Hemorrhagic invasive ductal carcinoma with immunohistological expression of b-subunit HCG: A case report.

A hemorrhagic breast mass was excised from a 27-year-old female. Microscopically, the tumor showed typical areas of invasive ductal carcinoma with intraductal component admixed with some trophoblast-like tumor giant cells in the hemorrhagic area. These cells exhibited β-subunit HCG by immunohistochemistry. The modified radical mastectomy was done after exclusion of the coexisting choriocarcinoma in breast cancer. Postoperatively, the HCG serum level was within normal limit and the gynecological check up showed no positive findings. The modified radical mastectomy specimen revealed that the residual tumor showed the same findings as seen in the previously excised mass.

Ability of clinical nodal staging to predict histologic nodal status in breast cancer patients.

Axillary lymph node metastasis is the most important prognostic factor for breast cancer. Pathologic examination of axillary lymph node dissection specimens is the gold standard for determining if the tumour has metastasized. Clinical nodal staging may help the physician to plan for management and to decide what advice to give the breast cancer patients. We studied the metastasis predictive ability of clinical lymph node staging, and tried to identify subgroups that were more reliable for clinical staging. Patients and Methods: We did a cross-sectional study by collecting the data of patients who had their breast cancers treated at Siriraj Hospital from 1983 to 1993. The lymph node status from preoperative physical examination was compared to the pathologic result of axillary lymph node dissections. Results: Of 1,355 breast cancer patients, 4 patients were stage 0, 224 were stage I, 891 were stage II, 161 were stage III, and 40 patients were stage IV (with 35 missing). Mean diameter of the cancer was 3.6 cm. The average age at diagnosis was 48.5 years. Fifty one percent (697 patients) had at least one palpable node from preoperative physical examination, and 50% of cases (678 patients) had pathologic axillary lymph node positive for metastasis. When compared to pathologic examination, the accuracy of clinical lymph node staging was 70.6%, with 70% sensitivity and 71% specificity. The accuracy was increased in patients with small (T1) or large primary tumor (T3,4) subgroups. Conclusion: Physical examination of axillary lymph node could be used as a guide for predicting metastasis of breast cancer, but with 25-30% of uncertainty.

The surgical correction of the bony ankylosis of the temporomandibular joint.

Bony ankylosis of the temporomandibular joint (TMJ) is an uncommon problem. Since 1997 only seven patients have been treated by the Department of Surgery, three with unilateral involvement and four with bilateral involvement. The associated deformity of the mandible is dependent on the age at the onset of disease or injury. Surgical correction is the only way of treatment, with the main objective being to resume joint movement and jaw function as well as to prevent relapse and, hopefully, restore appearance and occlusion. Surgical procedure included condylectomy with or without coronoidectomy, degloving of the masticator muscles, temporalis muscle flap interposition, costochondral grafting and granioplasty. Postoperative wound infection was found in three patients, one died of gentamicin-induced renal failure six weeks postoperatively. In the long-term follow-up, one patient developed recurrence that was successfully treated repeated surgery.

Surgical treatment of phyllodes tumour of the breast in Siriraj Hospital.

The authors studied retrospectively the surgical treatment of phyllodes tumour of the breast patients between 1989-1994 in the Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University. 24 patients were found. Their ages ranged from 18-60 years (mean 40 years). 17 patients were single and 7 patients were married. The pathological diagnoses of the growths were 15 benigns, 6 borderline malignants and 3 malignants. The size clinically were 1.5 to 30 cm (mean 10.7 cm.) and pathologically were 2 to 48 cm. (mean 10.98 cm.). 7 patients (29.17%) suffered recurrence of the growths. The time that the breast masses were detected before coming to the hospital ranged from 1 to 36 months (mean 7 months). The follow-up period ranged from 4 to 71 months (mean 17 months). The latest surgical procedures were 12 excisions, 7 simple mastectomies 2 subcutaneous mastectomies, 2 modified radical mastectomies, and 1 extended radical mastectomy.

