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A análise conjunta do MELD pós-operatório, do base excess e dos níveis séricos de lactato pode ser usada como um índice prognóstico para pacientes submetidos a transplante de fígado? ABSTRACT PURPOSE:The objective of the present study was to evaluate the postoperative levels of classical or pure MELD and changes in lactate or base excess (BE) levels as possible predictive factors of the type of outcome of patients submitted to orthotopic liver trasplantation (OLT). METHODS:The study was conducted on 60 patients submitted to OLT at the University Hospital, Faculty of Medicine of Ribeirão Preto, USP, between October 2008 and March 2012. The 30 latest survivor (S) and non-survivor (NS) cases were selected.All liver transplants were performed using the piggy-back technique. ALT, AST, BE and blood lactate values were determined for each group at five time points (immediate preoperative period, end of hypothermal ischemia, 5 and 60 minutes after arterial revascularization and in the immediate postoperative period, when the postoperative MELD was also calculated. RESULTS:The aminotransferases reached a maximum increase 24 hours after surgery in both the S and NS groups. There was a significantly higher increase in BE and blood lactate in the NS group, especially after 5 minutes of afterial reperfusion of the graft, p<0.05. There was no significant difference in preoperative MELD between groups (p>0.05), while the postoperative MELD was higher in the NS than in the S group (p<0.05) CONCLUSION: Joint analysis of postoperative MELD, BE and blood lactate can be used as an index of severity of the postoperative course of patients submitted to liver transplantation. . Avaliou-se para cada grupo, os valores ALT, AST, de base excess (BE) e lactato sanguíneos em cinco momentos (pré-operatório imediato, no final da isquemia hipotérmica, 5 e 60 minutos após a revascularização arterial e no pós-operatório imediato, quando também foi calculado o MELD pós-operatório. RESULTADOS:Com relação às aminotransferases, houve um aumento máximo após 24 horas de pós-operatório em ambos os grupos S e NS. Houve aumento significativo dos níveis de BE e lactato sanguíneo significativamente maior no grupo NS, sobretudo nos tempos após 5 minutos de reperfusão arterial do enxerto, p<0,05. Não houve diferença significativa entre o MELD pré-operatório em ambos os grupos (p>0,05). O MELD pós-operatório foi maior no grupo NS do que no grupo S (p<0,05). CONCLUSÃO:A análise conjunta do MELD pós-operatório, do BE e do lactato sanguíneo pode ser usada como índice de gravidade da evolução pós-operatória de pacientes submetidos ao OLT.Descritores: Ácido Láctico, Transplante de Fígado, Índice de gravidade de doença, Prognóstico.

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Introduction: The neoadjuvant chemotherapy (NAC) approach can expressively influence radiation therapy indications after breast surgery by theoretically altering the loco-regional relapse risk in accordance with clinical stage features. Precisely, it could reduce this risk for a subgroup of patients with locally advanced breast cancer who achieved a good pathologic response after NAC. Thus, this might raise clinical questions of whether these more favorable subset of patients do benefit from PORT therapy or whether radiation should be performed only for patients with gross residual tumor after neoadjuvant chemotherapy. In addition, there are many uncertainties about the most appropriate radiation therapy fields in patients who received NAC given that all recommendations are usually based on initial clinical and pathological aspects. Objectives: The aim of the current study was to assess the radiation therapy fields and survival outcomes in breast cancer patients who underwent (NAC) followed by surgery. Methods: We performed a retrospective analysis of all non-metastatic breast cancer patients treated between 2008 and 2014 at our institution, who received NAC and post-operative radiation therapy (PORT). Results: A total of 528 women were included of whom 396 were submitted to mastectomy or adenomastectomy. Most (92.8%) of the patients had locally advanced disease (clinical stage IIB to IIIC). All patients underwent irradiation for breast or chest wall. Most patients received radiation therapy of the supraclavicular and axillary (levels II and III) nodes (87.1 and 86.4% for breast-conserving surgery and 95.1 and 93.8% for mastectomy / adenomastectomy, respectively). Irradiation of level I axillary and internal mammary nodes was uncommon. The most common radiation therapy schedule was the conventional dose of 50Gy to 50.4Gy in 25 to 28 fractions. The mean overall survival was 66.6 months and the mean disease-free survival was 54.6 months. Conclusions: After NAC, most patients received irradiation of the breast/chest wall and axillary and supraclavicular nodes. Indications were based on initial disease presentation associated with relapse risk factors. In this setting, post-operative radiation therapy to breast/chest wall with or without regional nodal irradiation was effective management that is associated with acceptable survival rates.

