Breast conservation therapy for invasive lobular carcinoma: the impact of lobular carcinoma in situ in the surgical specimen on local recurrence and axillary node status.

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

An argument against routine sentinel node mapping for DCIS.

Indications for sentinel lymph node mapping (SLNM) for patients with ductal carcinoma in situ (DCIS) of the breast are controversial. We reviewed our institutional experience with SLNM for DCIS to determine the node positive rate and clarify indications for nodal staging in patients with DCIS. Since 1998 we have used SLNM to stage breast cancer patients using both blue dye and radiocolloid. In DCIS patients, SLNM has been reserved for patients considered at high risk for harboring coexistent invasive carcinoma or treated by mastectomy. All sentinel nodes were evaluated with serial sectioning, hematoxylin and eosin staining, and immunohistochemical evaluation for cytokeratins. We identified 44 patients with 46 cases of DCIS (two patients with bilateral disease). SLNM identified at least one sentinel node in all cases. In all cases, the sentinel node(s) were negative for axillary metastasis. We calculated the binomial probability of observing 0 of 46 cases as negative when the expected incidence according to published reports in the surgical literature was 13 per cent and found a P value of <0.01. Based on this case-series observation, we conclude SLNM should not be routinely performed for patients with DCIS. We now use SLNM only for DCIS patients treated by mastectomy.

An analysis of sestamibi-positive versus -negative patients with primary hyperparathyroidism.

We performed this study to evaluate two patient groups with primary hyperparathyroidism depending on whether their abnormal gland(s) could be preoperatively imaged with sestamibi. Patients with primary hyperparathyroidism evaluated by preoperative sestamibi examination from January 1999 to June 2000 were divided into two groups depending on the ability of sestamibi to localize their disease. Records were reviewed to determine pre- and postoperative biochemical data, weight of the excised glands, and total operating room time. When the sestamibi imaging was positive a minimally invasive parathyroidectomy was performed; however, when sestamibi scanning was negative patients underwent a formal bilateral neck exploration. All 40 patients in the sestamibi-positive group and 17 of 18 patients in the sestamibi-negative group were cured of their primary hyperparathyroidism as a result of surgery. Sestamibi scanning with a minimally invasive parathyroidectomy shortens operating room time and is most effective when adenomas are large. The results of this study suggest that strategies to preoperatively increase the activity of adenomas may improve the sensitivity of sestamibi scan localization of parathyroid adenomas.

A mass on breast imaging predicts coexisting invasive carcinoma in patients with a core biopsy diagnosis of ductal carcinoma in situ.

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

Image-guided breast biopsy.

Image-guided breast biopsy has become an attractive alternative to wire-localized excisional biopsy to evaluate women with nonpalpable abnormalities detected by breast imaging. We have organized a database from our institution that includes over 3,500 procedures. We have reviewed our institutional results and the literature pertaining to image-guided breast biopsy. Discussed in this review are the indications and contraindications for image-guided biopsy, common techniques employed, accuracy based on pathology, reimbursement issues, and the multidisciplinary approach used at our institution. The results of our review affirm our position that image-guided breast biopsy is the preferred technique to evaluate women with nonpalpable breast imaging abnormalities.

Biopsy technique has no impact on local recurrence after breast-conserving therapy.

Image-guided core needle breast biopsy (IGCNBB) is an incisional biopsy technique that has been associated with tumor cell displacement. Theoretically tumor cell displacement may affect local recurrence rates in patients treated with breast-conserving therapy (BCT). We performed a study to determine if the biopsy method impacted local control rates following BCT. Patients with nonpalpable breast cancer (invasive and intraductal) diagnosed at our institution and treated with BCT between July 1993 and July 1996 were selected to provide a follow-up period in which the majority of local recurrences should be detected. Patients were divided into two groups based on their method of diagnosis. Group I patients were diagnosed by IGCNBB and group II patients were diagnosed by wire localized excisional breast biopsy (WLEBB). Factors potentially affecting local recurrence rates were retrospectively reviewed. Two hundred eleven patients were treated with BCT, 132 were diagnosed by IGCNBB and 79 by WLEBB. The two patient groups were similar when compared for prognostic factors and treatment. All patients' BCT included histologically negative margins. There were 4 (3.0%) local recurrences in Group I at a median follow-up of 44.4 months and 2 (2.5%) local recurrences in group II at a median follow-up of 50.1 months. This difference was not significant. Breast cancer patients diagnosed by IGCNBB can be treated by BCT with acceptable local control rates. Additional surveillance of our institutional experience and others' is mandatory to validate IGCNBB as the preferred biopsy method for nonpalpable mammographic abnormalities.

