Mammographic findings after intraoperative radiotherapy of the breast.

Intraoperative Radiotherapy (IORT) is a form of accelerated partial breast radiation that has been shown to be equivalent to conventional whole breast external beam radiotherapy (EBRT) in terms of local cancer control. However, questions have been raised about the potential of f IORT to produce breast parenchymal changes that could interfere with mammographic surveillance of cancer recurrence. The purpose of this study was to identify, quantify, and compare the mammographic findings of patients who received IORT and EBRT in a prospective, randomized controlled clinical trial of women with early stage invasive breast cancer undergoing breast conserving therapy between July 2005 and December 2009. Treatment groups were compared with regard to the 1, 2 and 4-year incidence of 6 post-operative mammographic findings: architectural distortion, skin thickening, skin retraction, calcifications, fat necrosis, and mass density. Blinded review of 90 sets of mammograms of 15 IORT and 16 EBRT patients demonstrated a higher incidence of fat necrosis among IORT recipients at years 1, 2, and 4. However, none of the subjects were judged to have suspicious mammogram findings and fat necrosis did not interfere with mammographic interpretation.

Accuracy of predicting axillary lymph node positivity by physical examination, mammography, ultrasonography, and magnetic resonance imaging.

BACKGROUND: Axillary lymph node status continues to be among the most important prognostic variables regarding breast cancer survival. We were interested in our ability to accurately predict axillary nodal involvement by using physical examination and standard breast imaging studies in combination. METHODS: A retrospective review was performed of 244 consecutive patients diagnosed with invasive breast carcinoma between May 2008 and December 2010 who underwent physical examination of the axilla, digital mammography, axillary ultrasonography, and contrast-enhanced breast magnetic resonance imaging and who had subsequent histopathologic evaluation of one or more axillary lymph nodes. RESULTS: A total of 62 (25%) of 244 women were found to have positive axillary lymph nodes on final histopathologic examination, 42% of whom were able to be identified preoperatively. The sensitivity for predicting axillary metastasis if any one or more examination modalities were suspicious was 56.5%. The specificity for predicting axillary metastasis if any three or more modalities were suspicious was 100%. Of the patients who had all four modalities negative, 14% were ultimately found to have histologically positive nodes at the time of surgery. CONCLUSIONS: Physical examination and multimodal imaging in combination are useful for preoperative axillary staging and treatment planning. However, they remain inadequate definitive predictors of axillary lymph node involvement.

Ductal carcinoma in situ (DCIS) of the breast: perspectives on biology and controversies in current management.

The incidence of ductal carcinoma in situ (DCIS) has increased because of increasing use of sensitive imaging modalities. MRI is commonly used for the detection of breast cancer but has not yet been validated in randomized trials. There have not been randomized trials addressing optimal margins of excision or axillary sampling. Whole breast radiation after lumpectomy decreases the risk of recurrence but may be omitted in selected patients. Adjuvant Tamoxifen reduces the risk of recurrence but has no impact on overall survival rates.

Axillary recurrence is low in patients with breast cancer who do not undergo completion axillary lymph node dissection for micrometastases in sentinel lymph nodes.

Completion axillary lymph node dissection (CLND) is presently the standard of care after a positive sentinel lymph node biopsy (SLNB). We hypothesize that the incidence of axillary recurrence in patients who do not undergo CLND for micrometastases is low, and CLND is not necessary for locoregional control. We performed a retrospective chart review of patients with invasive breast carcinoma and micrometastases detected on SLNB. The Memorial Sloan Kettering Nomogram (MSKN) predicting the likelihood of nonsentinel lymph node (NSN) metastases was compared with the incidence of positive NSN. There were 61 patients identified with a mean follow-up of 70 months. The average tumor size was 2 cm. The median number of positive SLNs was one. Twenty-eight (46%) patients had a CLND; of these, 20 patients had one positive NSN (2 of 28 [7%]) and the mean MSKN score was 12 per cent. There were 33 (54%) patients who had SLNB alone, and their mean MSKN score was 13 per cent. Axillary recurrence in this group was 1.6 per cent. We conclude the incidence of axillary recurrence in patients with micrometastases detected by SLN biopsy who do not undergo CLND is low. The use of a predictive nomogram to estimate likelihood of metastatic disease to NSN may overestimate the actual incidence of positive NSN in patients with micrometastases.

