Bilateral Multiple Giant Juvenile Fibroadenomas in an Adolescent Girl.

Giant juvenile fibroadenomas are usually seen as rare variants of fibroadenomas in adolescents as unilateral solitary masses that may be managed by surgical excision with conservation of normal breast tissue. We report a case of a premenarchal 13-year-old female presenting with bilateral multifocal giant juvenile fibroadenomas requiring essentially bilateral subtotal nipple sparing mastectomies. Surgical evaluation revealed replacement of normal breast tissue on the right side. She then had development of two additional right-sided fibroadenomas requiring excision.

Savi Scout Radar Localization Versus Wire Localization for Breast Biopsy Regarding Positive Margin, Complication, and Reoperation Rates.

BACKGROUND: Breast cancer is the most commonly diagnosed noncutaneous malignancy and remains the second leading cause of cancer deaths in women. The Savi Scout (Cianna Medical, Merit Medical Systems, Inc. South Jordan, UT) is a wireless, nonradioactive, wave reflection implant system that enables surgeons to remove targeted breast lesions. Our study aims to be the largest comparison of wire and Savi Scout localization techniques for positive margin, complication, and reoperation rates. METHODS: Single-institution retrospective review of 512 patients that had Savi Scout Surgical Guidance System breast lesion biopsy or wire localized breast biopsy from May 2017 to December 2018. A RedCaps database was created and reviewed for outcomes. RESULTS: For 320 Savi scout patients, margins were positive or less than 1 mm in 18 cases (5.6%). 17 (5.3%) patients required reoperation. Surgical site occurrence was found in 7 (2.1%) patients, and 2 patients required intervention (0.6%). For 175 wire localization patients, margins were positive or less than 1 mm in 24 patients, and all required reoperation (13.7%). A surgical site occurrence was found in 13 (7.4%) patients and 5 patients required intervention (2.8%). DISCUSSION: In our series, the Savi Scout localization system resulted in a lower rate of positive margins, reoperation, and surgical site occurrence. These data suggest that Savi Scout localization is a reasonable replacement to wire localization for breast lesions and might produce superior results.

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management-American Society of Breast Surgeons Opioid/Pain Control Workgroup.

INTRODUCTION: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. METHODS: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. RESULTS: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. CONCLUSIONS: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.

The impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial: An institutional review.

BACKGROUND: Axillary dissection (AD) was historically recommended for all patients with breast tumor involvement discovered by sentinel lymph node biopsy (+SLNB). However, after the ACOSOG Z0011 trial, omission of AD became the recommendation for selected patients with a +SLNB. We report the impact of ACOSOG Z0011 on the completion AD rate in patients with +SLNB at our institution. METHODS: We retrospectively reviewed all patients diagnosed with breast cancer between March 2009 and February 2013 (n = 1781). This cohort was divided into two groups: 1) those diagnosed BEFORE Z0011 and 2) those diagnosed AFTER Z0011. We calculated both the percentage of patients with a +SNLB who underwent AD and, from those patients, the percentage who did and did not meet the Z0011 criteria. RESULTS: The BEFORE group contained 849 patients; 144 had +SLNB and from those 113 underwent AD. The AFTER group contained 932 patients: 139 had +SLNB and from those 73 underwent AD. The completion AD rate in the BEFORE group was 78.5%, compared to 52.5% in the AFTER group (p < 0.001). From the patients who met the Z0011 criteria, 75.6% of the BEFORE patients underwent AD, compared to only 2.2%% in the AFTER group (p < 0.001). Among those who did not meet the Z0011 criteria, a similar percentage of patients underwent AD in each group (BEFORE 79.8%, AFTER 74.4%, p = 0.384). CONCLUSION: Following the publication of the ACOSOG Z0011 trial, we experienced a significant decrease in the completion AD rate among patients with a +SLNB who met the Z0011 inclusion criteria.

Do patients with Down syndrome develop appendicitis?

BACKGROUND/PURPOSE: Given the number of individuals with Down syndrome (DS) and the high incidence of acute appendicitis (AA) in the general population, one would expect a certain number of patients with DS to develop AA. However, clinical experience suggests that AA is uncommon in patients with DS. This study was undertaken to determine whether the incidence of AA is significantly decreased in patients with DS. METHODS: A 13-year cross-sectional study of the state's hospital discharge database was performed to estimate the annual incidence of AA in patients with DS and in the general population. Estimates were generated for both pediatric (0-17 years) and adult (≥ 18 years) populations and were compared using 95% confidence intervals (CIs). In addition, the authors' hospital database was queried over a 10-year time frame. RESULTS: Incidence estimates of AA in children with DS and in the general pediatric population were 2.5 and 8.9 per 1000, respectively. In adults, the incidence estimates were 2.7 and 5.7 per 1000. CONCLUSIONS: The incidence of AA is markedly lower in patients with DS than in the general population. Although the biological basis for this remains unknown, this information is relevant in the evaluation of the acute abdomen in patients with DS.

