Volume 31,Issue 11,2022 Table of Contents

1 Interpretation of the surgery section of the American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism (2022)

SHE Jiantao , XIA Fada , DAI Bin , LI Xinying

2022, 31(11):1405-1413. DOI: 10.7659/j.issn.1005-6947.2022.11.001

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With the continuous increase of dialysis patients and the prolongation of dialysis time, the prevalence of chronic kidney disease (CKD) related secondary hyperparathyroidism (SHPT) is rising, and so is the number of patients requiring surgical intervention. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism was developed in 2022. Based on evidence-based medicine, the guidelines standardized the surgical indications for SHPT and tertiary hyperparathyroidism (THPT), with a systematic comparison of the strengths and weaknesses of different surgical approaches, and fully introduced the reoperation for patients with postoperative recurrence. However, due to the lack of RCT data, the evidence levels of some recommendations of the guidelines are relatively low. Here, the authors emphatically interpret the relevant surgery parts of the guidelines for SHPT due to renal failure, aiming to assist surgeons in further deepening their knowledge in the management of SHPT and promoting the standardization of its diagnosis and treatment.

2 Establishment and validation of postoperative risk scoring model for severe hypocalcemia in patients with secondary hyperparathyroidism after surgery

GUO Yingying , ZHOU Peng , LI Xiaolei , ZHUANG Dayong , YUAN Jing , YUE Tao , HE Qingqing

2022, 31(11):1414-1421. DOI: 10.7659/j.issn.1005-6947.2022.11.002

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Background and Aims Parathyroidectomy (PTX) is an effective method for the treatment of refractory or progressive secondary hyperparathyroidism (SHPT). Severe hypocalcemia (SH) is a common and serious postoperative complication. Preoperative prediction of SH has crucial clinical value for postoperative management and targeted intervention of SHPT patients, but the risk prediction scoring model has not been established. Therefore, this study was designed to investigate SH risk factors in patients with SHPT after PTX and construct a preoperative risk prediction score model for clinical application.Methods The clinical data of 513 patients with SHPT who underwent total PTX plus autotransplantation in the 960th Hospital of PLA from November 2010 to March 2022 were retrospectively analyzed. According to admission time, they were allocated to model group (404 cases) and validation group (109 cases). The patients were classified into SH and non-SH groups according to the lowest serum calcium level within 3 d after surgery. Univariate and multivariate analyses were conducted to determine the independent risk factors for postoperative SH. Logistic regression was used to establish a predictive scoring model. The receiver operating characteristic curve (ROC) was applied to verify the model internally and externally in the model and validation groups, respectively.Results In the whole group of 513 patients, SH occurred in 237 cases (46.20%). In the model group, univariate analysis showed that pruritus, height shortening, age, preoperative hemoglobin, alkaline phosphatase (ALP), albumin, serum calcium, intact parathyroid hormone (iPTH), osteocalcin, β-Crosslaps (β-CTX) were significantly associated with postoperative SH (all P<0.05). Multivariate analysis showed that preoperative ALP>363.5 U/L, iPTH>2 239 pg/mL, β-CTX>3.305 μg/L, and height shortening were independent risk factors for postoperative SH and preoperative serum calcium>2.50 mmol/L were protective factor against postoperative SH (all P<0.05). The ALP>363.5 U/L, iPTH>2 239 pg/mL, and β-CTX>3.305 μg/L were used to establish the SH risk prediction scoring model, with the positive corresponding points of 7, 4, and 6, respectively, and the negative value of 0. The results showed that the incidence of SH was 58.82% at 10-13 points and 82.93% at 17 points. The area under ROC curves for the model group and the validation group was 0.811 (95% CI=0.768-0.853) and 0.826 (95% CI=0.745-0.906), respectively, both of which were statistically significant (both P<0.05).Conclusion The risk prediction scoring model effectively predicts the incidence of SH after PTX in SHPT patients, which can be used to identify high-risk patients before operation and provide an essential reference for clinical guidance of postoperative management and treatment of SHPT patients.

3 Complications of transoral endoscopic thyroidectomy vestibular approach and the management: analysis of a single-center series of 1 941 cases and multi-center data of 152 cases reported by literature

LI Wu , WU Peng , LI Zan , ZHOU Bo , LU Chunliu , LI Hui , ZHOU Shiwei , WANG Qingxia , ZHAO Liya , SONG Xiaohua , WANG Zhiyuan , LI Jigang , XIA Xibin , PENG Xiaowei

