Palpable presentation of breast cancer persists in the era of screening mammography.

BACKGROUND: The aim was to describe cancer detection method and frequency of screening mammography in women undergoing breast cancer surgery in 2000. STUDY DESIGN: Patients undergoing breast cancer surgery were identified through an institutional database. Charts were reviewed to determine presentation at time of diagnosis. Presentation was coded "palpable" if the woman presented with a breast complaint or if a new mass was detected on examination versus "screening" if detected on screening mammogram. RESULTS: Five hundred ninety-two breast cancers were identified: 57% presenting by screening and 43% palpable. Cancer was more likely to present as palpable in patients with no previous screening mammography compared with those with previous mammography (67% versus 39%; p = 0.0002). Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years; p < 0.0001). CONCLUSIONS: Despite the frequent use of screening mammography, 43% of breast cancers presented as a palpable mass or otherwise symptomatic presentation.

Anterior acromioplasty for the shoulder impingement syndrome: long-term outcome.

This study reanalyzes a group of patients who had anterior acromioplasty between 1975 and 1979, whose results were reported in 1990 at a mean 8-year follow-up, to identify any continuing problems or new complications, to assess the frequency of further surgery, and to define long-term outcome. Thirty-two patients were included. The mean follow-up was 25 years (range, 21 to 27 years). All had the impingement syndrome. At surgery, there was tendon and bursal inflammation with fibrosis in 28 shoulders and a small rotator cuff tear in 4. Five shoulders have required additional surgery: distal clavicle excision in one, revision anterior acromioplasty in one, and repair of a new rotator cuff tear in three. Of the shoulders, 23 (72%) were reported as having no or slight pain. Positive patient satisfaction was expressed in 28 (88%). Comparisons were made to the opposite shoulder in this older patient group. The mean within-patient difference between the operative shoulder and the opposite shoulder on the Simple Shoulder Test was 0.4, with scores of 8.9 for the operative side and 9.3 for the opposite side (P = .47). The mean difference in the American Shoulder and Elbow Surgeon's score was 8.6 points, with scores of 75 for the operative side and 83 for the opposite side (P = .02). The results of open acromioplasty for the impingement syndrome are usually maintained over time. Acromioplasty does not always prevent the need for subsequent rotator cuff surgery, but the rate of reoperation has remained relatively low in the long follow-up period.

Crohn Disease: mural attenuation and thickness at contrast-enhanced CT Enterography--correlation with endoscopic and histologic findings of inflammation.

PURPOSE: To determine retrospectively if quantitative measures of small-bowel mural attenuation and thickness at computed tomographic (CT) enterography correlate with endoscopic and histologic findings of small-bowel inflammation and to estimate the performance of these measures in predicting inflammatory Crohn disease. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study, which was conducted with patient informed consent. CT enterography data in 96 patients (31 male patients and 65 female patients) who underwent ileoscopy with or without biopsy were examined for CT signs of active Crohn disease. The most highly enhancing segment of terminal ileum and a normal-appearing ileal loop were identified. After it was confirmed that semiautomated software could accurately measure mural attenuation and thickness, the selected terminal ileal and normal-appearing (control) ileal loops were examined (20 automated measurements at each location) to quantify mural attenuation and wall thickness. Results were compared with endoscopy and histology reports by using logistic regression analysis and receiver operating characteristic curves. RESULTS: Quantitative measures of terminal ileal mural attenuation and wall thickness correlated significantly with active Crohn disease (P < .001). Small-bowel wall thickness was not a significant factor after attenuation was taken into account. A threshold attenuation value with a sensitivity of 90% (18 of 20) for definite Crohn disease (compared with a sensitivity of 80% [16 of 20] for radiologist assessment) was selected. In patients who underwent ileal biopsy, threshold attenuation had a sensitivity identical to that of ileoscopy (81% [26 of 32]; 95% confidence interval: 64%, 93%) in predicting histologic inflammation. CONCLUSION: Quantitative measures of mural attenuation and wall thickness at CT enterography correlate highly with ileoscopic and histologic findings of inflammatory Crohn disease. Quantitative measures of mural attenuation are sensitive markers of small bowel inflammation.

