Evaluation of feasibility and accuracy of sentinel node biopsy in early breast cancer.

BACKGROUND: Current literature has suggested that sentinel node biopsy may eventually replace axillary dissection as the nodal staging procedure of choice in early breast cancer. The goals of our study were to determine the accuracy of the sentinel node in predicting axillary nodal status and to evaluate the feasibility of incorporating sentinel node biopsy into a general surgical practice. METHODS: Between June 1999 and August 2000, 158 clinically node negative women with a histological diagnosis of T1 or T2 breast cancer were enrolled in the study. Both technetium sulfur colloid radiotracer and isosulfan blue dye were used to guide sentinel node biopsy. Sentinel node biopsy was always followed by a complete axillary dissection. The histopathology of sentinel nodes using serial sectioning and cytokeratin immunohistochemistry was compared with that of the nonsentinel nodes evaluated with routine hematoxylin and eosin stain. RESULTS: The overall sentinel node detection rate was 84% (89 of 106 patients). Sentinel node biopsy was most successful when a combination of radiotracer and dye was used. The staging accuracy of sentinel node biopsy was 98% (87 of 89); the sensitivity of the method was 94% (34 of 36); the false negative rate was 6% (2 of 36); the negative predictive value was 96% (53 of 55); and the rate of metastases to the sentinel node only was 56% (20 of 36). The results varied considerably among surgeons. CONCLUSIONS: The findings in our study support the hypothesis that the sentinel node is an accurate predictor of axillary nodal status in women with early breast cancer. These results suggest that the excellent findings in the literature can be reproduced by a group of general surgeons in a community-based hospital.

An analysis of breast cancer surgery after free transverse rectus abdominis myocutaneous (TRAM) flap reconstruction.

BACKGROUND: Breast reconstruction is currently offered on a more routine basis to patients after mastectomy for breast cancer. This paper analyzes the outcomes of breast cancer surgery, and the results and effects of breast reconstruction using free TRAM flaps. METHODS: A retrospective review of 75 consecutive patients who had free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after breast cancer surgery was performed. A total of 92 free TRAM flaps were performed on 75 patients in Victoria, British Columbia, from January 1992 to May 1999. Thirty-three patients (44%) underwent primary breast cancer surgery and an immediate reconstruction (7 bilateral and 27 unilateral) and 42 patients (56%) had delayed reconstruction (10 bilateral and 32 unilateral). RESULTS: Twenty- one patients (28%) had stage 0 disease, 20 (26.7%) had stage I disease, 17 (22.7%) had stage IIA disease, 12 (15%) had stage IIB disease, and 4 (5.3%) had stage IIIA disease. In 1 patient the stage of disease was unknown. The mean patient age was 49.4 years (range 33 to 73). Of the patients undergoing immediate reconstruction 3 had postoperative chemotherapy and 1 had postoperative radiotherapy. Three patients had combined chemoradiotherapy. In none of these cases was the adjuvant therapy delayed by the reconstructive surgery. Overall mean follow-up time from cancer diagnosis was 56.8 months and from the time of TRAM flap reconstruction, 36.7 months. To date, 5 recurrences have been detected (6.6%). Mean time between reconstruction and detection of recurrence was 22.8 months. Detection of recurrence was achieved clinically and was not impaired in any of the cases by the presence of the free flap. Patient satisfaction was assessed via a telephone survey, with 93% of patients pleased with the cosmetic results of their surgery. CONCLUSIONS: For those patients with breast cancer requiring mastectomy, free TRAM flap reconstruction is a safe, cosmetically acceptable surgical alternative that impairs neither effective breast cancer surgery nor detection of recurrent disease.

Recurrence and survival after surgical management of rectal cancer.

BACKGROUND: Reported local recurrence rates for rectal cancer are significantly reduced using a combination of superior surgical technique, in the form of total mesorectal excision, and routine radiotherapy. In an attempt to determine the effectiveness of current local management strategies, a review of Vancouver Island Cancer Centre patients with rectal cancer was performed and the overall local recurrence rate was identified. METHODS: We retrospectively reviewed the charts of 272 rectal cancer patients from 1988 to 1998. Two hundred and twenty-nine patients met inclusion criteria. Analysis of patient factors included age, gender, type of surgery, and adjuvant therapy. Tumors were assessed for level, stage, and grade. Local recurrence and distant metastases were also documented. Variables influencing local recurrence in this group were identified and disease-free and actuarial survival determined. RESULTS: Of 229 patients analyzed, 12.7% (29) had local recurrences. Variables influencing local recurrence were number of positive lymph nodes, vascular invasion, and neural invasion. There was no significant difference in local recurrence between patients having anterior resection and those having abdominoperineal resection. None of the patients who received preoperative radiotherapy had a local recurrence. Actuarial disease-free survival was 87% at 5 years. CONCLUSIONS: Limiting local recurrence is one of the most important goals in the treatment of rectal cancer. It is essential to identify those patients with "high risk" tumors as identified by endorectal ultrasound or pathologic features. These patients comprise the group most likely to benefit from a routine mesorectal excision combined with adjuvant radiotherapy.

Carcinoids of the common bile duct: a case report and literature review.

Carcinoids of the extrahepatic bile ducts and particularly the common bile duct are extremely rare. A 65-year-old woman presented with obstructive jaundice. Laboratory and imaging studies gave results that were consistent with an obstructing lesion in the common bile duct. In this case, a stent was inserted initially to decompress the bile ducts. Subsequently a laparotomy and pancreaticoduodenectomy were performed and a tissue diagnosis of carcinoid of the common bile duct was made. The patient was well with no evidence of recurrence 17 months postoperatively. The authors believe this is the 19th reported case of an extrahepatic bile duct carcinoid.

