Articles

It is the dart that penetrates deep into my soul, every time I see with my own eyes how the incidence of cancer has grown in recent years. I am a pathologist. I am dedicated to diagnosing the disease from the cellular and tissue point of view. The answer to the question that haunts me may seem easy, simple, but I am not satisfied with knowing that advances in technology make it possible to diagnose a greater number of entities, many of them in early stages [1]. Of course, this statement is true. However, in recent years we have verified a greater number of cases with aggressive phenotypes, a fact that makes us ask ourselves certain questions. The first one is: Why? We know that cancer is a multifactorial disease in which genetics and different environmental factors participate. Are we witnessing the concurrence of factors that facilitate the greatest degree of neoplasms? Are habits the cause of this paradigm shift? On the table for debate is the therapeutic success of new strategies, of new drugs, of new algorithms, but the morphology is also changing. This change is exacerbated in the times of pandemic that we have lived through [2]. Pathologists attend a number of cancer diagnoses that have grown exponentially, as has the histological grade, not the staging, of it. And the initial question remains in the air, why? The fear of going to the hospital, the fear of self-exploration, the diversion of media attention to topics that arouse greater interest ... may be having a harmful effect on the health of patients [3]. I do not tell anything new, at least nothing that cannot be assumed by analyzing what happens every day in this new world, a world that will soon have to face, if not already, a cut in resources, research and other parameters that will negatively influence the answers to the eternal question: Why? In the era of personalized medicine, the same one that has reached or is close to reaching great milestones in the survival of once-deadly diseases, the microscope shows a parallel reality and allows, at least, to be pessimistic, or at least realistic: suffering…

Cervical cancer constitutes an issue in public health, becoming the leading cause of death by cancer in women between 20-40 years of age in Latin America. In Argentina 5000 new cases are diagnosed each year, where more than 56% are in advanced stages. The aim of the present current opinion or critical review article is to remark the importance of the prognostic significance of the Central Tumor Size in stages IIB and IIIB cervical cancer, as well as to propose a new FIGO Staging System for Cervical cancer and trying to find out a role for the different therapeutic strategies for those cases.

From my desk I could be watching the wind blow or the horses running. Practicing Medicine in a rural setting has these advantages: from time to time you can take the time to admire the beauty that surrounds you in the form of an obligatory pause within a marathon working day, and rest helps refresh your mind of prejudices to continue with the inescapable task that awaits us after a few minutes, the only ones allowed to order our thoughts.

Introduction: Serology (antibody) tests for the SARS-CoV-2 have been proposed as an instrument to inform health authorities about immunization during the COVID-19 pandemic. As there is a significant part of the population that may have some degree of immunity, it is of great interest to communicate the immunization results obtained in the first 500 healthcare workers (HCW), patients and relatives tested in a community-based Oncological Center. Materials and methods: Between April 9th, 2020 and May 8th, 2020, a group of healthcare workers (HCW), their families, and general public who had had the COVID-19 or had been in close contact with confirmed cases of COVID-19 were screened for IgG SARS-CoV-2 antibodies. The tests were carried out in a rigorous manner, strictly following the guidelines approved by the Spanish Ministry of Health (Ministerio de Sanidad). Results: The major objective of this study was to determine the proportion of asymptomatic infected individuals and those who had already secreted IgG against SARS-CoV-2 in our cancer treatment center or in the community of Barcelona. Patients were tested with PCR, Rapid diagnostic test (RDT) or enzyme-linked immunoabsorbent assay (ELISA). A total of 521 participants were tested, 206 with RDT and 315 with ELISA, 59 (11,32%) resulted positive to SARS-CoV-2. Conclusion: RDT and ELISA proved to be effective and sensible enough to determine the extent of SARS-CoV-2 immunization in a community-based oncological center. The degree of immunization reached is nowadays far away from what can be considered desirable for a herd immunization.