2022, 31(11):1422-1429. DOI: 10.7659/j.issn.1005-6947.2022.11.003

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Background and Aims Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can not only thoroughly remove the lesion but also be utterly traceless after operation. However, there are some difficulties in carrying out this technique, and surgical complications are inevitable. This study was conducted to summarize the experience in prevention and treatment of the complications of this procedure by analyzing the clinical data from the authors' center combined with the data from other centers.Methods The clinical data of 2 710 patients with thyroid tumors undergoing surgical treatment in the authors' center from March 2016 to October 2022 were analyzed retrospectively. Of the patients, 1 941 cases underwent TOETVA, 49 cases underwent transoral and submental endoscopic thyroidectomy (TOaST), 110 cases underwent transoral robotic thyroidectomy (TORT), and 610 cases underwent thyroidectomy via conventional transcervical approach (TCA). The incidence rates of surgical complications of each procedure and their treatment, as well as the clinical data concerning surgical complications of TOETVA from a study across 5 independent medical institutions, were analyzed.Results The data of the authors' center showed that skin injury occurred in 16 cases (0.82%), trachea injury occurred in 2 cases (0.1%), temporary recurrent laryngeal nerve injury occurred in 38 cases (1.96%), postoperative infection occurred in 5 cases (0.26%), and permanent hypoparathyroidism occurred in 1 case (0.05%) in TOETVA group; In the traditional cervical skin thyroidectomy group, there was 1 case (2.29%) of trachea injury, 14 cases (2.29%) of temporary recurrent laryngeal nerve injury, and 3 cases (0.49%) of postoperative infection; there were no significant differences in the main surgical complications in TOETVA group compared with other procedure groups (all P>0.05); all complications were resolved after appropriate treatments or spontaneously. The statistics of surgical complications in 152 TOETVA cases from the other 5 independent medical institutions showed that there were 9 cases (5.9%) of skin injury, 3 cases (1.3%) of trachea injury, 5 cases (4.7%) of temporary recurrent laryngeal nerve injury, and 1 case (0.7%) of postoperative infection.Conclusion In addition to its advantages, TOETVA will not increase the incidence of complications. The lower incidence rate of complications after TOETVA in the authors' center than that in literature reports suggests that the increase in operation cases and accumulation of surgical experience are the keys to reducing the surgical complications of TOETVA and improving the surgical quality.

4 Clinical study of gasless transoral endoscopic surgery for thyroid cancer

FANG Jing , ZHENG Xucai , ZHOU Jing , CHEN Gongpu , LIU Song , TANG Weifang , LIU Jianjun , WANG Shengying

2022, 31(11):1430-1436. DOI: 10.7659/j.issn.1005-6947.2022.11.004

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Background and Aims Since transoral endoscopic thyroidectomy is performed via a natural cavity, there is no scar on the body surface, and no blind spots of the visual field in the central neck area. So, it well-accepted by doctors and patients. However, the traditional transoral endoscopic thyroidectomy using CO₂ inflation to maintain the surgical space has a narrow working cavity with easy smoke generation, which affects the vision. In addition, compared with other approaches, transoral endoscopic thyroidectomy is more prone to CO₂-related complications. Therefore, the use of gasless method for endoscopic surgery may be a better choice. For this reason, our center has designed a new method to perform gasless transoral endoscopic thyroidectomy by percutaneous suspension and three-hole endoscopic surgery technique. After continuous improvement, this technique has matured considerably. This paper discusses the feasibility and safety of this technique through a retrospective analysis, so as to provide a reference for clinical decision-making.Methods The clinical data of patients who underwent non-inflatable transoral endoscopic surgery for thyroid cancer in the Department of Head and Neck Oncology, the First Affiliated Hospital of University of Science and Technology of China (Anhui Cancer Hospital) from October 2020 to March 2022 were retrospectively analyzed. The operation was performed with a self-made suspension retractor and modified trocar.Results A total of 106 patients with papillary thyroid carcinoma were included. Of the patients, 11 cases were males and 95 cases were females with a mean age of (35.5±8.1) years; 91 cases underwent unilateral thyroidectomy, and 15 cases underwent total thyroidectomy; 106 cases received central lymph node dissection, and 7 cases received selective neck lymph node dissection. The operative time for endoscopic thyroidectomy alone was (163.9±49.1) min, and for endoscopic thyroidectomy combined with lateral neck lymph node dissection was (331.0±103.9) min. The number of resected lymph nodes in the central area was 8.6±6.1 and in the unilateral neck was 19.4±7.6 after operation. The length of postoperative hospital stay was (5.4±1.4) d. Transient hoarseness and lymphatic leakage occurred in one case each after the operation, and no postoperative complications such as bleeding, infection, and permanent mental nerve injury occurred.Conclusion Gasless transoral endoscopic thyroidectomy has no CO2-related complications. The use of self-made suspension hooks can maintain enough operation space. The application of an improved trocar reduces the interference of instruments, and the added endoscopic aspirator is convenient for surgical operation.

