Axillary lymph node dissection (ALND) has been the standard treatment of breast cancer axillary staging in Indonesia. The limited facilities of radioisotope tracer and isosulfan or patent blue dye (PBD) have been the major obstacles to perform sentinel node biopsy (SNB) in our country. We studied the application of 1% methylene blue dye (MBD) alone for SNB to overcome the problem. This prospective study enrolled 108 patients with suspicious malignant lesions or breast cancer stages I–III. SNB was performed using 2–5 cc of 1% MBD and proceeded with ALND. The histopathology results of sentinel nodes (SNs) were compared with axillary lymph nodes (ALNs) for diagnostic value assessments. There were 96 patients with invasive carcinoma from July 2012 to September 2014 who were included in the final analysis. The median age was 50 (25–69) years, and the median pathological tumor size was 3 cm (1–10). Identification rate of SNs was 91.7%, and the median number of the identified SNs was 2 (1–8). Sentinel node metastasis was found in 53.4% cases and 89.4% of them were macrometastases. The negative predictive value (NPV) of SNs to predict axillary metastasis was 90% (95% CI, 81–99%). There were no anaphylactic reactions, but we found 2 cases with skin necrosis. The application of 1% MBD as a single technique in breast cancer SNB has favorable identification rates and predictive values. It can be used for axillary staging, but nevertheless the technique should be applied with attention to the tumor size and grade to avoid false negative results.

Objective: Molecular testing of thyroid nodules becomes important for improving the accuracy of fine-needle aspiration biopsy (FNAB). This study aimed to investigate the diagnostic utility of BRAF, NRAS, and TERT promoter mutation in thyroid nodules at Dharmais Cancer Hospital.Methods: We performed a prospective diagnostic study involving 50 patients with thyroid nodules who needed surgery between September 2013 and August 2014. Mutational hotspots in BRAF exon 15, NRAS exon 3, and TERT promoter region were analyzed by Sanger sequencing from FNAB specimens. Cytology and molecular data were compared to histopathology results.Result: Of the 50 cases included in the analysis, 39 cases (78%) were thyroid malignancies. Mutations of BRAF, NRAS, and TERT promoter were detected in 31% (12/39), 18% (7/39), and 13% (5/39) cases, respectively. BRAF and NRAS mutations were found mutually exclusive, while all of TERT promoter mutation was found coexistent either with BRAF (40%) or NRAS (60%). The combination of FNAB cytology and molecular testing resulted in 69% sensitivity, 100% specificity, 100% positive predictive value, 48% negative predictive value, and 76% accuracy.Conclusion: Molecular testing of BRAF, NRAS, and TERT mutations improve the sensitivity of thyroid FNAB and is beneficial for more definitive treatment in selective cases. However, the NPV is relatively low to avoid the need for diagnostic surgery. Therefore, further studies to identify more sensitive methods and more comprehensive molecular markers in the diagnosis of thyroid nodules are needed.

Background Locally advanced breast cancer is commonly found in Indonesia. In this group of patients, aggressive treatment such as axillary lymph nodes dissection (ALND) with or without regional nodal irradiation (RNI) will increase the risk of breast cancer treatment-related lymphedema (BCRL) in our patients. Lymphaticovenular anastomosis (LVA) has been established as a minimally invasive approach in lymphedema surgery. In this study, we report our first experience of LVAs in BCRL patients.Methods This was a cross-sectional study taken from breast cancer patients receiving ALND with or without RNI. From December 2018 until June 2020, we collected and described general patient information, tumor characteristics, diagnostic methods, and the outcome of LVA. Postoperative subjective symptoms scores (lymphedema quality-of-life score [LeQOLiS]) and lymphedematous volume (upper extremity lymphedema [UEL] index) were compared with preoperative ones.Results Seventy patients experienced BCRL with the mean age of 54.8 (9.4) years and mean body mass index of 28.1 (4.5). ALND was performed in 66 (97.1%) cases and RNI was given in 58 (82.9%) patients. Thirty-one (44.3%) patients were in the International Society of Lymphology stage 1, 24 (34.3%) in stage 2A, and 15 (21.4%) in stage 2B. The mean lymphatic vessel diameter was 0.5 (0.26) mm and 0.80 (0.54) mm for the vein. Lymphosclerosis severity was 7 (4%) in S0 type, 129 (74.1%) in S1 type, 37 (21.3%) in S2 type, and 1 (0.6%) in S3 type. In histopathology examination, S1 types were in lower grade injury, while S2 and S3 types were in the higher grade. Seven (53.8%) cases of S2 type showed severe fibrosis from trichrome staining. Postoperative LeQOLiSs were significantly lower than preoperative ones (5.6 ± 2.4 vs. 3.7 ± 2.6; p = 0.000). With the mean follow-up of 7.4 (3.7) months, the overall UEL index reduction was 9.2%; mean –11 (16.8). Postoperative UEL index was significantly lower than preoperative ones (117.7 ± 26.5 vs. 106.9 ± 18.5; p = 0.000). No complications were observed during this period.Conclusion LVA reduced the subjective symptoms and UEL index in BCRL cases. Future studies using updated imaging technologies of the lymphatic system and longer follow-up time are needed to confirm our results.

We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.

