrolled in the study.The Child-Pugh score was grade B in 69 cases,and grade C in the remaining 11 cases.HSC transplantation was performed via the portal vein in 36 patients and via the hepatic artery in 44 patients.ALT levels decreased while serum albumin levels increased significantly in both groups at 6 and 12 months after HSC transplantation(P<0.05 compared with pre-transplantation levels).Total bilirubin levels decreased significantly in both groups at 3,6,and 12 months after HSC transplantation(P<0.05 compared with pre-transplantation levels).Additionally,prothrombin time decreased in both groups at 12 months after HSC transplantation(P<0.05 compared with pre-transplantation level).There were no significant differences in ALT,total bilirubin and prothrombin time between the two groups either before or after transplantation.Moreover,Knodell score decreased significantly at 6 and 12 months.Histological examination showed that liver cell edema,degeneration,necrosis,and inflammation were significantly relieved at 3,6,and 12 months after transplantation.The incidence of portal vein thrombosis,upper gastrointestinal bleeding,and hepatic encephalopathy were 1.25%,3.75%,and 2.5% respectively.The one-year survival rate was 100%.Conclusions Autologous HSC transplantation improves liver function and histology in ESLD patients.The administration route of HSC has no significant impact on the efficacy of transplantation.

Percutaneous electrochemotherapy in the treatment of portal vein tumor thrombosis at hepatic hilum in patients with hepatocellular carcinoma in cirrhosis: A feasibility study

AIM To treated with electrochemotherapy(ECT) a prospective case series of patients with liver cirrhosis and Vp3-Vp4- portal vein tumor thrombus(PVTT) from hepatocellular carcinoma(HCC), in order to evaluate the feasibility, safety and efficacy of this new non thermal ablative technique in those patients. METHODS Six patients(5 males and 1 female), aged 61-85 years(mean age, 70 years), four in Child-Pugh A and two in Child-Pugh B class, entered our study series. All patients were studied with three-phase computed tomography(CT), contrast enhanced ultrasound(CEUS) and ultrasound-guided percutaneous biopsy of the thrombus before ECT. All patients underwent ECT treatment(Cliniporator Vitae?, IGEA Sp A, Carpi, Modena, Italy) of Vp3-Vp4 PVTT in a single session. At the end of the procedure a post-treatment biopsy of the thrombus was performed. Scheduled follow-up in all patients entailed: CEUS within 24 h after treatment; triphasic contrastenhanced CT and CEUS at 3 mo after treatment and every six months thereafter.RESULTS Post-treatment CEUS showed complete absence of enhancement of the treated thrombus in all cases. Post-treatment biopsy showed apoptosis and necrosis of tumor cells in all cases. The follow-up ranged from 9 to 20 mo(median, 14 mo). In 2 patients, the followup CT and CEUS demonstrated complete patency of the treated portal vein. Other 3 patients showed a persistent avascular non-tumoral shrinked thrombus at CEUS and CT during follow-up. No local recurrence was observed at follow-up CT and CEUS in 5/6 patients. One patient was lost to follow-up because of death from gastrointestinal hemorrage 5 wk after ECT. CONCLUSION In patients with cirrhosis, ECT seems effective and safe for curative treatment of Vp3-Vp4 PVTT from HCC.

Supraclavicular lymph node metastases from malignant gastrointestinal stromal tumor of the jejunum: A case report with review of the literature

Gastrointestinal stromal tumors(GISTs) represent the most common mesenchymal tumors of the alimentary tract. These tumors may have different clinical and biological behaviors. Malignant forms usually spread via a hematogenous route, and lymph node metastases rarely occur. Herein, we report a patient with a jejunal GIST who developed supraclavicular lymph node metastasis. We conclude that lymphatic diffusion via the mediastinal lymphatic station to the supraclavicular lymph nodes can be a potential metastatic route for GISTs.

Surgical treatment of hepatocellular carcinoma in the era of COVID-19 pandemic:A comprehensive review of current recommendations