5 Application of endoscopic thyroidectomy plus lateral neck dissection via breast approach combined with transoral approach

WANG Yuanyuan , WU Guoyang , LUO Yezhe , LIN Fusheng , GAO Danyang

2022, 31(11):1437-1444. DOI: 10.7659/j.issn.1005-6947.2022.11.005

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Background and Aims Endoscopic thyroid cancer surgery via breast approach has been widely carried out. However, whether a thorough lymph node dissection, especially the dissection of the lower neck level Ⅵ and Ⅳ lymph nodes, can be completed under the endoscope in patients with lateral neck lymph node metastasis remains controversial. This study was conducted to summarize and analyze the clinical data of patients undergoing endoscopic thyroidectomy plus lateral cervical lymph node dissection via breast approach combined with transoral approach performed by the author's team to investigate the necessity and safety of adopting this procedure.Methods The data of 63 patients with papillary thyroid cancer undergoing endoscopic thyroidectomy plus central and lateral neck dissection in Zhongshan Hospital of Xiamen University from February 2015 to December 2021 were reviewed. Of the patients, 41 cases underwent endoscopic central and lateral neck dissection via breast approach combined with transoral approach (combined approach group), including 12 cases undergoing complementary level VI and IV lymph node dissection via transoral approach after thyroidectomy plus central and lateral neck dissection via breast approach, and the other 29 cases undergoing appropriate integration of surgical procedures via both breast and transoral approaches, without additional complementary level Ⅵ and Ⅳ lymph node dissection; 22 cases underwent endoscopic thyroidectomy and lateral neck dissection via breast approach alone (breast approach group). The main clinical variables were compared between the two groups of patients.Results There were no differences in age, sex, and tumor size between the two groups of patients (all P>0.05). Lymph nodes were detected in the specimens of 8 cases among the 12 patients undergoing complementary lymph node dissection in the combined approach group. Positive lymph nodes were found in 2 of them. In combined approach group and breast approach group, the total numbers of central compartment lymph nodes obtained were 8.80±5.78 and 8.23±3.53, and the total numbers of lateral cervical lymph nodes retrieved were 31.49±14.90 and 29.05±7.80, respectively. Both differences had no statistical significance (both P>0.05). There were no significant differences between the two groups in the operative time, the length of postoperative hospital stay, and the incidence rates of complications such as postoperative bleeding, recurrent laryngeal nerve paralysis, hypoparathyroidism, accessory nerve injury, chyle leak and Horner's syndrome (all P>0.05). During postoperative follow-up, recurrence of postoperative lateral lymph node metastasis occurred in one patient in combined approach group, and recurrence of lymph node metastasis of the dissected side was found in one patient in breast approach group.Conclusion Endoscopic thyroidectomy plus lateral cervical lymph node dissection via breast approach combined with transoral approach is safe and effective. It has a similar efficacy as that via breast approach alone. Still, the positive lymph nodes detected by complementary lymph node dissection suggest that endoscopic lateral cervical lymph node dissection via breast approach combined with transoral approach may have particular application value for those with more lymph node metastasis. However, the number of cases is small, and the follow-up time is relatively short in this study, so this method's safety, effectiveness, and necessity should be further evaluated by multi-center, large-sample controlled studies and long-term follow-up results.

6 Application carbon nanoparticle tracer for lymph node dissection in robotic thyroidectomy

LIU Xu , YU Fang , WANG Gang , HOU Lei , FAN Ziyi , HE Qingqing

2022, 31(11):1445-1452. DOI: 10.7659/j.issn.1005-6947.2022.11.006

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Background and Aims As a new lymph tracer, nanocarbons have been widely used in traditional thyroidectomy. Minimally invasive surgery is nowadays the theme of surgery. Robotic technology has spurred the development of minimally invasive surgery, and its safety and effectiveness have been widely recognized. This study was conducted to investigate the effect of using a carbon nanoparticle tracer for lymph node dissection in robotic thyroidectomy to provide a reference for clinical use.Methods The data of 294 patients with papillary thyroid carcinoma who underwent radical resection by Da Vinci robotic surgical system were retrospectively analyzed. Of the patients, carbon nanoparticle tracer was used in 160 cases (observation group) and not in 134 cases (control group) during surgery. The total number of central and lateral cervical lymph node dissections, number of positive lymph nodes, operative time for lymph node dissection, and incidence of complications of lateral cervical lymph node dissection were compared between the two groups.Results There were no significant differences in age, gender, tumor size, TNM stage, and the presence or absence of capsular invasion between the two groups (all P>0.05). In observation group versus control group, the average number of central lymph nodes dissected (13.46 vs. 8.66) and the average number of positive lymph nodes detected (3.38 vs. 2.31) were significantly higher (both P<0.05); the average number of lateral cervical lymph nodes dissected was significantly higher (15.21 vs. 1.44, P<0.05), but its average number of positive lymph nodes detected showed no significant difference (P>0.05). The operative time for unilateral central lymph node dissection (77.08 min vs. 88.83 min), bilateral central lymph node dissection (128.29 min vs.160.11 min), and for central plus lateral cervical lymph node dissection (199.93 min vs. 221.64 min) were significantly reduced in observation group compared with control group (all P<0.05). There were no significant differences in incidence rates of all specific postoperative complications following lateral cervical lymph node dissection between the two groups (all P>0.05).Conclusion The application of nanocarbon in robotic thyroid cancer surgery can significantly increase the number of lymph nodes detected, improve the detection rate of positive central lymph nodes, and shorten the operative time for neck dissection.