The use of sentinel lymph node biopsy in ductal carcinoma in situ.

Although ductal carcinoma in situ (DCIS) does not require axillary evaluation, controversy exists regarding the use of sentinel lymph node biopsy (SLNB) in patients with DCIS diagnosed by core needle biopsy (CNB). Advocates of concomitant SLNB and lumpectomy cite the low morbidity of SLNB, the high rate of invasive ductal carcinoma in resected specimens, and the positive nodes found in 1 to 2 per cent of patients with resected DCIS despite finding no invasive component. Opponents of this practice cite the complication risk and the improbability of clinically significant axillary recurrence. We therefore proposed to determine our rate of invasive cancer in DCIS diagnosed by CNB and to determine whether SLNB at first operation would decrease return to the operating room. We retrospectively reviewed patients diagnosed with DCIS by CNB from 2003 to 2008. Standard clinicopathological data were collected and analyzed. In 110 patients, the prevalence of invasive cancer on final resection pathology was 13.6 per cent (15 of 110). Of those patients with invasive cancer, 93 per cent (14 of 15) had high-grade DCIS (P = 0.077) by CNB. Seventeen per cent (14 of 82) of patients with high-grade DCIS had invasive cancer. Of 34 patients with SLNB, three (9%) had positive nodes. Fifteen patients required re-excision to obtain negative margins, including 13 patients with invasive cancer. Five patients (4.5%) were spared additional operative intervention by initially performing SLNB. We suggest using concomitant SLNB when a high clinical suspicion of invasive cancer exists, in the presence of a palpable mass, or when mastectomy precludes future SLNB. Intraoperative margin assessment is needed to avoid return to the operating room.

Anaplastic thyroid carcinoma: an overview.

Thyroid cancer is an uncommon malignancy that accounts for roughly 1% of all new cancers. Although anaplastic lesions constitute fewer than 5% of thyroid cancers, they represent over half of thyroid cancer-related deaths. The relative rarity of anaplastic thyroid cancer, its aggressive nature, and its rapidly fatal course have contributed to the difficulty in developing effective treatment for this disease. Radiation, chemotherapy, and surgery are rarely curative, but combinations of these modalities appear to offer greater benefit than any single treatment. New treatment modalities are desperately required, and promising molecular-based therapies are being investigated.

Randomized multicenter trial of hyperthermic isolated limb perfusion with melphalan alone compared with melphalan plus tumor necrosis factor: American College of Surgeons Oncology Group Trial Z0020.

PURPOSE: To determine in a randomized prospective multi-institutional trial whether the addition of tumor necrosis factor alpha (TNF-alpha) to a melphalan-based hyperthermic isolated limb perfusion (HILP) treatment would improve the complete response rate for locally advanced extremity melanoma. PATIENTS AND METHODS: Patients with locally advanced extremity melanoma were randomly assigned to receive melphalan or melphalan plus TNF-alpha during standard HILP. Patient randomization was stratified according to disease/treatment status and regional nodal disease status. RESULTS: The intervention was completed in 124 patients of the 133 enrolled. Grade 4 adverse events were observed in 14 (12%) of 129 patients, with three (4%) of 64 in the melphalan-alone arm and 11 (16%) of 65 in the melphalan-plus-TNF-alpha arm (P = .0436). There were two toxicity-related lower extremity amputations in the melphalan-plus-TNF-alpha arm, and one disease progression-related upper extremity amputation in the melphalan-alone arm. There was no treatment-related mortality in either arm of the study. One hundred sixteen patients were assessable at 3 months postoperatively. Sixty-four percent of patients (36 of 58) in the melphalan-alone arm and 69% of patients (40 of 58) in the melphalan-plus-TNF-alpha arm showed a response to treatment at 3 months, with a complete response rate of 25% (14 of 58 patients) in the melphalan-alone arm and 26% (15 of 58 patients) in the melphalan-plus-TNF-alpha arm (P = .435 and P = .890, respectively). CONCLUSION: In locally advanced extremity melanoma treated with HILP, the addition of TNF-alpha to melphalan did not demonstrate a significant enhancement of short-term response rates over melphalan alone by the 3-month follow-up, and TNF-alpha plus melphalan was associated with a higher complication rate.