A critical appraisal of treatment for T3N0 colon cancer.

The purpose of this study was to evaluate the impact of adjuvant chemotherapy on survival after surgery for T3N0 colon cancer. All patients with node-negative (N0) colon cancer with tumor invasion beyond the muscularis propria (T3) treated with colectomy between 1982 and 1995 at a single institution were included. Patients were divided into two groups depending on postcolectomy treatment with or without adjuvant chemotherapy. Groups were evaluated to determine perioperative and pathologic variables that could potentially influence outcome and surveillance data to determine disease-free and overall survival. In 253 patients with T3N0 colon cancer 226 remained under observation and 27 were treated with adjuvant chemotherapy. The groups were similar (P = not significant) when compared for tumor location, size, differentiation, number of nodes harvested, and transfusion requirements. Four of the 27 patients who received chemotherapy developed a recurrence (14.8%), whereas 22 of the 226 observation patients developed a recurrence (9.7%). Disease-free survival for the chemotherapy group at 5 years was 84 per cent and for the observation group 87 per cent. Statistical analysis (Mantel-Cox) showed no significant difference between the groups on the basis of survival (P = 0.3743). We conclude that resection alone is a highly effective treatment for T3N0 colon cancer leaving limited opportunity for adjuvant chemotherapy to significantly impact survival. Adjuvant chemotherapy for T3N0 colon cancer patients should be limited to patients enrolled in clinical trials designed to identify subgroups of T3N0 colon cancer patients at a survival disadvantage or less toxic adjuvant chemotherapies.

Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T(is,1,2) breast cancer.

BACKGROUND: We hypothesized that wide-field brachytherapy (BRT) after margin negative excision would result in complication rates, local recurrence rates, and cosmesis scores equivalent to external beam radiotherapy (ERT). METHODS: Patients with T(is,1,2) tumors less than or equal to 4 cm, 0 to 3 positive axillary nodes, and negative inked surgical margins were entered prospectively into BRT phase I/II trial. Patients who met the eligibility criteria for BRT but were treated with ERT during the same time period were retrospectively identified as controls. A blinded panel of healthcare professionals graded cosmetic outcome. RESULTS: Fifty patients with 51 breast cancers received BRT from January 1992 to October 1993. We identified 94 patients eligible for BRT but concurrently treated with ERT. At a median follow-up of 75 months, the two groups were similar for grade III treatment toxicities, local/regional recurrence rates, and cosmesis scores. CONCLUSIONS: For selected breast cancer patients undergoing breast-conserving therapy, BRT is an attractive alternative to ERT.

Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma.

OBJECTIVE: To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS: A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS: The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS: Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.

Benign diagnosis by image-guided core-needle breast biopsy.