7 Experience in surgical treatment of locally advanced thyroid carcinoma and accompanying tracheal invasion

ZHANG Junbin , ZHANG Yulian , TANG Xi , GONG Jinglin , ZHANG Chengyao

2022, 31(11):1453-1461. DOI: 10.7659/j.issn.1005-6947.2022.11.007

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Background and Aims Surgery is the preferred treatment for locally advanced thyroid cancer that invades the trachea. According to the location and degree of trachea invasion, the treatment methods are varied. Appropriate treatment choice is crucial for patients' prognosis and quality of life. Usually, tracheal invasion of thyroid cancer is accompanied by lymph node metastasis, adhesion of vessels, and even invasion of esophagus and larynx. Due to its complex and variable anatomical structure, there are still no high-level evidence-based medical recommendations to guide the treatment. This study was designated to investigate the clinical features and surgical management of locally advanced thyroid carcinoma with tracheal invasion.Methods The data of 20 patients with locally advanced thyroid cancer and accompanying tracheal invasion from July 2019 to July 2021 were reviewed. Of the patients, 16 cases were males, and 4 cases were females, aged from 13 to 78 years with a median age of 53.5 years; there were 2 cases of thyroid follicular carcinoma, 2 cases of medullary carcinoma and 16 cases of thyroid papillary carcinoma; three cases underwent shave resection for superficial tracheal invasion, 5 cases underwent window resection for tracheal mucosal and luminal invasion, 10 cases underwent tracheal sleeve resection and end-to-end anastomosis, one case underwent total laryngectomy and trachea permanent tracheostomy, one case underwent total laryngectomy and permanent tracheostomy with pectoralis major myocutaneous flap repair. All patients received systemic treatment, including radioiodine therapy or molecular targeted therapy.Results The follow-up time of the patients ranged from 4 months to 2 years. No tumor recurrence or tracheal fistula was found in the 3 patients undergoing tracheal shave excision; all 5 patients receiving tracheal window resection had phase I tracheal repair with tracheal wound suture; no airway stenosis or bilateral vocal cord paralysis occurred in the 10 patients undergoing sleeve resection and end-to-end anastomosis, of whom, one case developed a local infection and local trachea fistula after the operation, which healed after dressing change; two cases undergoing total laryngectomy and permanent tracheostomy lived with an indwelling catheter. There was no tumor progression in all patients included as of the submission of this paper.Conclusion Resection and reconstruction of cervical trachea is a complex problem that surgeons may usually face and should deal with. The authors' treatment principle is that surgical treatment is generally the first choice whenever possible on the premise of complete lesion removal and the treatment tolerance of patients. For patients with locally advanced thyroid cancer invading the trachea and its adjacent organs, treatment plans should be developed collaboratively under the guidance of MDT discussion, and sufficient preoperative preparations, as well as measures for complications, should be made. The appropriate range of tracheal resection and reconstruction methods should be selected according to the different degrees of invasion. The first choice is a phase I repair and reconstruction, followed by phase Ⅱ or multiple stages. However, whether surgical or comprehensive treatment is selected, the purpose of treatment is to prolong the survival period and improve the quality of life of thyroid cancer patients.

8 Expressions of BRAF^V600E mutant protein, β-catenin and cyclin D1 in cN0 papillary thyroid microcarcinoma and the significance

SONG Chuangye , MENG Yanlin , LIU Bing , LIU Panyun , LI Wei , YAN Li , LI Xiaowu , MIAO Jianjun , SHANG Peizhong

2022, 31(11):1462-1470. DOI: 10.7659/j.issn.1005-6947.2022.11.008

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Background and Aims Although the progression of papillary thyroid microcarcinoma (PTMC) is relatively slow, cervical lymph node metastasis is still present. The previous study suggested that the BRAF^V600E mutation and the abnormal expressions of relevant proteins of the Wnt/β-catenin signaling pathway may be associated with the occurrence and development and cervical lymph node metastasis of PTMC. Therefore, this study was conducted to investigate further the BRAF^V600E mutation and the expressions of β-catenin and cyclin D1 in the clinically node-negative (cN0) PTMC tissue and the significance.Methods The surgical specimens and clinicopathologic data of 120 patients with confirmed cN0 PTMC from March 2018 to September 2021 were collected. The BRAFV600E mutation and expression levels of β-catenin and cyclin D1 in the tissue samples were determined by immunohistochemical staining, and their relations with the clinicopathologic characteristics of patients were analyzed.Results The favorable expression rates of BRAFV600E mutant protein, β-catenin, and cyclin D1 in PTMC tissue were significantly higher than those in tumor-adjacent tissue (70% vs. 31.7%, 35.8% vs. 20.8%, 57.5% vs. 34.2%, all P<0.05). Positive expression of cyclin D1 protein was significantly related to tumor diameter, positive expression of BRAFV600E mutant protein was significantly associated with the number of lesions, and positive expressions of BRAFV600E mutant protein, β-catenin, and cyclin D1 were all mainly related to central lymph node metastasis (all P<0.05).Conclusion BRAFV600E mutation, β-catenin, and cyclin D1 expressions are significantly enhanced in cN0 PTMC tissue. Their expressions may be the essential reason for the progression and central lymph node metastasis of PTMC.

