Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Should Patients Undergoing Prophylactic Mastectomy Undergo Sentinel Lymph Node Biopsy (SLNB)?

Rodrigo Arrangoiz MS, MD, FACS, FSSO

 

👉Prophylactic mastectomy rates are rapidly rising in the United States.

👉Prophylactic mastectomy may be associated with a 3.5 to 5% occurrence of occult carcinoma depending on the indication for the operation.

👉 SLNB at the time of prophylactic mastectomy may eliminate the need for axillary lymph node dissection (ALND) if occult disease is identified.

👉A recent meta-analysis reviewed 14 studies where SLNB was routinely performed for prophylactic mastectomy in patients undergoing bilateral mastectomy for unilateral cancer.

👉This study found metastatic disease in the SLNB of the prophylactic mastectomy in 0% to 4% of patients with contralateral cancer.

👉The majority of metastatic disease was associated with contralateral axillary tumor spread from the primary tumor, not an occult primary tumor.

👉In patients who were found to have occult malignancy in the prophylactic mastectomy breast, less than 1% of sentinel lymph nodes were positive for metastatic disease.

👉Given the low rates of occult malignancy and axillary metastasis, SLNB is not indicated for patients undergoing prophylactic mastectomy.

👉Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

New Technique to Reduce the Risk For Hypocalcemia in Thyroid Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉In this issue of JAMA Surgery, Benmiloud et provide evidence that the common and harmful complication of early postoperative hypocalcemia may be reduced with this new technique.

👉The primary aim of the study, was to see post operative hypocalcemia may be reduced by using the fluorescent properties of the parathyroid glands intraoperatively.

👉Although some important data are not reported in the study, particularly concerning how and by whom the patients were followed up, the completeness of follow-up, and biochemical data with blood levels of calcium and parathyroid hormone at 6 months, the results suggest that the concept of parathyroid autofluorescence can be used to reduce early postoperative hypocalcemia.

👉If these results are reproduced by other centers in randomized clinical trials with other devices, and for long-term hypoparathyroidism, this will represent a substantial improvement in the quality of thyroid surgery.

Commentary: New Technique to Reduce the Risk For Hypocalcemia in Thyroid Surgery https://ja.ma/2ClR5CO

Delaying surgery for a noninvasive breast cancer can have dire consequences.

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉A new study published by researchers from Fox Chase Cancer Center showed that delaying surgery for a noninvasive breast cancer can have dire consequences.

👉Longer delays in surgery for ductal carcinoma in situ (DCIS) breast cancer lead to a higher risk of invasive ductal carcinoma and a slightly lower survival rate says Dr. Arrangoiz based on the results of the study.

👉For each month of delay, there was well under a 1% difference in survival.

👉But for each month of delay, there was an approximate 1% increase in the finding of invasive cancer.

👉DCIS arises from abnormal cells form the milk duct of the breast and is the earliest stage of breast cancer.

👉When cancerous cells spread beyond the milk duct, it becomes invasive ductal carcinoma.

👉Standard treatment for DCIS is surgery and radiotherapy, along with endocrine therapy.

👉But research suggests that some DCIS may never progress to invasive disease, and clinical trials are being conducted to determine whether DCIS can be observed, rather than surgically removed.

👉This study suggests that delays in operative management of DCIS are associated with invasion and slightly worse short-term outcomes.

👉Since observation represents infinite delay, it suggests that observation should not yet be pursued outside of a clinical trial in patients who will tolerate excision.

👉The study included more than 140,600 U.S. women (123,947 with DCIS, 16,668 with invasive ductal carcinoma).

👉They were diagnosed between 2004 and 2014.

👉Survival was compared with five time intervals in delays to have surgery: less than 30 days, 31-60 days, 61-90 days, 91-120 days, or 121-365 days.

👉Overall survival was 95.8%, with a median time from diagnosis to surgery of 38 days.

👉However, each increase in diagnosis-to-surgery interval was associated with a 7.4% increase in the risk of death.

👉The study was published in the Annals of Surgical Oncology.

👉👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

Surgical Evaluation of the Axilla

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉The physical examination alone cannot accurately predict the presence of axillary disease.

👉The accuracy of a physical examination to detect axillary metastasis ranges from 61% to 68% when compared with resection. 👉Ultrasonography, magnetic resonance imaging, and positron emission tomography–computed tomography have all been used to evaluate the axilla, and although these imaging modalities may improve on physical examination, they are not as accurate as lymphadenectomy for small deposits and have a higher rate of false positives.

👉A level I and II axillary lymph node dissection (ALND) has been the gold standard for evaluating the extent of axillary disease.

👉Unfortunately, the incidences of lymphedema, chronic pain, seroma development, future cellulitis, numbness, and limits to mobility are all significant sequelae following ALND.

👉Approximately 70% of patients who are clinically node negative will have no evidence of disease detected with ALND, putting these patients needlessly at risk for complications.

👉In 1991, the technique of sentinel lymph node biopsy (SLNB) was proposed as an alternative to ALND in breast cancer patients.