Laparoscopic esophageal myotomy for achalasia: factors affecting functional results.

BACKGROUND: We reviewed our experience and analyzed factors affecting functional results after laparoscopic esophageal myotomy (LEM) for achalasia. METHODS: From January 1996 through October 2003, the records of 211 patients (110 men and 101 women) who had LEM for achalasia were reviewed, and factors affecting morbidity and functional results were analyzed. RESULTS: Median age was 47 years (range, 12 to 85). One hundred and twenty-five patients (59%) had prior esophageal dilatation and/or botulinum toxin injection and 19 (9%) had a prior myotomy. A partial fundoplication was performed in 198 patients (94%); posterior in 135 and anterior in 63. Median operative time was 208 minutes (range, 90 to 527). Intraoperative complications occurred in 37 patients (17.5%), and included mucosal perforation in 32, pneumothorax in 2, and retained needle, splenic capsular tear, and gastric short vessel bleeding in 1 each. Five patients (2%) required conversion to an open procedure. Postoperative complications occurred in 17 patients (8%) including 2 patients who required reoperation for leak. There were no perioperative deaths. Median hospitalization was 3 days (range, 1 to 48). Follow-up was complete in 167 patients (79%) and ranged from 1 to 70.5 months (median, 5.3). Functional results were classified as excellent in 105 patients (63%), good in 43 (26 %), and fair or poor in 19 (11%). Previous esophageal surgery for achalasia adversely affected functional results (p = 0.0139). Preoperative bougie dilatation (p = 0.9851), pneumatic dilatation (p = 0.8548), botulinum toxin injection (p = 0.1724), and the type of fundoplication (p = 0.5904) did not affect functional results. Preoperative bougie dilatation (p = 0.441), pneumatic dilatation (p = 0.1060), and botulinum toxin injection (p = 0.3938) did not affect the incidence of intraoperative perforation. As experience is gained, the incidence of intraoperative complications has decreased significantly (p = 0.0075). CONCLUSIONS: Laparoscopic myotomy for achalasia is safe and effective in the majority of patients. The incidence of intraoperative complications decreases as experience is gained. Preoperative endoscopic treatment does not preclude successful surgical outcome. Excellent or good functional results are achieved in the majority of patients although previous surgical treatment adversely affects functional results.

Intraductal papillary mucinous neoplasms of the pancreas: CT patterns of recurrence and multiobserver performance in detecting recurrent neoplasm after surgical resection.

OBJECTIVE: The purposes of our study were to describe the CT appearance of recurrent intraductal papillary mucinous neoplasms of the pancreas after surgical resection and estimate the performance of CT in detecting recurrent neoplasms. MATERIALS AND METHODS: A single unblinded reviewer characterized the presence and appearance of recurrent intraductal papillary mucinous neoplasms on 66 CT scans of 17 patients with proven recurrence, noting location and appearance of recurrent neoplasm. These results, described in this article, were summarized in tabular format and shown to three blinded observer. The observers then evaluated one postoperative CT examination from every patient at our institution who underwent surgical removal of intraductal papillary mucinous neoplasms (n = 45) for the presence or absence of local or distant recurrence. RESULTS: The unblinded reviewer found 11 cases of local recurrence. Extrapancreatic local recurrences tend to have solid components (5/6), tend to be located adjacent to the resection margin (5/6), and may exhibit vascular invasion (2/6). Intrapancreatic neoplasms are usually cystic (4/5). Nine patients had distant metastases. Prospective sensitivity for recurrent tumor ranged from 76% (13/17) to 94% (16/17). Sensitivity for local recurrence ranged from 55% (6/11) to 82% (9/11). Specificity ranged from 79% (22/28) to 96% (27/28). Interobserver agreement for predicting recurrence was moderate to substantial (kappa = 0.51-0.65). CONCLUSION: Locally recurrent intraductal papillary mucinous neoplasms of the pancreas tend to be either extrapancreatic and solid at the resection margin or intrapancreatic and cystic. CT can detect most recurrent intraductal papillary mucinous neoplasms of the pancreas with moderate to substantial interobserver agreement.