9 Relationship between cuproptosis related gene PDHA1 and prognosis of breast cancer and its nomogram construction

YANG Qiuyi , YI Jianing , GUO Miaolan , FAN Peizhi , YU Jie , ZENG Jie

2022, 31(11):1471-1482. DOI: 10.7659/j.issn.1005-6947.2022.11.009

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Background and Aims The α subunit of pyruvate dehydrogenase E1 component (PDHA1) is the key regulatory site of pyruvate dehydrogenase complex, playing an important role in connecting glycolysis and tricarboxylic acid cycle, and it is of great significance for the metabolic transformation of cancers. The latest research has found a new cell death mechanism, namely cuproptosis. PDHA1 is a gene related to cuproptosis and participates in the regulation of its process. The purpose of this study was to explore the relationship between PDHA1 and the prognosis of breast cancer by using bioinformatics methods and establish a nomogram model related to the prognosis.Methods The clinicopathologic relationship, expression, protein-protein interaction network, gene-gene interaction network, prognostic value, gene set enrichment of PDHA1 in breast cancer were analyzed by using the TCGA, TIMER, UALCAN, HPA, STRING, Gene MANIA, Kaplan-Meier, GEPIA, GeneCards and other databases. The nomogram model was constructed with R language.Results PDHA1 expression was associated with breast cancer T Stage (P<0.001), pathologic stage (P=0.031), race (P<0.001), histological type (P<0.001), PR status (P<0.001), ER status (P<0.001), and PAM50 subtype (P<0.001). TCGA database results showed that the expression level of PDHA1 mRNA in breast cancer tissues was significantly lower than that in normal breast tissues (P<0.001), while UALCAN database results showed that PDHA1 protein was lowly expressed in breast cancer (P<0.001), which was further verified by HPA database. The PPI protein-protein interaction network revealed 15 PDHA1-related interaction proteins. Twenty PDHA1-related interacting genes were obtained from the gene-gene interaction network diagram. Patients in the PDHA1 high-expression group had lower overall survival (HR=1.26, 95% CI=1.02-1.54, P=0.029), relapse-free survival (HR=1.18, 95% CI=1.05-1.32, P=0.005 1), post-progression survival (HR=1.41, 95% CI=1.07-1.86, P=0.015), and metastasis-free survival (HR=1.29, 95% CI=1.1-1.52, P=0.002 3). GSEA results showed that PDHA1 co-expressed genes were mainly involved in the S stage and tricarboxylic acid cycle in breast cancer. Ten compounds related to PDHA1 expression were identified from GeneCards. A nomogram model was constructed by integrating the PDHA1 expression, age, radiation therapy, N stage and M stage, and the calibration chart shows that there was excellent consistency between the nomogram prediction and the actual observation.Conclusion The prognosis of breast cancer patients with high PDHA1 expression is worse than that of patients with low PDHA1 expression. The expression level of PDHA1 is a related factor affecting the prognosis of breast cancer patients. The nomogram model constructed based on PDHA1 expression has certain value in estimating the prognosis of breast cancer patients.