Image-guided core-needle breast biopsy (IGCNBB) is widely used to evaluate patients with abnormal mammograms; however, information is limited regarding the reliability of a benign diagnosis. The goal of this study was to demonstrate that a benign diagnosis obtained by IGCNBB is accurate and amenable to mammographic surveillance. Records of all patients evaluated by IGCNBB from July 1993 through July 1996 were reviewed. Biopsies were classified as malignant, atypical, or benign. All benign cases were followed by surveillance mammography beginning 6 months after IGCNBB. Of the 1110 patients evaluated by IGCNBB during the study period, 855 revealed benign pathology. A total of 728 of the 855 patients (85%) complied with the recommendation for surveillance mammography. A total of 196 IGCNBBs were classified as malignant; 59 cases were classified as atypical. The atypical cases were excluded from the statistical analysis. Only two patients have demonstrated carcinoma after a benign IGCNBB during the 2-year minimum follow-up period. The sensitivity and specificity of a benign result were 100.0 and 98.9 per cent, respectively. A benign diagnosis obtained by IGCNBB is accurate and therefore amenable to mammographic surveillance. The results of this study support IGCNBB as the preferred method of evaluating women with abnormal mammograms.

Understanding patterns of failure in breast cancer treatment argues for a more thorough investigation of axillary lymph nodes in node negative patients.

BACKGROUND: An understanding of the patterns of failure after potentially curative treatment of breast cancer patients can lead to the development of improved methods of patient management. METHODS: We compared two groups of patients in whom breast cancer recurred after potentially curative treatment. Patients were assigned to their groups based on the status of their lymph nodes at the time of presentation. RESULTS: In all, 294 recurrences were analyzed to demonstrate that the patterns of failure for the two groups were identical. In the node-positive group, recurrence occurred sooner and their primary tumors were larger. CONCLUSION: The nearly identical patterns of treatment failure in lymph node negative and positive breast cancer patients suggests that metastasis in node negative patients occurs by a similar mechanism. The shorter time to recurrence and larger primary tumor may only reflect a lead time bias, in that node-positive patients have a greater tumor burden in their lymph nodes that facilitates identification by pathologists.

A better understanding of the term radial scar.

BACKGROUND: Radial scar is a breast lesion with mammographic and histologic features similar to carcinoma. We reviewed the characteristics of patients with radial scars to better understand these lesions and to determine the incidence of associated carcinoma. METHODS: Records for all patients undergoing diagnostic wire localized excisional breast biopsy from January 1993 to September 1999 were reviewed to identify those with histologic or mammographic evidence of radial scar. Clinical records, mammograms, and pathologic slides of these patients were reviewed. RESULTS: We identified 45 cases of radial scar: 10 patients had mammographic and histologic evidence of radial scar (group I), 29 only mammographic evidence (group II), and 6 only histologic evidence (group III). Breast cancer risk was similar in the three patient groups. Carcinoma was identified in 18 patients with mammographic radial scars. CONCLUSION: Mammographically detected radial scars were associated with carcinoma in 18 of 39 (46%) cases. Histologically identified radial scars are not associated with malignancy and should not be confused with mammographically identified lesions.

Steep learning curve of laparoscopic splenectomy.

BACKGROUND AND PURPOSE: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned. METHODS: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed. RESULTS: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy. CONCLUSION: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.

Laparoscopic adrenalectomy is superior to an open approach to treat primary hyperaldosteronism.

We reviewed our institutional experience with primary hyperaldosteronism to compare clinical outcomes after laparoscopic versus open adrenalectomy. All patients surgically treated for primary hyperaldosteronism from 1988 through 1999 are included in this study. Patients were assigned to either the LA (laparoscopic) or OA (open) group depending on the initial surgical approach selected for treatment. Records were reviewed to determine demographics, operative results, and complications. Twenty-four patients were surgically treated for primary hyperaldosteronism. There were no significant differences between groups with respect to age, weight, number of preoperative antihypertensive medications, or preoperative potassium level. The results of adrenalectomy with respect to number of postoperative antihypertensive medications or serum potassium level were also similar. Operative times were not significantly different (191 +/- 53 minutes for OA and 205 +/- 88 minutes for LA) between groups, but four LA patients were converted to OA. Estimated blood loss was 401 +/- 513 cm3 for OA and 127 +/- 131 cm3 for LA (P = 0.07). Hospital length of stay was 6.7 +/- 3.7 days for OA and 3.3 +/- 2.7 days for LA (P = 0.02). Complications were nine for OA and three for LA (P = 0.001 by Pearson's Chi square). LA is similar to OA in the treatment of primary hyperaldosteronism. The significantly fewer complications and shorter length of hospital stay associated with LA makes the laparoscopic approach the preferred method for treating primary hyperaldosteronism.