The effect of ageing on function and quality of life in ileal pouch patients: a single cohort experience of 409 patients with chronic ulcerative colitis.

OBJECTIVE: To evaluate in what manner ageing affects functional outcome and quality of life (QoL) in patients with chronic ulcerative colitis (CUC) after ileal pouch-anal anastomosis (IPAA). SUMMARY BACKGROUND DATA: Short-term function and QoL after IPAA is good. However, patients are usually young, and little is known about the influence of time and ageing on long-term outcomes after IPAA. METHODS: Using a standardized questionnaire, functional outcome, QoL, and complications were assessed prospectively in a cohort of 409 patients followed annually for 15 years after IPAA. RESULTS: Follow-up was complete in the single cohort of 409 patients and functional and QoL outcomes summarized at 5, 10, and 15 years. Daytime stool frequency changed little (mean 6), while nighttime frequency increased from 1 stool to 2 stools. Incontinence for gas and stool increased from 1% to 10% during the day and from 2% to 24% at night over 15 years. The cumulative probability of pouchitis increased from 28% at 5 years to 38% at 10 years and to 47% at 15 years. Bowel obstruction and stricture were other principal long-term complications. At 15 years, 91% of patients had kept the same job. Work was not affected by the surgery in 83%, while social activities, sports, traveling, and sexual life all improved after surgery and did not deteriorate over time. CONCLUSIONS: These long-term results in a single cohort of 409 IPAA patients are unique and are likely a more accurate reflection of long-term outcome than has been previously reported. These data support the conclusion that IPAA is a durable operation for patients requiring proctocolectomy for CUC; functional and QoL outcomes are good, predictable, and stable for 15 years after operation.

Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients.

HYPOTHESIS: Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival. DESIGN: Retrospective outcome study. SETTING: Single tertiary referral institution. PATIENTS: Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy. MAIN OUTCOME MEASURES: Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality. RESULTS: Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional. CONCLUSIONS: The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.

Time interval between abnormalities seen on CT and the clinical diagnosis of pancreatic cancer: retrospective review of CT scans obtained before diagnosis.

OBJECTIVE: Our purpose was to determine whether abdominal CT can detect pancreatic cancer before its clinical diagnosis. SUBJECTS AND METHODS: Two radiologists interpreted in a blinded manner 62 CT scans in 28 pancreatic cancer patients that were obtained before histologic diagnosis and 89 CT scans in 89 control subjects and noted specific CT findings. The presence of pancreatic cancer was characterized as definite, suspicious, low probability, or normal. The scans of the pancreatic cancer patients were divided into four groups on the basis of the time interval preceding cancer diagnosis (0-2, 2-6, 6-18, or > 18 months), and one scan (closest to 18 months) was selected per patient per time interval. Sensitivity and specificity for pancreatic cancer and interobserver agreement for CT findings were calculated. RESULTS: Radiologists agreed that CT findings definite or suspicious for pancreatic cancer were present in 50% of the scans obtained 2-6 and 6-18 months before the diagnosis of pancreatic cancer (3/6 and 4/8 scans, respectively), but they noted such CT findings in only 7% (1/15) of the scans obtained more than 18 months before diagnosis. Pancreatic duct dilatation and cutoff were early CT findings identified by both radiologists and were associated with near-perfect and substantial interobserver agreement (kappa = 0.84 and 0.76, respectively). Ninety-five percent confidence intervals of specificity for tumor absence ranged from 92% to 100%. CONCLUSION: CT can detect a significant proportion of asymptomatic incident pancreatic cancers before the clinical diagnosis of pancreatic cancer. CT should be considered in screening at-risk patient populations. Pancreatic duct dilatation and cutoff are early findings associated with the development of pancreatic cancer and can be detected on CT with a high degree of reproducibility.