10 Effect of pituitary tumor transforming gene 1 on immune infiltration in breast cancer and its prognostic value

ZENG Baohui , GUO Xinmin , GUO Shunhua

2022, 31(11):1483-1492. DOI: 10.7659/j.issn.1005-6947.2022.11.010

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Background and Aims Pituitary tumor transforming gene 1 (PTTG1) is an oncogene highly expressed in various tumors and can be used as a biomarker for cancer invasion and metastasis. However, the expression level of PTTG1 in breast cancer and its relationship with the patient's prognosis is unclear. This study was conducted to investigate the relationship between the expression of PTTG1 in breast cancer and the prognosis of patients and its effect on immune cell infiltration, and preliminarily explore the possible mechanism of PTTG1 in the occurrence and development of breast cancer.Methods The expression of PTTG1 in breast cancer tissues and its prognostic value were analyzed using Oncomine 4.5 database and Kaplan-Meier Plotter database. The co-expressed genes of PTTG1 screened by Coexpedia and the enriched pathways by co-expressed genes were analyzed through GO and KEGG databases. TIMER database was used to analyze the relationship between PTTG1 gene expression level and immune cell infiltration in breast cancer. MultiMiR method of R language bundle was adopted to predict the microRNAs interacting with PTTG1 and its co-expressed genes, and Cytoscape was used for network visualization.Results PTTG1 expression was significantly increased in breast cancer tissues, and the prognosis of patients with high PTTG1 expression was significantly worse than that of patients with low PTTG1 expression (P<0.001). In breast cancer, the GO function of PTTG1 gene and its co-expressed gene set was mainly enriched in nuclear division, organelle separation, and chromosome separation. In contrast, the KEGG pathway was enriched in cell cycle, meiosis, human T lymphocytic leukemia virus type I (HTLV-1) infection and p53 signal transduction pathway. The expression level of PTTG1 was significantly positively correlated with the infiltration level of CD4+ Th1 cells (r=0.490, P=3.52e-61), CD4+ Th2 cells (r=0.765, P=3.7e-192), macrophages (r=0.308, P=2.8e-23), B cells (r=0.228, P=3.69e-13) and neutrophils (r=0.121, P=1.27e-04), but was significantly negatively correlated with the infiltration level of CD8+ T cells (r=-0.198, P=3.16e-10). The multiMiR language data package analysis showed that there were 17 microRNAs co-targeting PTTG1 and its co-expressed genes.Conclusion PTTG1 is highly expressed in breast cancer tissue and is associated with poor prognosis in patients. The expression level of PTTG1 in breast cancer is closely related to immune infiltration. High expression of PTTG1 may enhance tumor proliferation and invasion ability by regulating cell cycle and p53 signaling pathway, thereby leading to poor prognosis of breast cancer. PTTG1 may play an oncogene role in breast cancer, suggesting that PTTG1 can be used as a potential diagnostic and prognostic marker for breast cancer.

11 Correlation of WAVE2 expression with replacement histopathological growth pattern of colorectal liver metastases

PEI Lei , TAN Fengbo , PEI Qian , LUO Jia , WANG Zhiming , TAO Yiming

2022, 31(11):1493-1500. DOI: 10.7659/j.issn.1005-6947.2022.11.011

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Background and Aims Colorectal cancer liver metastases (CLM) have different histopathological growth patterns (HGP), among which replacement HGP (RHGP) is closely associated with vessel co-option, which directly affects the effect of anti-angiogenic therapy and leads to poor prognosis. Therefore, this study was conducted to investigate the molecular pathological features of HGP, so as to provide a basis for the study of the molecular mechanism of CLM.Methods The clinical data and paraffin-embedded specimens of 103 patients with CLM undergoing surgical resection between 2010 to 2020 in the Department of General Surgery of Xiangya Hospital, Central South University were collected, in which 58 cases were desmoplastic HGP (DHGP) and 45 cases were RHGP. The correlation between RHGP and clinicopathologic factors of CLM patients was assessed based on the international HGP consensus guidelines. The associations of RHGP with vessel co-option and WAVE2 were analyzed through immunohistochemical staining for the protein expressions of WAVE2 and CD31. The correlation between WAVE2 and immune infiltration was analyzed using TIMER2.0 database. WAVE2 interaction signaling molecules were analyzed by KEGG database.Results HGP was significantly associated with the time to liver metastasis occurrence and lymph metastasis (both P<0.05). The CD31 positive rate was 27.5% and 37.0% in DHGP group and RHGP group, and high WAVE2 expression rate was 58.6% in DHGP group and 82.2% in RHGP group respectively, and the differences had statistical significance (P=0.023, P=0.011). WAVE2 expression was significantly correlated with B cells (r=0.258, P=1.41e-07), CD4+ T cells (r=0.467, P=3.67e-23), CD8+ T cells (r=0.318, P=5.47e-11), and neutrophils (r=0.407, P=2.02e-17), macrophages (r=0.301, P=6.63e-10) and dendritic cells (r=0.438, P=3.01e-20) immune infiltration. WAVE2 expression was significantly positively associated with CTTN (r=0.454, P=1.26e-24), HDAC4 (r=0.54, P=5.43e-36), CYFIP1 (r=0.39, P=4.24e-18), CDC42 (r=0.443, P=2.12e-23), PDGFB (r=0.316, P=4.25e-12), PRKACA (r=0.363, P=1.05e-15), and other downstream molecules.Conclusion WAVE2 expression may be involved in the formation of RHGP by promoting the migration of colorectal cancer cells and regulating vessel co-option and tumor immune microenvironment.