The new coronavirus disease 2019 (COVID-19) pandemic has resulted in a globalhealth emergency that has also caused profound changes in the treatment ofcancer. The management of hepatocellular carcinoma (HCC) across the world hasbeen modified according to the scarcity of care resources that have been divertedmostly to face the surge of hospitalized COVID-19 patients. Oncological andhepatobiliary societies have drafted recommendations regarding the adaptation ofguidelines for the management of HCC to the current healthcare situation. Thisreview focuses on specific recommendations for the surgical treatment of HCC (i.e., hepatic resection and liver transplantation), which still represents the bestchance of cure for patients with very early and early HCC. While surgery shouldbe pursued for very selected patients in institutions where standards of care aremaintained, alternative or bridging methods, mostly thermoablation and transarterialtherapies, can be used until surgery can be performed. The prognosis ofpatients with HCC largely depends on both the characteristics of the tumour andthe stage of underlying liver disease. Risk stratification plays a pivotal role indetermining the most appropriate treatment for each case and needs to balancethe chance of cure and the risk of COVID-19 infection during hospitalization.Current recommendations have been critically reviewed to provide a reference forbest practices in the clinical setting, with adaptation based on pandemic trendsand categorization according to COVID-19 prevalence.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduode- nectomies in the setting of chronic pancreatitis

BACKGROUND： The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients under- going pancreaticoduodenectomy （PD） for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. METHODS： Eighty-eight patients （85.4%） with a clinicoradio- logical picture highly suggestive for malignancy received for- mal PD （group 1）. Fifteen patients （14.6%） in whom preopera- tive diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation （PHEX） for intraoperative tissue diagnosis （group 2）： those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy （P]）. RESULTS： No patient received PD for benign disease. All pa- tients in group I had adenocarcinoma on final histology. Eight patients of group 2 （53.3%） received PD after intraoperative diagnosis of cancer, whereas 7 （46.7%） received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 （P=0.509）. CONCLUSION： Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

Liver resection vs radiofrequency ablation in single hepatocellular carcinoma of posterosuperior segments in elderly patients

BACKGROUND Liver resection and radiofrequency ablation are considered curative options for hepatocellular carcinoma.The choice between these techniques is still controversial especially in cases of hepatocellular carcinoma affecting posterosuperior segments in elderly patients.AIM To compare post-operative outcomes between liver resection and radiofrequency ablation in elderly with single hepatocellular carcinoma located in posterosuperior segments.METHODS A retrospective multicentric study was performed enrolling 77 patients age≥70-years-old with single hepatocellular carcinoma(≤30 mm),located in posterosuperior segments(4a,7,8).Patients were divided into liver resection and radiofrequency ablation groups and preoperative,peri-operative and long-term outcomes were retrospectively analyzed and compared using a 1:1 propensity score matching.RESULTS After propensity score matching,twenty-six patients were included in each group.Operative time and overall postoperative complications were higher in the resection group compared to the ablation group(165 min vs 20 min,P<0.01;54%vs 19%P=0.02 respectively).A median hospital stay was significantly longer in the resection group than in the ablation group(7.5 d vs 3 d,P<0.01).Ninety-day mortality was comparable between the two groups.There were no significant differences between resection and ablation group in terms of overall survival and disease free survival at 1,3,and 5 years.CONCLUSION Radiofrequency ablation in posterosuperior segments in elderly is safe and feasible and ensures a short hospital stay,better quality of life and does not modify the overall and disease-free survival.

Emergency surgery in COVID-19 outbreak:Has anything changed?Single center experience

BACKGROUND The current coronavirus disease 19(COVID-19)pandemic is changing the organization of health care and has had a direct impact on the management of surgical patients.At the General Surgery Department of Sant’Anna University Hospital in Ferrara,Italy,surgical activities were progressively reduced during the peak of the COVID-19 outbreak in Italy.During this period,only one operating room was available for elective cancer surgeries and another for emergency surgeries.Moreover,the number of beds for surgical patients had to be reduced to provide beds and personnel for the new COVID-19 wards.AIM To compare 2 different period(from March 9 to April 92019 and from March 9 to April 92020),searching differences in terms of number and type of interventions in emergency surgery of a main University Hospital in Ferrara,a city in Emilia Romagna region,North of Italy.METHODS This retrospective study was carried out at the General Surgery Department of Sant’Anna University Hospital in Ferrara,Italy.We examined the number of emergency surgeries performed and patient outcomes during the peak of the COVID-19 outbreak in Italy and subsequent total lockdown.We then drew a comparison with the number of surgeries performed and their outcomes during the same period in 2019.The study examined all adult patients who underwent emergency surgery from March 9 to April 9,2019(n=46),and those who underwent surgery during the first month of the lockdown,from March 9 to April 9,2020(n=27).Analyses were adjusted for age,gender,American Society of Anesthesiologists classification scores and types of surgery.RESULTS A total of 27 patients underwent emergency surgery at Sant’Anna University Hospital in Ferrara during the first month of the lockdown.This represents a 41.3%reduction in the number of patients who were hospitalized and underwent emergency surgery compared to the same period in 2019.The complication rate during the pandemic period was substantially higher than it was during the analogous period in 2019:15 out of 27 cases from March 9 to April 9,2020(55)vs 17 out of 46 cases from March 9 to April 9,2019(36.9).Of the 27 patients who underwent emergency surgery during the pandemic,10 were screened for COVID-19 using both thorax high resolution computerized tomography and a naso-pharyngeal swab,while 9 only underwent thorax high resolution computerized tomography.Only 1 patient tested positive for SARS-CoV-2 and died following surgery.CONCLUSION There was a significant reduction in emergency surgeries at our center during the COVID-19 pandemic,and it is plausible that there were analogous reductions at other centers across Italy.

