Bilateral pseudoangiomatous stromal hyperplasia in a human immunodeficiency viral-infected patient.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon mesenchymal neoplasm of the breast demonstrating stromal myofi broblastic proliferation and having the appearance of anastomosing slit-like pseudovascular spaces lined by spindle-shaped cells. A case of nodular PASH of the bilateral breasts in a 40-year-old woman with clinically presenting with a progressive enlarged breast lump is reported. Mammographic and ultrasonographic features of the right and left breasts showed a large solid lump with well-circumscribed border measuring 4 cm  1.7 cm  3.4 cm and 13.8 cm  10.9 cm  12.1 cm, respectively. Wide excision of the right breast and quadrantectomy of the left breast were performed. The histopathological examination of the lesion showed anastomosing slit-like pseudovascular spaces. The stromal cells were immunoreactive for muscle actin (HHF35), smooth muscle actin, and progesterone receptor. Clinical and pathological fi ndings with briefl y reviewed relevant literatures are discussed. This is the fi rst clinicopathological and radiological report of bilateral mammary nodular PASH in a human immunodefi ciency viral-infected patient.

A laparoscopic versus open adrenalectomy in Ramathibodi Hospital.

OBJECTIVE: To compare the results of laparoscopic adrenalectomy with those of open adrenalectomy in Ramathibodi Hospital. MATERIAL AND METHOD: Medical charts of 41 laparoscopic and 39 open adrenalectomy patients were reviewed Baseline characteristics and outcomes of treatment were compared between these two patient groups, using univariable statistical tests and multivariable statistical procedures. RESULTS: There were significant baseline differences between the two groups in terms of gender, body mass index, ASA class, and preoperative diagnosis. The outcomes operative time, estimated blood loss and length of hospital stay were also significantly different. After adjusting for the effects of baseline differences, laparoscopic adrenalectomy was associated with a significant reduction of length of hospital stay by 40%. CONCLUSION: Laparoscopic adrenalectomy is a safe and effective procedure and should help hasten postoperative recovery and may save the costs of hospitalization.

Acute effects of postmastectomy radiotherapy after immediate TRAM flap reconstruction in breast cancer patients.

OBJECTIVES: To study the acute effects of radiotherapy after mastectomy and immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction in breast cancer patients treated at Ramathibodi Hospital. MATERIAL AND METHOD: Between January 2004 and March 2005, ten breast cancer patients (age 32-51 years) were treated with postoperative radiotherapy after mastectomy and immediate TRAM flap reconstruction. Medical records of these patients were retrospectively reviewed. Radiotherapy was delivered to the chest wall and reconstructed TRAM flap using 6-MV x-ray or Cobalt-60. The total dose was 45 to 50.4 Gy delivered in 25 to 28 fractions. Patients were evaluated weekly during the course of radiation and then at 1 and 2 months after treatment completion to determine acute effects or toxicities of radiation. RESULTS: During radiation, 3 patients developed erythema or mild hyperpigmentation of the skin, and 4 developed moderate hyperpigmentation. Three patients who were treated with Cobalt-60 and/or bolus to the chest wall developed skin desquamation (1 dry desquamation, 2 moist desquamation). No patient required a treatment break because of acute side effects. One patient who received chemotherapy after radiation developed recalled moist desquamation. CONCLUSION: Radiotherapy after mastectomy and immediate TRAM flap reconstruction is well tolerated and is not associated with increased acute complication or radiation interruption. The authors have noticed that chemotherapy given after radiation was related to severe skin reaction, so it should be used with caution.

Thoracic epidural anesthesia (TEA) with 0.2% ropivacaine in combination with ipsilateral brachial plexus block (BPB) for modified radical mastectomy (MRM).

BACKGROUND: Breast cancer is the 2nd most common tumors in Thai women. Until now, oncologic breast surgeries are typically performed by general anesthesia (GA). However, GA cannot provide adequate postoperative pain control and routine use of parenteral opioids aggravate postoperative sedation, nausea, emesis, impaired oxygenation and depressed ventilation. Thoracic epidural anesthesia (TEA) is one of the regional anesthetic techniques that can be done by using a low dose of local anesthetic in combination with ipsilateral brachial plexus block (BPB) for axillary node dissection. TEA can provide a better pain relief without potential paralysis of respiratory muscle and sedation. MATERIAL AND METHOD: Fifty ASA PS I-III patients undergoing MRM were randomly assigned to two study groups of 25 patients each. In the TEA group, an epidural catheter was inserted at T4 to T5, and 10-15 ml of 0.2% ropivacaine was injected, then interscalene BPB was done with 8 ml of 0.2% ropivacaine. Anesthesia was maintained with 5-10 ml of 0.2% ropivacaine per hour. GA was induced with 1 microg/kg of fentanyl followed by 1.5-2 mg/kg of propofol and was maintained with sevoflurane and 70% N2O in oxygen. The authors evaluated the adequacy of anesthesia, surgical condition, postanesthetic recovery, postanesthetic analgesia and patients' satisfaction. RESULTS: The demographic data was similar in both groups. The number of patients immediately arrived at PACU with a sedation score of 1 was significantly greater in TEA group (p = 0.003) while the number of patients with an Aldrete score of 10 was greater but not statistically significant (p = 0.25). The verbal rating scale and analgesic requirement were significantly lower in the TEA group (p < 0.001 and p = 0.002 respectively). Patients' satisfaction was greater with TEA than with GA (p = 0.014). Surgical condition was similar in both groups. CONCLUSION: The present study shows that TEA combined with BPB by using a low dose of 0.2% ropivacaine is a safe and reliable alternative technique for MRM. It can provide not only effective anesthesia but also better postoperative pain relief faster anesthetic recovery and greater patient satisfaction than those of the GA technique.