12 Impact of BRCA1/2 mutation on local recurrence of breast cancer patients following breast conserving surgery and construction of related prognostic model

ZHANG Mingkun , WANG Zhe , YANG Liu , HOU Lan , ZHANG Juliang

2022, 31(11):1501-1509. DOI: 10.7659/j.issn.1005-6947.2022.11.012

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Abstract:
Background and Aims Breast conserving surgery has become one of the standard surgical methods for breast cancer. Breast conserving surgery can preserve the mammary contour of patients and greatly improve the postoperative psychological state and quality of life. BRCA1/2 gene is a susceptibility gene closely related to breast cancer. The impact of BRCA1/2 gene mutation on local recurrence of breast cancer patients after breast conserving surgery is still controversial. This study was conducted to investigate the association of BRCA1/2 mutation with local recurrence of breast cancer patients undergoing breast conserving surgery, and construct a related prognostic model to predict the local recurrence free survival (LRFS) rate of breast cancer patients following breast conserving surgery, so as to provide guidance on indications for breast cancer patients to receive breast conserving surgery.Methods The clinical data of 189 breast cancer patients undergoing breast conserving surgery in Fourth Military Medical University Affiliated Xijing Hospital from June 2014 to June 2016 were retrospectively analyzed. The differences in BRCA1/2 mutation among patients with different clinicopathologic features were compared. The effects of BRCA1/2 mutation and other clinicopathologic factors on local recurrence were analyzed by univariate and multivariate Cox proportional regression models, and a nomogram was constructed to predict the LRFS rate. The model was internally verified by concordance index (C-index), receiver operating characteristic (ROC) curve, and area under curve (AUC). The accuracy of the model was assessed by calibration curves and the clinical benefits and application value of the model were evaluated by clinical decision curve analysis (DCA).Results There were significant differences in age and molecular subtype between the patients with and without BRCA1/2 gene mutation (both P<0.05). The results of univariate Cox equal proportional regression model showed that BRCA1/2 mutation, tumor grade, tumor size, N stage and molecular subtype were relevant risk factors for LRFS of breast patients receiving breast conserving surgery (all P<0.1). The results of multivariate Cox equal proportional regression model showed that BRCA1/2 mutation, tumor size, N stage and molecular subtype were independent risk factors for LRFS of breast patients after breast conserving surgery (all P<0.05). Based on the above variables, the nomogram models were constructed. The C-index of the model was 0.86, and the C-index for internal validation was 0.81. The ROC curve analysis results showed that the AUC of 3- and 5-year LRFS of the model were 0.89 and 0.85, respectively. The calibration curve analysis showed that predicted LRFS of the model had a good consistency with the actual observed values. The DCA showed that the model had high clinical benefit and application value.Conclusion BRCA1/2 mutation is associated with local recurrence in breast cancer patients undergoing breast conserving surgery. The nomogram model based on BRCA1/2 gene mutation can accurately predict the LRFS rate of breast cancer patients after breast conserving surgery, and provide an effective scientific basis for the selection of surgical methods for breast cancer patients.

13 Laparoscopic right colon cancer resection by transrectal specimen extraction without abdominal auxiliary incision (ileocecal junction preservation): a case report and literature review

GUAN Xu , JIAO Shuai , CHEN Haipeng , ZHENG Zhaoxu , WANG Xishan

2022, 31(11):1510-1517. DOI: 10.7659/j.issn.1005-6947.2022.11.013

[Abstract](807) [HTML](483) [PDF 1.20 M](1061)

Abstract:
Background and Aims In recent years, natural orifice specimen extraction surgery (NOSES) has been widely carried out in the surgical treatment of early colorectal cancer. The main advantages of this procedure include reducing surgical trauma, accelerating patient recovery, and alleviating adverse psychological implications in patients. However, NOSES is still in the development stage in the treatment of right colon cancer, and many key points of this technique still need to be continuously improved. Therefore, this study was conducted to investigate the feasibility and safety as well as the relevant key issues of NOSES surgery for right colon cancer.Methods The clinical data of a patient who underwent laparoscopic right hemicolectomy (ileocecal junction preservation) and transrectal specimen extraction without abdominal auxiliary incision at the Cancer Hospital Chinese Academy of Medical Sciences were retrospectively analyzed. Combined with the relevant literature reports on NOSES, the key issues such as the scope of bowel resection, the degree of lymph node dissection, the reconstruction method of the digestive tract, and the way of specimen removal in the NOSES operation for right colon cancer were systematically analyzed.Results The case was a 49-year-old male patient who was admitted to the hospital for surgery because of a right-sided colon mass detected by physical examination. The preoperative clinical stage was cT2N0M0. The surgical procedures mainly included dissociation of the right colon, ligation of the right colic artery and vein and dissection of regional lymph nodes; division of the colon at appropriately 10 cm from the proximal end of the tumor after dissection of the mesentery, and division of the ascending colon at 5 cm distal to the entrance of the ileocecal valve after complete shaving of the mesentery, and side-to-side anastomosis between the ascending and transverse colons; incision of the rectum at 5 cm above the peritoneal reflection, and transanal extraction of the specimen; closure of the rectal incision with a barbed suture followed by reinforcement of the seromuscular layer. The postoperative pathological stage was pT2N0. The patient showed first bowel movement at postoperative day (POD) 1, had liquid food intake at POD 2, and was discharged from the hospital at POD 5. Literature review of 10 previous articles indicated that in NOSES compared with conventional laparoscopic surgery, the incidence of postoperative complications did not increase but was even somewhat reduced, and offered better minimally invasive results in terms of postoperative recovery, while showed no obvious differences in other surgical variables.Conclusion This case of NOSES with ileocecal junction preservation for right colon cancer demonstrates the combination of minimal invasiveness, functional preservation and meticulous operation. However, this procedure also has specific technical difficulties, so comprehensive preoperative assessment and close cooperation are necessary to ensure the successful implementation of the process. In the future, more high-quality clinical studies are needed to provide evidence-based information to systemically evaluate its short-term and long-term efficacy.