A simple approach to nipple discharge.

Evaluation and management of patients with nipple discharge (ND) aims to identify carcinoma when present, and in benign cases, stop the discharge when bothersome. We reviewed our recent experience with ND to develop a simple and effective algorithm to manage these patients. Records of all patients with ND evaluated from December 1996 through June 1999 were reviewed. Patients were liberally offered duct excision for a clinical suspicion of malignancy (persistent clear or bloody fluid) or to stop bothersome discharge. Patients with breast imaging abnormalities (mammography or ultrasound) related to their ND underwent biopsy and were considered separately. Of 104 patients with ND, 11 underwent biopsy as a result of mammographic findings; three of these cases proved malignant. The remaining 93 patients were evaluated with 55 tests that did not demonstrate malignancy, including ductography, discharge fluid cytology, serum prolactin and thyroid-stimulating hormone levels, and image-guided breast or nipple biopsy. Thirty-nine patients underwent duct excision with only a single patient demonstrating malignancy. Clinical follow-up has not identified malignancy in any patient managed nonoperatively. When diagnostic breast imaging is negative, malignancy related to ND is uncommon. Patients with ND should have diagnostic breast imaging and, if it is negative, should be offered duct excision. There is little role for ductography, cytology, or laboratory studies in evaluating these patients.

Lessons learned from the initial 100 patient experience with sentinel lymph node mapping in the evaluation of breast cancer.

The initial reports of sentinel lymph node mapping for breast cancer currently appearing in the surgical literature are demonstrating the practicality and accuracy of the technique to evaluate patients for axillary nodal disease. We reviewed our initial 100 patient experience with sentinel node mapping to evaluate our ability to employ this technique in breast cancer patients. We combined a peritumoral injection of a radioactive substance and blue dye. Each sentinel node was evaluated with frozen section analysis, hematoxylin and eosin staining, and, if still negative, five re-cuts were taken from deeper levels of the node and evaluated for immunohistochemical evidence of cytokeratin staining. Sentinel node(s) were identified in all but two patients with 51% demonstrating metastasis. We have demonstrated the ability to accurately perform sentinel node mapping in the evaluation of our breast cancer patients. This exciting advance should become a standard part of breast cancer surgery.

Minimally invasive abdominal surgery.

In the last decade, laparoscopy has been the most innovative surgical movement in general surgery. Minimally invasive surgery performed through a few small incisions, laparoscopy is the standard of care for the treatment of gallbladder disease and the gold standard for the treatment of reflux disease. The indications for a laparoscopic approach to abdominal disease continue to increase, and many diseases may be treated with laparoscopic techniques. At Ochsner, laparoscopic techniques have demonstrated better cosmetic results, shorter recovery times, and an earlier return to normal activity compared with open surgery.

Minimally invasive parathyroid surgery.

Minimally invasive parathyroidectomy offers patients a less morbid surgical approach to treat primary hyperparathyroidism. Biochemically diagnosed hyperparathyroid patients undergo a preoperative sestamibi scan to localize abnormal parathyroid tissue. If the scan is positive, a focused unilateral neck exploration is performed through a 2-3 cm incision with the aid of a gamma detector to identify the radioactive, abnormal parathyroid gland(s).In the Ochsner Clinic's initial experience with minimally invasive parathyroidectomy, 34 patients were evaluated with 20 positive scans, 4 suggestive scans, and 10 negative scans. Of the 24 patients with scans demonstrating abnormal parathyroid activity, 23 were successfully managed with the minimally invasive technique. The mean total surgical time was 72.9 minutes, and the mean weight of the excised parathyroid glands was 1445.4 mg. All 10 patients with negative scans had a traditional bilateral neck exploration lasting a mean time of 146.5 minutes; the mean weight of the excised parathyroid glands was 388.6 mg. Hypercalcemia was cured in all 24 patients in the positive group and 9 of 10 patients in the negative scan group.Ochsner's initial experience with minimally invasive parathyroidectomy demonstrates that about 70% of patients can expect to be candidates for this technique, which is associated with excellent cure rates and shorter operative times.