The superior medial pedicle breast reduction in gigantomastia: A report of 2 cases.

Gigantomastia is an uncommon condition that may occur in puberty or during pregnancy. The etiology remains unknown. Since 1989, we had treated only 2 cases with massive breast hypertrophy that was unrelated to pregnancy. To alleviate the discomfort of the patients, the superior medical pedicle breast reduction was performed. The entire breast parenchyma and skin in the lower quadrant and some breast tissue in the upper outer quadrant of the breast was removed. The viability of the nipple-areola complex depended on the perforating branches of the internal mammary artery. The operations were uneventful and there has been no recurrence of the gigantomaatia during the follow-up period to the present.

Reduction mammoplasty by the inferior dermoglandular pedicle technique.

Since 1989, at our department, the inferior dermoglandular pedicle breast reduction had been performed in 22 patients. Twenty patients had macromastia and ptosis, one required this operation for opposite breast reduction during immediate breast reconstruction for cancer, one had asymmetrical breasts. The patient ages ranged from 18 to 61 years with a median of 28 year. Half of the patient were in the age between 18-23 years, all had virginal macromastia. This technique reserved the inferior dermoglandular portion of breast with nipple - areola complex from the inframammary crease to 1-2 cm. above the nipple - areola. The rest of breast parenchyma was removed in a monobloc fashion. The resected breast tissues ranged from 250 gm. To 850 gm. On each side. There was no postoperative nipple necrosis or impairment of nipple sensation and projection. One had partial dermal necrosis on both ends of the inverted T scar which required debridement and secondary suture. Two developed hypertrophic scar that needed revision after one year follow-up. The advantages of the inferior pedicle technique is that 1) there is a good blood supply to the nipple - areola, 2) the nerve supply is preserved and the duct integrity is retained.

Bloody and serosanguineous nipple discharge.

Spontaneous bloody and serosanguineous nipple discharge is not only a relatively uncommon condition but also an alarming experience for women who suffer it. The objective of this study is to find the underlying causes, clinical pattern and proper management for the individual patient. From 1986 to June 1993 at the Department of Surgery, Siriraj Hospital, 32 cases were identified from the surgical records. All were female who had nonlactational, solitary, unilateral and spontaneous bloody or serosanguineous nipple discharge. Their ages ranged from 16 to 76 years with a mean age of 42 years. 11 of the 32 cases also had an associated definite breast mass and 2 had a subareolar induration. All but one were surgically treated by microdochectomy, segmental resection, excisional biopsy of the mass, and frozen section with mastectomy in 18, 6, 5 and 2 cases respectively. Intraductal papilloma or papillomatosis was the leading underlying cause followed by invasive ductal carcinoma which was found in 9 cases or 28% of the series. The malignant patents tended to be older and almost always had an associated breast mass on physical examination (8 in 9 cases). The risk of malignancy for the associated definite breast mass was statistically significant. Therefore, to eradicate the bleeding and establish a pathological diagnosis, all patients should be treated surgically regardless of the results of investigations. And those who have an associated definite breast mass should be considered to have a malignant growth until proved otherwise.

Total lower lip and chin reconstruction with the infrahyoid musculocutaneous flap.

A composite resection of total lip, chin and part of the mandible creates a defect that challenges the capability for reconstruction to obtain an acceptable result, both functionally and aesthetically. We have successfully used the infrahyoid musculocutaneous flap to reconstruct such a defect in a patient who had basal cell carcinoma of the low lip. Since the flap is pliable, relatively thin and can be used to reconstruct the defect in one stage, it deserves consideration as one of the flaps of choice for this particular defect.

Benign parotid tumors: 31 year experience at MDACC.