Cytoreductive surgery and HIPEC after neoadjuvant chemotherapy for advanced epithelial ovarian cancer

AIM: To reduce postoperative complications and to make possible an optimal cytoreduction, neoadjuvant chemotherapy(NACT) followed by interval debulking surgery has been applied with encouraging results. METHODS: Between December 2009 and February 2012, patients with stage ⅢC-Ⅳ epithelial ovarian cancer(EOC) underwent diagnostic laparoscopy, to assess the feasibility of optimal debulking surgery. The modifi ed Fagotti score was applied to assess the feasibility of resection with zero residual tumor. Patients who were not candidate for upfront debulking surgery were submitted to NACT, then reassessed according to the RECIST 1.1 criteria and submitted to cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC) if they showed clinical response or stable disease. The remaining cycles of adjuvant systemic chemotherapy(ASCT) were administered postoperatively, to complete 6 cycles of systemic chemotherapy.RESULTS: Nine patients were included. Clinical response to NACT was complete in 3 patients and partial in 5 patients; one patient had stable disease. All patients underwent CRS resulting in CC0 disease prior to HIPEC. Average operative time was 510 min. Average intensive care unit stay was 2 d. Average postoperative hospital stay was 25 d. No postoperative mortality was observed. One patient experienced pelvic abscess. One patient refused ASCT. The remaining 8 patients started ASCT. Average time to chemotherapy was 36 d. All patients are alive, with an average follow up of 11 mo. Eight patients are disease-free at follow up.CONCLUSION: HIPEC after CRS for advanced EOC is feasible with acceptable morbidity and mortality. NACT may increase the chance for achieving complete cytoreduction. Phase 3 studies are needed to determine the effects of HIPEC on survival.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymph-adenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer(GC). A number of randomized controlled trials and meta-analysis provide phase Ⅲ evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomyfor cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Robot-assisted laparoscopic vs open gastrectomy for gastric cancer:Systematic review and meta-analysis

AIM To evaluate the potential effectiveness of robot-assisted gastrectomy(RAG) in comparison to open gastrectomy(OG) for gastric cancer patients.METHODS A comprehensive systematic literature search using PubM ed,EMBASE,and the Cochrane Library was carried out to identify studies comparing RAG and OG in gastric cancer.Participants of any age and sex were considered for inclusion in comparative studies of the two techniques independently from type of gastrectomy.A meta-analysis of short-term perioperative outcomes was performed to evaluate whether RAG is equivalent to OG.The primary outcome measures were set for estimated blood loss,operative time,conversion rate,morbidity,and hospital stay.Secondary among postoperative complications,wound infection,bleeding and anastomotic leakage were also analysed.RESULTS A total of 6 articles,5 retrospective and 1 randomized controlled study,involving 6123 patients overall,with 689(11.3%) cases submitted to RAG and 5434(88.7%) to OG,satisfied the eligibility criteria and were included in the meta-analysis.RAG was associated with longer operation time than OG(weighted mean difference 72.20 min;P < 0.001),but with reduction in blood loss and shorter hospital stay(weighted mean difference-166.83 mL and-1.97 d respectively;P < 0.001).No differences were found with respect to overall postoperative complications(P = 0.65),wound infection(P = 0.35),bleeding(P = 0.65),and anastomotic leakage(P = 0.06).The postoperative mortality rates were similar between the two groups.With respect to oncological outcomes,no statistical differences among the number of harvested lymph nodes were found(weighted mean difference-1.12;P = 0.10).CONCLUSION RAG seems to be a technically valid alternative to OG for performing radical gastrectomy in gastric cancer resulting in safe complications.