Rhabdomyosarcomas are the most common soft tissue tumors of childhood. They are characterized by their poor prognosis. Vaginal location is very rare after puberty and exceptional in the post menopause. Treatment is based on several therapeutic measures combining neoadjuvant chemotherapy followed by surgery and/or external beam radiation therapy. We report herein the case of a 25 years-old woman, presented with vaginal embryonal RMS revealed by metrorrhagia and pelvic pain. The diagnosis was confirmed by biopsy and histopathological study. Pre-treatment workup was negative for metastatic disease. She has received chemotherapy based on vincristine, doxorubicin, and cyclophosphamide. The clinical evolution was marked by improvement of symptoms, unfortunately the patient died following febrile neutropenia after the third cycle of chemotherapy.

Inferior vena cava (IVC) involvement by intraluminal extension of tumor is infrequent, occuring in 4% to 10% of patients with renal cell carcinoma (RCC) [1-5]. Based on the cephalic extension of the thrombus, Mayo [6] described a classification of inferior vena cava thrombi in 4 categories, which has implications on surgical complexity, estimated blood loss (EBL) and peri-operative complications, but not cancer-specific survival [2,7]. Level III IVC thrombus is classified as being located in the retro-hepatic IVC below the diaphragm. Total resection of this tumor is the best chance of cure when no distant metastases are present [4,8]. Actually, open radical nephrectomy with concomitant thrombectomy is still the standard treatment. This procedure is technically challenging and involves a large incision and prolonged convalescence [9]. Recently, the feasibility of robotic IVC thrombectomy has been demonstrated, with potential lower EBL and shorter hospitalization and convalescence [7,10-14]. This surgery requires thorough knowledge of surgical anatomy, detailed pre-operative preparation and meticulous robotic technique [7]. The key point in the surgical management is the correct assessment of the extension of the endocaval thrombus, what is mainly based on radiological examinations [8]. Although Ultrasonography (US) and computerized tomography (CT) are useful in demonstrating the extent of the thrombus, CT is not always accurate in delineating the superior margin of the tumor in the IVC. More precisely, magnetic resonance imaging (MRI) can demonstrate a tumor thrombus and its extension, besides signs of wall invasion, being extremely useful to surgical procedure planning [8,15]. Vena cavography is not additive to US, CT, and MRI, and it increases the risk of contrast-associated renal injury [4,8]. However, new modern image technologies has emerged to help surgical planning, as three-dimensional visualization technique (3DVT) based on routine CT or MRI processed image data [16-20]. Recently, a comparative study showed advantage of 3DVT in management of complex renal tumor during laparoscopic partial nephrectomy [20]. This modality is able to demonstrate anatomy relations, allowing the surgeon to observe the relationship between targeted tumor and peripheral structure before surgery and perform virtual manipulation. This kind of preoperative accurate assessment can enhance surgeons confidence of surgical procedure and decrease surgical risk and incidence of complications [20]. There is no report in the literature of the use of this type of technology in cases of IVC tumor thrombus. We present the use of 3D holographic interactive reconstruction in a single case of robotic radical nephrectomy with level III IVC thrombectomy.

The surgical treatment of prostate cancer (PCa) had as its initial milestone the first prostatectomy, performed by H.H. Young at the Johns Hopkins Hospital, in 1904 [1], however, the procedure only reached a fundamental role after 1982, based on a better understanding and description of the male pelvic anatomy, by Walsh [2-6] and other [7-11]. Subsequently, minimally invasive approaches emerged: laparoscopic prostatectomy (1992) [12] and robot- assisted laparoscopic prostatectomy (RALP) (2000) [13], which modified and optimized the execution of key surgical steps of this procedure, such as bladder neck preservation, nerve-sparing dissection, and prostate apex management [14].