14 Research progress of pre- and intraoperative localization of parathyroid gland in surgery for hyperparathyroidism

PENG Yubei , YE Mengxing , MA Kexin , KOU Zhen , LIU Liping

2022, 31(11):1518-1526. DOI: 10.7659/j.issn.1005-6947.2022.11.014

[Abstract](594) [HTML](693) [PDF 647.83 K](1289)

Abstract:
Parathyroid gland is a nodular endocrine gland in the neck of the human body, which is located behind the thyroid gland. Its main function is to secrete parathyroid hormone (PTH), which regulates blood calcium. Hyperparathyroidism (HPT) means that the parathyroid gland secretes abnormally high PTH levels, which causes blood biochemical changes, damage of related system function, seriously affects the quality of life of patients, and even leads to death. The most important treatment is surgical resection of the diseased parathyroid gland, and accurate location is significant for minimally invasive parathyroidectomy. Because it can improve the success rate of operation and minimize the incidence of accidental parathyroid injury and injury-related complications. In recent years, with the innovation and popularization of technology and equipment, different positioning methods provide better sensitivity and accuracy. The continuous deepening and updating of clinical research offer a better guiding significance for the localization of different types of HPT. At present, minimally invasive parathyroid surgery has replaced the traditional extensive exploration, which ensures the success rate of operation, brings fewer injuries and complications, and demands a higher requirement for parathyroid localization. Therefore, the author reviews the research progress of parathyroid localization in HPT to provide better localization choices and some new ideas and directions for the surgical treatment of HPT.

15 Current status and research progress of diagnosis and treatment of phyllodes tumor of the breast

XU Jiawei , LI Xiaoxing , YU Tenghua , SUN Zhengkui

2022, 31(11):1527-1534. DOI: 10.7659/j.issn.1005-6947.2022.11.015

[Abstract](1052) [HTML](429) [PDF 631.93 K](1523)

Abstract:
Phyllodes tumor of the breast (PTB) is a type of breast tumor with low clinical incidence. PTB most often manifest as a progressively enlarged painless mass and may easily be confused with other diseases, such as breast fibroadenoma, breast metaplastic carcinoma. Its accurate diagnosis is difficult to achieve by preoperative aspiration biopsy, and the definitive diagnosis is based on molecular pathology after total tumor resection. At present, surgical operation is the main method for the treatment of PTB and extended resection of the tumor for ensuring an adequate negative margin is considered to be the standard surgical procedure. Radiotherapy can further reduce the risk of local recurrence in patients with borderline and malignant PTB. Currently, Studies related to systemic treatments such as chemotherapy are scarce, and the clinical benefit is limited and controversial. Here, the authors review the latest research progress in the epidemiology, clinical presentation, diagnostic imaging, and pathology of PTB at home and abroad, and sort out different new viewpoints of clinical diagnosis and treatment.

16 Application status and research progress of negative pressure wound therapy in the prevention and treatment of complications after prosthesis-based breast reconstruction

YAO Yu , MU Dali

2022, 31(11):1535-1542. DOI: 10.7659/j.issn.1005-6947.2022.11.016

[Abstract](664) [HTML](557) [PDF 637.61 K](1118)

Abstract:
Prosthesis-based breast reconstruction is the mainstream of breast reconstruction after breast cancer surgery. However, postoperative complications such as poor incision healing and tissue infection after breast reconstruction not only increase medical costs and affect aesthetics but also lead to prosthesis loss and even breast reconstruction failure in severe cases, which significantly affect the quality of life of patients. With the progress of negative pressure technology, closed incision negative pressure therapy (ciNPWT) and negative pressure wound therapy with instillation and dwell (NPWTi-d) have been proven to have significant advantages in preventing and treating complications after prosthesis-based breast reconstruction. At the same time, the exact mechanism, the optimal conditions, and selection of negative pressure technology are still unclear. This review provides a comprehensive and systematic review of the application status and mechanism research of ciNPWT and NPWTi-d.

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Volume 31,Issue 11,2022 Table of Contents

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