Bouveret's syndrome complicated by a distal gallstone ileus

AIM: Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret's syndrome. Endoscopic lithotomy is the first-step treatment,however, surgery is indicated in case of failure or complication during this procedure.METHODS: We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone. She underwent an endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus. Physical examination was irrelevant.RESULTS: Endoscopy revealed multiple erosions around the cardia, a large stone in the second part of the duodenum causing complete obstruction, and wide ulceration in the duodenal wall where the stone was impacted. Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory. Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone, 5 cm×4 cm×3 cm, loggingat the proximal jejunum and another one, 2.5 cm×2 cm×2 cm,in the duodenal bulb causing a closed-loop syndrome. She underwent laparotomy and the jejunal stone was removed by enterotomy. Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound. Therefore,cholecystoduodenal fistula was broken down, the stone was retrieved and cholecystectomy with duodenal repair was carried out. She was discharged after an uneventful postoperative course.CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret's syndrome.When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary in every case, conditions may urge the surgeon to perform such operations even though they carry high morbidity and mortality.

Prognostic Factors for Patients after Curative Resection for Proximal Gastric Cancer

The factors influencing the long-term survival of patients with proximal gastric cancer (PGC) after curative resection were investigated. Data from 171 patients who underwent curative resection for PGC were retrospectively analyzed. The patients were grouped according to the clinicopathological factors and operative procedures. The tumor depth (T stage) and lymph node metastasis (pN stage) were graded according to the fifth edition of TNM Staging System published by UICC in 1997. The metastatic lymph node ratio (MLR) was divided into four levels: 0%, 30%. The data of survival rate were analyzed by Kaplan-Meier method (log-rank test) and Cox regression model. The 5-year overall survival rate of 171 patients was 37.32%. The univariate analysis demonstrated that the survival time of the postoperative patients with PGC was related to tumor size (χ2=4.57, P=0.0325), gross type (χ2=21.38, P30% (χ2=13.34, P=0.0003), TNM Ⅲ (χ2=14.05, P=0.0002) or TNM Ⅳ stage (χ2=4.37, P=0.0366); and combining splenectomy was beneficial to the cases of T3 (χ2=5.68, P=0.0171) or MLR >30% (χ2=6.11, P=0.0134). It was concluded that MLR, pN stage, TNM stage, T stage, and gross type had advantages in providing a precise prognostic evaluation for patients undergoing curative resection for PGC, in which MLR was the most valuable index. TG and combining splenectomy were useful to improve the prognosis to patients with PGC of TNM Ⅲ/Ⅲ stage, serosa invasion, or extensive regional lymph node metastasis.

严重感染患者血清白蛋白动力学研究(英文)

目的了解感染状态下血清白蛋白的分解和分布动力学的变化,以进一步明确感染患者低白蛋白血症的发生机制。方法对照组10例,全部为男性健康志愿者;感染组10例,均为严重感染患者,APACHEⅡ评分8～22(平均13)。采用氯胺T法,用125I 标记人体白蛋白。所有受试者一次性从上臂静脉注射20μCi的125I白蛋白,分别在第0、1、2、4、8、12、24h,第2、3、4、5、6、7、9、11、13、15、18、22、25天抽血,测定γ射线量(dpm),拟合浓度时间曲线,计算标记白蛋白的半衰期(t1/2),分布容积(Vd),中央池向周边池的转运速率(K12)。结果感染组的125I标记白蛋白t1/2(d)明显短于对照组(8.2±1.4vs.12.5±1.7,P<0.01);感染组标记白蛋白从中央池向周边池的转运速率(K12)显著高于对照组[(4.4±1.9)×10-2/hvs.(2.4±0.6)×10-2/h,P<0.05];两组分布容积(Vd)则没有显著的差异(P>0.05)。结论在感染条件下,血清白蛋白从血管内到血管外的分布速率明显增加,白蛋白的分解速率也显著增加。

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase Ⅲ evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robotassisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase Ⅲ trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric cancer.

Edmonton Symptom Assessment Scale may reduce medical visits in patients undergoing chemotherapy for breast cancer