Methods: Experimental phase: Performed a partial nephrectomy off clamp in pig model followed by cauterization of lidocaine gel 2% with different power (control, 30W, 50W and 100W) in the kidney resection bed to evaluate efficacy and deep injury extension. Clinical phase: 20 patients submitted to laparoscopic or partial nephrectomy for low risk RENAL score were utilized greased lidocaine gel 2% with 50W in cautery scalpel to hemostasis of renal parenchima to validate efficacy and safety. Results: Experimental study shows that this technique is effective and promote better hemostasis with 50W and 100W, with deep injury of less than 3 mm. Clinical study confirm efficacy, good control of hemorrage, few complications and no transfusion. Minimal changes in hematocrit, haemoglobin and creatinine were observed. Conclusion: In this preliminary experience the use of this new alternative to hemostasis for low risk partial nephrectomy was satisfactory and with good intra and postoperative results. The best advantages were safety in terms of the depth thermal injury, low cost and absence of artifacts over the resection area observed at CT scan postoperatively.

Rectourethral fistula (RUF) is a divesting complication after prostate cancer treatment. The RUF incidence after radical prostatectomy is about 0.5% to 2%, [1,2]. Radiotherapy, criotherapy and high intensity focused ultrasound are other more severe causes [3,4]. Repair of RUF is a challenging surgical procedure. There are some possible approaches but transperineal is the most utilized. In cases of complex fistulas interposition of muscle flaps between the rectum and urethra is highly recommended. Gracilis muscle transposition (GMT) is the preferred, due to excellent mobility and vascularization for perineal reconstruction [5,6]. Dissection of the gracilis muscle is done using one, 2 or 3 large incisions in the medial border of the thigh. The aim of this report is present a new minimally invasive access to obtain a pediculate flap of gracilis muscle to interposition between bladder and rectum to treat RUF.

According to the World Health Organization definition, palliative care is an approach aimed at increasing the quality of life of patients and their relatives by addressing physical, psychosocial and spiritual needs and treating conditions early, such as pain while they are coming to terms with a life-threatening disease [1]. Palliative care services have started a rapid progress in developed countries such as Scandinavian countries, England and Canada since the beginning of 1990 [2]. Although palliative care cares for any patient who is in need of care, whether bed-bound or unable to look after themselves, one of the main area of interest is of course oncological patients and their relatives. Patients with advanced cancer, frequent sufferings from physical and psychological symptoms - primarily pain, reduced functional capacity, and reduced quality of life are in the scope of palliative care protocol [3]. The most common end-of-life symptoms and signs in palliative cancer patients are pain, anorexia, nausea, cachexia, weakness, dyspnea, ascites, anxiety, agitation, delirium, confusion and pressure sores. In order to achieve quality and continuous care in case management, a family doctor, specific branch specialist, nurse, dietician, psychologist, cleric, etc. should work together in a multidisciplinary approach and clinical guidelines and care protocols should be implemented [4]. However, it should be kept in mind that increasing the medication dose may not always be beneficial to the oncological patients in palliative services. The goal should always be maximum benefit with minimal tests and treatment. Palliative care does not aim to accelerate or postpone death; but it has many benefits in cancer patients and their relatives including the integration of the psychosocial and spiritual aspects of patient care into physical care, providing support for patients to live as active as possible until the last moment, improving the quality of life and the disease process, providing help and support in the grieving process [1,5]. Providing good care to advanced cancer patients requires that caregivers are educated and supported about their patients’ physical, psychological and social care needs. Balancing the physical and emotional needs of the caregivers will reduce the stress they experience, as well as increase the quality of life of their patients [6,7]. Professionalism in palliative care comes into play right at this point. There is no consensus in the medical world about by whom, when and to whom palliative care should be given. In this regard, the conflicts of opinion between specific branches such as anesthesia, internal medicine and neurology are inevitable. We think that the team leader should be a family physician or a palliative care specialist. The reason for this is the family medicine’s principles of core competencies including biopsycosocial, holistic, comprehensive approach and equal distance to specific branches. Of course when the palliative care specialist is the team leader the patient’s own family doctor still provides invaluable service because of his intimate and long-term knowledge about the patients. One key difference in some countries is that no distinction is being made between palliative and hospice care. Neither the insurance companies nor the state demands such classification because it doesn’t serve any practical purpose at the moment. However, in due time such distinction will be inevitable as one of the cost-cutting measure. Medical oncology will have to report about the expected survival of the cancer patients and it will further increase their workload given the exponential increase in cancer cases.