From 1954-1984 at M.D.Anderson Cancer Center (MDACC), 81 cases of benign parotid tumor were identified among more than 400 parotidectomized patients who were retrospectively reviewed. The ate of the patients ranged from 3-84 years with a median of 52 years. Twenty two out of 81 cases were previously treated patients from elsewhere. Benign mixed tumor and Warthin’s tumor were the 2 most common tumors which were found in 50 and 20 cases respectively. Superficial, total, superficial and partial deep lobe parotidectomy, total deep and partial superficial parotidectomy and excision were done in 49, 16, 14, 1 and 1 cases respectively. Facial nerves were sacrificed in 14 (main trunk = 1, branches of facial nerve = 13) and immediate nerve repair was accomplished in 10. Upper neck dissection was performed in 22 cases. The follow up time ranged from 4 to 34 years with a median of 10 years. There were no postoperative deaths. Only 5 cases (6% of the series) developed local recurrences. All of them were those who had been previously treated elsewhere, had benign missed tumor, and the recurrence developed in scar and soft tissue and were salvageable by further surgery. There was no recurrence among all 59 previously untreated patients. Adequate parotidectomy with facial nerve preservation is the treatment of choice for most benign parotid tumor. Enucleating or excision of the tumor not only causes an unacceptable high recurrent rate, but also makes the subsequent surgery (if necessary) more difficulty ad the facial nerve more vulnerable to injury.

Platysma myocutaneous flap for hypopharyngeal reconstruction.

Ten male patients with hypopharyngeal and/or laryngeal cancer underwent hypopharyngeal reconstruction after tumor ablation, using platysma myocutaneous flaps. Their age ranged from 41-82 years, (mean age of 62.7 years). All were examined by barium swallowing before and 2 weeks after operation in order to compare the size and function of hypopharynx. The immediate postoperative period was uneventful and satisfactory except one patient (10%) who suffered from the separation of suture lines on the flap leading to the development of saliva fistula and neck infection. The surgical technique, minor complications and long-term postoperative results were fully described in the report.

Mitoxantrone as single agent in the treatment of advanced breast cancer: Clinical study at Siriraj Hospital.

During August 1986 – August 1988, a total of 35 patients with advanced breast cancer were treated with Mitoxantrone (Novantrone), 14 mg/M3 intravenously every 3 weeks. Of these, 27 patients with total 78 lesions could be evaluated for response and 30 patients for toxicity. The mean follow-up period was 18 months (2-24 months). The median time to achieve response was 9 weeks after treatment. Eleven patients (41%) achieved an objection tumor response (CR+PR) including four (7%) complete response. In another way of evaluation, a total of 78 evaluable lesions were assessed of which 29 (37%) achieved response (CR+PR), including 10 (13%) complete response. The duration of response varied from minimum 2 months to more than 19 months (median=5 months). The median time to treatment failure was 5.9 months. Myelosuppression was the dose-limiting toxicity and was observed with moderate to severe degree in 19 patients (63%). The most frequent non-haematological toxicities were mild grade of nausea and vomiting occurred in 137 cycles from the total number of 195 evaluable cycles (70%). No cardiotoxicity was noted in this study after the maximum cumulative dose of Mitoxantrone 157.5 mg. This agent is well tolerated and offers comparable efficacy with less tolerable toxicity than other effective agents currently used as single agent in the treatment of advanced breast cancer.

Splenic salvage: A safe procedure.

Eighty five patients with splenic injury, 72 males and 13 females, 2-18 years of age, from the Department of Surgery, Siriraj Hospital, were managed by standard surgical procedure with an attempt to preserve the spleen. There were only 20 cases (23.53%) in which the splenic salvage succeeded, others had too much contraindication for splenic salvage. In the 20 cases, one had non-bleeding capsular tear, 14 underwent splenorrhaphy, 4 underwent partial splenectomy and splenic artery ligation was performed in one case. During a period of 2 years and 5 months, the success rate of the splenic salvage increased progressively from 10% in the first year to 33.3% in the last 5 months. In 65 cases of the splenectomy, 6 cases underwent splenic reimplantation without postoperative complication. Recently, the more conservative procedure is often performed instead of the splenectomy in all patients with splenic injury. Even one who undergoes splenectomy, splenic reimplantation also plays an alternative method in restoring normal protective function against the overwhelming post-splenectomy infection in selected case.