Background/Aim: Post-operative radiation therapy (PORT) is associated with improvement in loco-regional control and survival rates in early breast cancer. However, the evidence of benefit in patients after treatment with neoadjuvant chemotherapy (NAC) is poor. We aimed to assess the impact of the type of surgery in the PORT plan and the role of the PORT fields in clinical outcomes in breast cancer patients who had undergone NAC followed by surgery. Materials and methods:We performed a retrospective analysis of all non-metastatic breast cancer patients treated between 2008 and 2014 at our institution who had received NAC and PORT.Results: A total of 528 women were included of whom 396 were submitted to mastectomy or nipple-sparing/skin-sparing mastectomy. Most (92.8%) of the patients had locally advanced disease (clinical stage IIB to IIIC). All patients underwent irradiation for breast or chest wall.Most patients received PORT to the supraclavicular and axillary (levels II and III) nodes (87.1% and 86.4% for breast-conserving surgery and 95.1% and 93.8% for mastectomy and nipplesparing/skin-sparing mastectomy, respectively). Irradiation of level I axillary and internal mammary nodes was uncommon. The disease-free survival and overall survival rates at 3 years were 72% and 85%, respectively. There were no statistically significant differences in clinical outcomes according to the use of nodal irradiation.

PURPOSE:To analyze the intraoperative and immediate postoperative biochemical parameters of patients submitted to orthotopic liver transplantation. METHODS:Forty four consecutive orthotopic liver transplants performed from October 2009 to December 2010 were analyzed.The patients (38 male and eight female) were divided into two groups: group A, survivors, and group B, non-survivors. Fifty percent of group A patients were Chid-Pugh C, 40% Chid-Pugh B and 10% Chid-Pugh A. In group B, 52% of the patients were Chid-Pugh C, 41% Chid-Pugh B, and 17% Chid-Pugh A. All orthotopic liver transplants were performed by the piggy-back technique without a portacaval shunt in an anhepatic phase. ALT, AST, LDH and lactate levels were determined preoperatively, at five, 60 minutes after arterial revascularization of the graft and 24 and 48 hours after the end of the surgery.( or: after the surgery was finished). RESULTS:There were no preoperative clinical differences (Child and Meld) between the two groups. The times of warm and hypothermal ischemia were similar for both groups (p>0.05). Serum aminotransferases levels at five and 60 minutes after arterial revascularization of the graft were similar (p>0.05) for both groups, as also were lactate levels at the time points studied. There was no significant difference in Δ lactate between groups at any time point studied (p>0.05). No significant difference was observed between groups during the first 24 and 48 hours after surgery (p>0.05). CONCLUSION:No significant difference in any of the parameters studied was observed between groups. Under the conditions of the present study and considering the parameters evaluated, no direct relationship was detected between the intraoperative situation and the type of evolution of the patients of the two groups studied.

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The surgical bed clipping in breast conserving surgery is not a worldwide systematic practice, leading to a major difficulty in the definition of the boost volume. In practice, when the surgical bed is not marked, to compensate for uncertainties, the boost dose is given to the whole quadrant (tumor pre-surgical clinical location). The purpose of this study was to evaluate the role of surgical clips placement in the definition of boost treatment volume. Materials/Methods: Clinical Target Volumes (CTV) were defined as: CTV Breast, CTV Quadrant (based on physical exam and pre-surgical images), CTV Boost, defined by clip plus margin (1 cm for 2 or more clips and 2 cm for 1 clip only) plus radiological changes, CTV NT (normal tissue), defined by CTV Quadrant minus CTV Boost and CTV MISS (CTV that would be outside the treatment volume), defined by CTV Boost minus CTV Quadrant. Results: A total of 247 patients were included. Upper lateral quadrant was the most common clinical location (47.3%). The median number of clips used was three. The mean volumes were: CTV Breast: 982.52cc, CTV Boost: 36.59cc, CTV Quadrant: 285.07cc, CTV NT: 210.1cc and CTV MISS: 13.57cc. Only 50.6% (125) of the patients presented the CTV Boost completely inside the CTV Quadrant and in 47.3% (117), partially inside. Among patients with any CTV MISS, 80.3% (98) had 10% or more of CTV Boost outside the treatment volume. Regarding CTV MISS, there were no statistically significant differences between the groups with 1 clip versus 2 or more clips, nor between patients with or without reconstructive surgery. In average, the CTV Boost was 87% smaller than the CTV Quadrant. The whole quadrant irradiation would lead to unnecessary irradiation of 26% of normal breast tissue. Conclusion: Surgical bed clipping is up most important in the definition of the boost volume irradiation to ensure precision minimizing geographical miss and optimizing surrounding normal tissue sparing.