👉The development of SLNB has now replaced ALND as a highly accurate and less morbid axillary staging procedure for most patients. 

👉Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

To identify FISH-Positive HER-2 Testing Results Based on Current American Society of Clinical Oncology / College of American Pathologists (ASCO/CAP) Guidelines

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉HER-2 expression in breast cancer is primarily assessed semiquantitatively by IHC.

👉The 2013 ASCO guidelines outline an IHC scoring method based on four classes:

– 0, 1+, 2+, and 3+.

👉A score of 0 is negative, indicating no observed staining in invasive tumor cells.

👉A score of 1+ is negative and indicates weak, incomplete membrane staining in any proportion of invasive tumor cells or weak, complete membrane staining in less than 10% of invasive tumor cells.

👉A score of 2+ is equivocal, indicating circumferential membrane staining that is incomplete and/or weak/moderate and in more than 10% of invasive tumor cells or complete and circumferential membrane staining that is intense and in 10% or less of invasive tumor cells.

👉All 2+ equivocal cases undergo subsequent testing by FISH.

👉A score of 3+ is positive and indicates circumferential membrane staining that is complete and intense in a homogeneous and contiguous population, present in more than 10% of invasive tumor cells, and readily appreciated using a low-power objective. 

👉FISH is a sensitive and accurate method of scoring invasive breast tumor tissue for HER-2 expression.

👉Initial gene amplification studies by FISH assessment used chromosome 17 centromere (CEP17) or another gene on the same chromosome as an internal control, with a ratio of 2.0 or more considered evidence of HER-2 amplification.

👉These criteria were used as the cutoff for enrollment in trials evaluating HER-2 targeted therapies.

👉In 2007, the ASCO/CAP guidelines were changed to define HER-2 amplified as a ratio of 2.2 or more.

👉More recent guidelines have changed the ratio cutoff back to a ratio of 2.0 or more with the inclusion of criteria to account for HER-2 copy number per tumor cell.

👉Based on the recent guidelines, HER-2 is amplified in cases where the HER-2/CEP17 ratio is 2.0 or more with an average HER-2 copy number of less than 4.0 signals/cell or the HER-2/CEP17 ratio is less than 2.0 with an average HER-2 copy number of 6.0 or more signals/cell using a dual probe or a HER-2 copy number of 6.0 or more copies/cell using a single probe.

👉FISH testing is negative for HER-2 amplification with a HER-2/CEP17 ratio of less than 2.0 with an average HER-2 copy number of less than 4.0 signals/cell or an average HER-2 copy number of less than 4.0 signals/cell using a single probe.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y cirujano de mama miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

Breast Cancer Risk In BRCA Positive Women

Rodrigo Arrangoiz MS, MD, FACS, FSSO
👉When BRCA mutation carriers are diagnosed at a young age, the risk of a contralateral breast cancer is approximately 63% at 25 years.
👉For an average patient, the risk of developing contralateral breast cancer is approximately 0.5% to 1% per year, which decreases further with the use of systemic therapy, particularly, endocrine therapy which further reduces these contralateral breast cancer risks by about half in estrogen receptor-positive breast cancers.
👉Therefore, for a very young patient who has an early-stage breast cancer her risk of development of contralateral breast cancer is higher than the average postmenopausal woman but much lower than that of a BRCA mutation carrier.
👉Contralateral prophylactic mastectomy is a controversial area in breast surgical oncology and patient decision making around this process continues to be studied. 

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

REPORT THIS AD

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

REFERENCES

  1. Graeser MK, Engel C, Rhiem K, et al. Contralateral breast cancer risk in BRCA1 and BRCA2 mutation carriers. J Clin Oncol. 2009;27:5887-5892. http://www.ncbi.nlm.nih.gov/pubmed/19858402
  2. Parker PA, Peterson SK, Bedrosian I, et al. Prospective study of surgical decision-making processes for contralateral prophylactic mastectomy in women with breast cancer. Ann Surg. 2016;263:178-183. http://www.ncbi.nlm.nih.gov/pubmed/25822675

Tomosynthesis for BREAST Cancer Screening

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Digital breast tomosynthesis (DBT) is increasingly used for routine breast cancer screening. This study evaluates the long-term impact and cost-effectivenss of DBT compared to digital mammography.

The Year in Thyroidology

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Tumor kinetics matter in active surveillance
  • Molecular markers help many patients avoid thyroid surgery for indeterminate thyroid nodules (Bethesda III and IV)
  • BRAF V600E interacts with patients age and gender
  • ATA 2015 guidelines are cost effective
  • High volumen thyroid surgeons clean up the neck
  • Surgery improves quality of life in Hashimoto’s patients
  • Surgery more attractive for Graves’ disease?

👉Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello y cirugía endocrina de Sociedad Quirúrgica S.C. es experto en el manejo de nódulos tiroides y del cáncer de tiroides.