Image-guided core-needle breast biopsy is an accurate technique to evaluate patients with nonpalpable imaging abnormalities.

OBJECTIVE: The goal was to evaluate one institution's experience with image-guided core-needle breast biopsy (IGCNBB) and compare the pathologic results with wire-localized excisional breast biopsy (WLEBB) for patients with positive cores and the mammographic surveillance results for patients with negative cores. SUMMARY BACKGROUND DATA: IGCNBB is becoming a popular, minimally invasive alternative to WLEBB in the evaluation of patients with nonpalpable abnormalities. METHODS: This study includes all patients with nonpalpable breast imaging abnormalities evaluated by IGCNBB from July 1993 to February 1997. Patients with positive cores (atypical hyperplasia, carcinoma in situ, or invasive carcinoma) were evaluated by WLEBB. Patients with negative cores (benign histology) were followed with a standard mammographic protocol. IGCNBB results were compared with WLEBB results to determine the sensitivity and specificity for each IGCNBB pathologic diagnosis. RESULTS: Of 1440 IGCNBBs performed during the study period, 1106 were classified as benign, and during surveillance follow-up only a single patient was demonstrated to have a carcinoma in the index part of the breast evaluated by IGCNBB (97.3% sensitivity, 99.7% specificity). IGCNBB demonstrated atypical hyperplasia in 72 patients, 5 of whom refused WLEBB. The remaining 67 patients were evaluated by WLEBB: nonmalignant findings were found in 31, carcinoma in situ was found in 25, and invasive carcinoma was found in 11 (100% sensitivity, 88.8% specificity). IGCNBB demonstrated carcinoma in situ in 84 patients; WLEBB confirmed carcinoma in situ in 54 and invasive carcinoma in 30 (65.4% sensitivity, 97.7% specificity). IGCNBB demonstrated invasive carcinoma in 178 patients. Three were lost to follow-up. On WLEBB, 173 of the remaining 175 had invasive carcinoma; the other 2 patients had carcinoma in situ (80.8% sensitivity, 99.8% specificity). CONCLUSIONS: An IGCNBB that demonstrates atypical hyperplasia or carcinoma in situ requires WLEBB to define the extent of breast pathology. Mammographic surveillance for a patient with a benign IGCNBB is supported by nearly 100% specificity. An IGCNBB diagnosis of invasive carcinoma is also associated with nearly 100% specificity; therefore, these patients can have definitive surgical therapy, including axillary dissection or mastectomy, without waiting for the pathologic results of a WLEBB. Based on the authors' findings, IGCNBB can safely replace WLEBB in evaluating patients with nonpalpable breast abnormalities.

The etiology of intestinal obstruction in patients without prior laparotomy or hernia.

Patients with clinical features of intestinal obstruction without a history of prior laparotomy or physical evidence of a hernia can be a diagnostic challenge. We attempted to evaluate our preoperative diagnostic accuracy, to assess the effectiveness of our diagnostic tools, and to determine the incidence of various causes of intestinal obstruction in this select group. Medical records of all patients admitted to our institution and taken to surgery with a diagnosis of intestinal obstruction from 1975 through 1995 were reviewed. Patients with a history of prior laparotomy, evidence of hernia, or emergent indications for surgery on admission were excluded. The most common cause of intestinal obstruction in this select group of patients was malignancy. The ability to detect malignancy preoperatively is significantly better than the ability to detect benign causes of obstruction (Pearson Chi square = 4.09 with a P value of 0.04). Preoperative detection of malignancy in these patients is critical for optimal treatment planning and counseling for patients and their families.