Surgical Perspective of T1799A BRAF Mutation Diagnostic Value in Papillary Thyroid Carcinoma Papillary thyroid carcinoma;BRAF mutation;fine needle aspiration;diagnostic value; Background: Throughout Indonesia, thyroid cancer is one of the ten commonest malignancies, with papillary thyroid carcinoma (PTC) in our hospital accounting for about 60% of all thyroid nodules. Although fine needle aspiration biopsy (FNAB) is the most reliable diagnostic tool, some nodules are diagnosed as indeterminate and second surgery is common for PTC. The aim of this study was to establish the diagnostic value and feasibility of testing the BRAF T1799A mutation on FNA specimens for improving PTC diagnosis. Materials and Methods: This prospective study enrolled 95 patients with thyroid nodules and future surgery planned. Results of mutational status were compared with surgical pathology diagnosis. Results: Of the 70 cases included in the final analysis, 62.8% were PTC and the prevalence of BRAF mutation was 38.6%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for BRAF mutation analysis were 36%, 100%, 100% and 48%, respectively. With other data findings, nodules with

The novel coronavirus disease (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread to many countries, including Indonesia. The outbreak started within early March 2020 and in just less than a month the virus has infected 1285 patients and 114 death in Indonesia by March 30, 2020 [1]. It does not only take many lives of patients, but also our colleagues as health care providers. On behalf of the Indonesian Journal of Cancer, we would like to express our deepest condolences to all patients and especially to our doctors, nurses, and all health care workers, who could not survive in the battle against this virus.Looking at how serious the disease is, it is estimated that the situation will give major changes to cancer patients’ management, and unfortunately, it is happening in the middle of our efforts to upgrade cancer management in Indonesia. It is going to be a hard time, but we must be ready to overcome the COVID-19 crisis in the field of oncology. Let us take a brief look at published articles and recommendations in oncology.A recent publication by Liang et al. [2] in China revealed that cancer patients with COVID-19 had higher risk of severe events, which were defined by more frequent intensive care unit admission, requirement of mechanical ventilator, and higher death rate, hence they also proposed to withhold chemotherapy and elective surgery for stable cancer in the endemic areas. However, this initial result of 18 cancer patients out of 1590 COVID-19 cases should be interpreted cautiously because of insufficient evidence to be recommended in every cancer patient [3]. More robust evidence is needed to address this issue in the field of cancer, from prevention, screening, advances in therapies, until palliative management. In the meantime, some guidelines have been proposed by several oncology socities [4-6]. Postponing cancer screening and elective surgeries such as in benign disease and risk-reducing surgery sound-wise for the time being, but surgical oncologists should remember that most of the cancer surgeries cannot be considered “elective”. American College of Surgeons has also released a triage guideline for surgical cases and recommended using the Elective Surgery Acuity Scale (ESAS) from St. Louis University to assist surgical decision-making [5]. To date, no direct evidence has been reported to support withholding radiotherapy, chemotherapy, and immunotherapy in daily cases, although some practice changes in several situations such as postponing, switching, or stopping aggressive adjuvant treatment in stable and low-risk cancer could be considered [4-5]. We must underline the potential harm of delaying cancer treatment and the benefit of reducing the risk of COVID-19 infection or vice versa. Individual discussions with patients should be made because many factors will contribute to giving the best answer.We are preparing for skyrocketing COVID-19 cases in Indonesia within the next few days or weeks. How do we prepare without letting behind our main goal as oncologists to care for cancer patients? A published article by Ueda et al. [7] could be a good example for us to start with and to learn how they managed the cancer service during the early outbreak in Washington. They started with patients’ triage, education for patient and family through handouts and web-site, and strengthening the policy of “stay at home”. A phone triage line, providing personal protective equipment (PPE), and also test to symptomatic medical staff, were provided. In outpatient service, rescheduling visits of “well” patients, or postponing the second consultation for patients who already had treatment access in initial health care, were being conducted. Telemedicine also plays an important part of their strategy. Cancer surgery was their priority when PPE, team members, and bed capacity were available. A surgeon-to-patient phone call discussion was made when a delay in schedule was expected. Many patients with aggressive hematologic malignancies were managed not to get a treatment delay and planned to conduct a limitation for clinical trials except for the studies that will bring benefit to participants. They also mentioned that it is imperative to discuss ethical issues in the end-of-life setting when a final-stage patient acquires COVID-19 [7].Managing cancer surgeries in our surgical oncology unit is not so simple even in the time before COVID-19, since many complex and urgent cancer cases were referred to us. When the outbreak occurred, the continuity to perform surgery has been even more challenging for us. We decided to proceed with the surgery and several adjustments were made to make sure the safety of patients and team members. Neither benign cases nor breast reconstructions are performed at the moment. Emergency conditons, aggressive-behavior cancer, and post-neoadjuvant chemotherapy surgeries are also prioritized. The onco-microsurgical reconstruction is only performed for complex head and neck cancer, soft tissue sarcoma, and cancer treatment-related lymphedema with the risk of having dermatolymphangioadenitis. Having an urgent complex case on the table, I am fortunate and honored to work with dedicated colleagues and operating room team who are willing to follow our strict rules: we do not do multiple surgeries or outpatient clinic service on the scheduled day; the surgery must be started early to avoid late hours working time; which could reduce the physical and mental health of each team member; everyone must stay focused with their parts, so “quick-in-quick-out” surgery can be accomplished to prevent or reduce patients’ immunosuppressive effect due to a long surgery; a well-screened patient and the availability of PPE is mandatory before the surgery is started. It is just a modest example and we are aware that adjustment of our current protocol should be done when...