BACKGROUND Adjuvant chemotherapy is recommended in high-risk breast cancer. However, no universally accepted guidelines exist on pre-chemotherapy assessment. In particular, the number and frequency of medical visits vary according to each institution’s policy. We hypothesised that the Edmonton Symptom Assessment Scale(ESAS) may have a favourable impact on the pre-treatment assessment in candidates for adjuvant chemotherapy.AIM To investigate whether the ESAS can be used to safely reduce the number of medical visits in women with breast cancer undergoing adjuvant chemotherapy.METHODS In a retrospectively prospective matched-pair analysis, 100 patients who completed the ESAS questionnaire before administration of adjuvant chemotherapy(ESAS Group) were compared with 100 patients who underwent chemotherapy according to the traditional modality, without ESAS(no-ESAS Group). Patients of the ESAS Group received additional visits before treatment if their ESAS score was > 3. The primary endpoint was the total number of medical visits during the entire duration of the chemotherapy period. The secondary endpoints were the occurrence of severe complications(grade 3-4) and the number of unplanned visits during the chemotherapy period.RESULTS The study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group(age P = 0.880;breast cancer stage P = 0.56;cancer histology P = 0.415;tumour size P = 0.258;lymph node status P = 0.883;immunohistochemical classification P = 0.754;type of surgery P = 0.157), except for premenopausal status(P = 0.015). The study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group regarding age, cancer stage, histology, tumour size, lymph node status, immunohistochemical classification, and type of surgery. Unplanned visits during the entire duration of chemotherapy were 8 in the ESAS Group and 18 in the no-ESAS Group visits(P = 0.035). Grade 3-4 toxicity did not differ between the study groups(P = 0.652). Forty-eight patients of the ESAS Group received additional visits due to an ESAS score > 3. The mean number of medical visits was 4.38 ± 0.51 in the ESAS Group and 16.18 ± 1.82 in the no-ESAS group(P < 0.001). With multivariate analysis, women of the ESAS group were more likely to undergo additional visits for an ESAS score > 3 if they were aged 60 or older, received a mastectomy, or had tumour stage Ⅱ/Ⅲ.CONCLUSION The ESAS score may safely reduce the number of medical visits in candidates for adjuvant chemotherapy for early breast cancer. Our results suggest that the ESAS score may be used for selecting a group of breast cancer patients for whom it is safe to reduce the number of medical visits in the setting of adjuvant chemotherapy. This may translate into several advantages, such as a more rational utilization of human resources and a possible reduction of coronavirus pandemic infection risk in oncologic patients.

How the COVID-19 pandemic has affected the colorectal cancer screening in Italy:A minireview

The coronavirus disease 2019(COVID-19)pandemic has caused detrimental effects on many aspects of healthcare practice.Screening programs for the commonest malignancies,namely colorectal cancer(CRC),breast cancer and cervical cancer have been discontinued or interrupted since the beginning of restriction measures aimed to limit transmission of the new coronavirus infection.Robust evidence exists in favour of the role of screening campaigns in reducing mortality from CRC.In fact,the majority of pre-malignant lesions of the colon and rectum can be diagnosed with colonoscopy and treated by endoscopic or surgical resection.Besides,colonoscopy screening allows the diagnosis of CRCs in their pre-clinical stage.Italy was one of the first European countries where a high level of COVID-19 infections and deaths was observed,and one of the first where lockdowns and strict measures were adopted to reduce the risk of COVID-19 diffusion among the population.A systematic review of the literature was performed,including the PubMed,Scopus,Web of Sciences,and Reference Citation Analysis databases,with the aim of critically evaluating the impact of the COVID-19 pandemic on CRC screening in Italy.We found that reduction of CRC screening activity surpassed 50%in most endoscopic units,with almost 600000 fewer CRC screening exams conducted in the first 5 mo of 2020 vs the same period of 2019.While the consequences of the discontinuation of endoscopy screening for the prognosis and mortality of CRC will be evident in the next few years,recent data confirm that CRC is currently treated at a more advanced stage than in the pre-COVID-19 era.Since delays in CRC prevention and early diagnosis may translate to increased CRC-specific mortality,world healthcare systems should adopt strategies to maintain the regularity of CRC screening during subsequent peaks of the COVID-19 pandemic,or future events that might hamper screening programs.

Diet and nutrition against inflammatory bowel disease: Trick or treat(ment)?

Even if the relationships between nutrition and inflammatory bowel disease(IBD)remain underexplored,the current literature is providing,day by day,much more evidence on the effects of various diets in both prevention and treatment of such illnesses.Wrong dietary habits,together with other environmental factors such as pollution,breastfeeding,smoke,and/or antibiotics,are among the theoretical pathogenetic causes of IBD,whose multifactorial aetiology has been already confirmed.While some of these risk factors are potentially reversible,some others cannot be avoided,and efficient treatments become necessary to prevent IBD spread or recurrence.Furthermore,the drugs currently available for treatment of such disease provide low-to-no effect against the symptoms,making the illnesses still strongly disabling.Whether nutrition and specific diets will prove to effectively interrupt the course of IBD has still to be clarified and,in this sense,further research concerning the applications of such dietary interventions is still needed.