Articulo publicado por el Dr. Arrangoiz sobre el manejo de nódulos tiroides:

https://file.scirp.org/pdf/IJOHNS_2018072717023407.pdf

Es pionero en México:

  • Cirugia tiroidea minimamente invasiva
  • La cirugia minimamente invasiva radio-guiada de paratiroides

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010image-48• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012image-39• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012image-50• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

image-6image-51 

http://www.sociedadquirurgica.com

http://www.hiperparatiroidismo.info

http://www.cirugiatiroides.com

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

 

The Six W´s of Surgical Thyroidology

Rodrigo Arrangoiz MS, MD, FACS, FSSO

W ho (should have thyroid surgery)?

W hat (operation should be performed)?

W here (should the surgery be performed)?

W hen (to intervene)?

W hy (should be operate or not)?

How (innovations in surgical technique)

👉Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello y cirugía endocrina de Sociedad Quirúrgica S.C. es experto en el manejo de nódulos tiroides y del cáncer de tiroides.

👉Articulo publicado por el Dr. Arrangoiz sobre el manejo de nódulos tiroides:

https://file.scirp.org/pdf/IJOHNS_2018072717023407.pdf

👉Es pionero en México:

  • Cirugia tiroidea minimamente invasiva
  • La cirugia minimamente invasiva radio-guiada de paratiroides

👉Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010image-48• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012image-39• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012image-50• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

image-6image-51 

http://www.sociedadquirurgica.com

http://www.hiperparatiroidismo.info

http://www.cirugiatiroides.com

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

 

Primary Lymphoma of the Breast

Rodrigo Arrangoiz MS, MD, FACS, FSSO
👉Primary lymphoma of the breast is a rare, non-epithelial neoplasm that represents less than 0.5% of breast malignancies.
👉It most commonly presents in women over the age of 40 years.
👉Though a variety of histologic types may be seen, most primary breast lymphomas are non-Hodgkin lymphomas of the diffuse large B-cell type.
👉There has been a recent association between breast implants and anaplastic large cell lymphoma, a T-cell lymphoma subtype.
👉About 10% of patients will report constitutional B symptoms (ie, fever, night sweats, weight loss).
👉Wiseman and Liao described four criteria defining primary breast lymphomas in 1972:
👉All of the following must be met for this diagnosis:
👉First, the breast is the clinical site of presentation.
👉Second, there is no history of lymphoma or evidence of widespread disease.
👉Third, there is lymphoma in close association with breast parenchyma on pathologic evaluation.
👉Fourth, ipsilateral nodal involvement, if present, developed simultaneously with the breast tumor.
👉Lymphomas of the breast that do not meet these criteria qualify as secondary tumors.
👉Primary breast lymphoma is either stage IE—localized to the breast or stage IIE—involving both the breast and the ipsilateral axillary lymph nodes.
👉Concurrent axillary nodal involvement is seen in about 30% of patients. 

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

  • Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

REFERENCES

  1. Aviles A, Delgado S, Nambo MJ, Neri N, Murillo E, Cleto S. Primary breast lymphoma: results of a controlled clinical trial. Oncology. 2005;69:256-260. [PubMed: 16166814]. http://www.ncbi.nlm.nih.gov/pubmed/16166814
  2. Aviv A, Tadmor T, Polliack A. Primary diffuse large B-cell lymphoma of the breast: looking at pathogenesis, clinical issues and therapeutic options. Ann Oncol. 2013;24:2236-2244. [PubMed: 23712546]. http://www.ncbi.nlm.nih.gov/pubmed/?term=23712546
  3. el-Ghazawy IM, Singletary SE. Surgical management of primary lymphoma of the breast. Ann Surg. 1991;214:724-726. [PubMed: 1741653]. http://www.ncbi.nlm.nih.gov/pubmed/?term=1741653
  4. Jennings WC, Baker RS, Murray SS, et al. Primary breast lymphoma: the role of mastectomy and the importance of lymph node status. Ann Surg. 2007;245:784-789. [PubMed: 17457172] http://www.ncbi.nlm.nih.gov/pubmed/?term=17457172
  5. Miranda RN, Aladily TN, Prince HM, et al. Breast implant-associated anaplastic large-cell lymphoma: long-term follow-up of 60 patients. J Clin Oncol. 2013;32:114-120. [PubMed: 25254804]. https://www.ncbi.nlm.nih.gov/pubmed/24323027
  6. Ryan G, Martinelli G, Kuper-Hommel M, et al; International Extranodal Lymphoma Study Group. Primary diffuse large B-cell lymphoma of the breast: prognostic factors and outcomes of a study by the International Extranodal Lymphoma Study Group. Ann Oncol. 2008;19:233-241. [PubMed: 17932394]. https://www.ncbi.nlm.nih.gov/pubmed/17932394
  7. Wiseman C, Liao KT. Primary lymphoma of the breast. Cancer. 1972;29:1705-1712. [PubMed: 4555557]. http://www.ncbi.nlm.nih.gov/pubmed/4555557