Long-term outcome of endoscopic colorectal stenting for malignant and benign disease.

Although the technical success rate of endoscopic stenting has been defined, there is a paucity of outcome data. The purpose of this study was to evaluate the long-term results of colorectal stenting for both malignant and benign disease. A retrospective review was conducted of patients who underwent stenting at a tertiary center over 4 years. One surgeon performed all stents under endoscopic and fluoroscopic guidance. A total of 49 stent procedures were performed in 36 patients (19 females, mean age 65 years). Mean follow-up was 15 months. Twenty-eight patients (78%) underwent stenting for malignant disease and eight patients (22%) for benign conditions. The most common reason for intervention was obstruction (81%). Technical success rate was 72 per cent. Carcinomatosis was associated with a higher technical failure rate. Procedural related complications occurred in two patients (6%). Long-term stent migration rate was 24 per cent and was more common in patients with benign disease and patients who received nonmetal stents or stents with diameter < 25 mm. Endoscopic reintervention was required in 33 per cent of patients with initial technical success. Long-term need for subsequent operative intervention was 14 per cent. Endoscopic stenting is a viable option for a select group of patients with colorectal disease. Patient's selection and stent choice influence outcome.

Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure.

Lateral internal sphincterotomy (LIS) is the gold standard surgical treatment for anal fissure. However, it carries potential complications, including fecal incontinence. The goal of this retrospective study was to compare the outcome of botulinum toxin A injection coupled with fissurectomy ([BTX + FIS) versus LIS. There were 59 patients who underwent BTX + FIS or LIS over a 5-year period. LIS was performed in the standard fashion without fissurectomy. BTX + FIS entailed internal sphincter injection with 80 units of botulinum toxin A coupled with fissurectomy. Forty patients underwent LIS and 19 had BTX + FIS. The choice of operation was based on the patient's preference. Primary healing rate was 90 and 74 per cent in the LIS and BTX + FIS groups, respectively (P = 0.13). The complication rate was 10 per cent in the LIS vs 0 per cent in the BTX + FIS groups (P = 0.29). Complications of LIS included anal sepsis in one patient and flatal and/or fecal incontinence in three patients. During a mean follow up of 19 months; recurrence rate was 0 and 5 per cent in the LIS and BTX+FIS groups, respectively (P = 0.32). The results of this study demonstrate that BTX + FIS is a viable alternative to LIS for patients with chronic anal fissure and should be considered as an alternative first-line surgical therapy.

Laparoscopic repair of perineal hernia.

Perineal hernia is a rare but known complication following major pelvic surgery. It may occur spontaneously or following abdominoperineal resection, sacrectomy, or pelvic exenteration. Very little is known about spontaneous perineal hernia. Surgical repair via open transabdominal and transperineal approaches has been previously described. We report laparoscopic repair of spontaneous and postoperative perineal hernia in 2 patients.

Changing paradigms in breast cancer management: introducing molecular genetics into the treatment algorithm.

Advances in molecular genetics aimed at individualizing breast cancer treatment have been validated. We examined the use of gene assays predictive of distant recurrence in breast cancer and their impact on adjuvant treatment. A retrospective chart review of 58 T1/T2, node-negative, estrogen-receptor positive breast cancer patients that underwent Oncotype DX gene assay testing between January and December 2006 was performed. We compared treatment received after gene assay evaluation to treatment based on National Comprehensive Cancer Network guidelines. Patients were grouped using these recommendations: Low-risk group (T1a/T1b), no chemotherapy; High-risk group (T1c/T2), chemotherapy. Oncotype DX recommendations are as follows: Low recurrence risk, no chemotherapy; high recurrence risk, chemotherapy. A change in management was defined as chemotherapy for T1a/T1b disease and no chemotherapy for T1c/T2 disease. Two T1a/T1b patients had high risk of recurrence per gene assay scores and were treated with chemotherapy (P < 0.05). Eighteen T1c/T2 patients had low recurrence risk scores; 13 (72%) were spared chemotherapy. The recurrence score increased the number of patients classified as low risk of recurrence by 12 per cent and downstaged 63 per cent of high-risk patients (P < 0.003). Gene assay results changed management in 15 of 58 (26%) patients (P < 0.05). The use of gene assays allowed us to better tailor treatment in a significant number of our patients.