Technetium99m-sestamibi scanning before initial neck exploration in patients with primary hyperparathyroidism.

Technetium99m (Tc) sestamibi(mibi) has been proposed as an alternative to the standard radionuclide imaging technique of thallium 201 chloride-99mTc pertechnetate subtraction scan (TTS) in patients with primary hyperparathyroidism. In the present study, mibi was evaluated as an alternative to TTS in 37 patients who had either mibi-99mTc pertechnetate subtraction scans, mibi-iodine123 (I) subtraction scans or mibi single isotope washout scans. There were 30 females and 7 males with an average age of 57 years (range, 27-78 years). Parathyroid adenomas were found in 35 patients and hyperplasia in 2. Twenty-eight mibi scans were positive and 25 of these correctly localized the parathyroid abnormality for a sensitivity of 68% (25 of 37) and a positive predictive value of 89% (25 of 28). There were 3 false-positives (8%) and 9 false-negatives (25%). The scan was not helpful in either patient with parathyroid gland hyperplasia. Mibi-123I subtraction was the most accurate scan and was diagnostic clinically in all 7 patients studied. Mibi scans were significantly more likely to identify inferior rather than superior adenomas (P = 0.01). Twenty-seven of the 37 patients also had a TTS which was correct in only 37% of cases while the mibi scan was correct in 68% (P = 0.02). However, routine use of nuclear scanning with mibi was still not supported by these data. Further clinical evaluation of various techniques may improve accuracy. Since mibi was significantly more accurate than TTS, it should be considered preferentially when radionuclide imaging is used in patients with recurrent hyperparathyroidism.

Effects of age and severity of illness on outcome and length of stay in geriatric surgical patients.

From April 1, 1990, to March 31, 1992, 8,899 patients who were 65 years of age and older underwent an anesthetic and surgical procedure in a 1,000-bed community hospital in Victoria, British Columbia, Canada. The hospital has been using a proprietary system called MedisGroups for assessing the severity of illness on admission and in-hospital morbidity. All patients were followed up until death or discharge from the hospital. Using the hospital database, we analyzed the patient sample to test the hypothesis that severity of illness was more important than age in predicting postoperative morbidity and mortality rates. Using correlation and multiple regression analysis, we found that the severity of illness was a much better predictor of outcome than age. The results were significant at the level of p < 0.001. Based on the results of this study, we recommend that age not be used in surgical decisions in the elderly.

The use of sedative-hypnotic drugs in a university teaching hospital.

We reviewed the charts of 476 patients admitted to a university teaching hospital to determine whether sedative-hypnotic drugs (SHDs) were being used excessively and to examine the use of SHDs as hypnotics. The frequency of medical and surgical indications for barbiturates and benzodiazepines or other minor tranquillizers as well as the use of such drugs were compared among different groups of patients and specialty wards. Of the patients 29% had a regular order and 40% had a PRN order; only 77% of the PRN orders were administered. A total of 215 patients (45%) received an SHD during their hospital stay, and 160 (34%) received the drug as a hypnotic. Medical indications accounted for 49% of the regular orders but only 2% of the PRN orders; moreover, 89% of all the PRN orders were for insomnia. On average, patients receiving SHDs as hypnotics were older (p less than 0.05) and stayed longer in hospital (p less than 0.01) than those who did not; however, no patient on the geriatric or pediatric ward received an SHD as a hypnotic during the hospital stay. The differences in use between patient groups may have been influenced by orientation of ward staff. Physicians should review their rationale for prescribing hypnotics and avoid routine orders on admission.

Management of duodenal injuries.

Between 1975 and 1986, 42 patients with duodenal trauma were seen at six major hospitals serving the province of Saskatchewan. Twenty-six patients had blunt trauma and 16 penetrating trauma. The mean age of the patients was 25 years and 38 were male. An assessment of patient management revealed an unacceptable rate of duodenal fistulas (17%) and death (14%). Detailed analysis suggests that duodenal injuries must be diagnosed early with prompt and appropriate surgical correction.

Preoperative needle localization to detect early breast cancer.

A retrospective review of 200 consecutive female patients who had undergone mammographically controlled needle localizations was performed to assess the effectiveness of the technique and to analyze the number and characteristics of malignancies found in this group. Fine-needle localization was recommended if one of the following criteria was present: (1) evidence of a mass, (2) microcalcifications, (3) architectural distortion. Of the 200 localizations, 192 specimen radiographs were analyzed: 186 contained the lesion, 6 (3 percent) missed the lesion. Forty-eight cancers were detected (24 percent). The reasons for biopsy were microcalcification, 61 percent; presence of a mass, 25 percent; abnormal architecture, 14 percent. Histologically the cancers included 38 invasive plus 10 in-situ tumors. The predominant histologic cell type was ductal in origin with only four having lobular characteristics. In the definitive treatment of these patients, pathologic findings of the lymph nodes showed 2 of the 38 were positive for metastases. In summary, the technique of preoperative needle localization in this series indicates a 93 percent success rate. An analysis of the surgical intervention indicates that conservative breast surgery is the treatment of choice. Another result is the detection of high-risk malignant lesions such as duct and lobular hyperplasia that require close follow-up.

Pancreatitis associated with pancreas divisum: results of surgical intervention.

The embryologic defect that results when the ventral and dorsal anlages of the pancreas do not fuse has been referred to as pancreas divisum. The patients who present with recurrent pancreatitis or pancreatitis-like pain in association with pancreas divisum should be investigated to determine the presence of minor papilla stenosis. In the present study of 11 patients, 9 became asymptomatic with surgical decompression of the dorsal pancreatic duct. Two surgical failures were related to wrong diagnosis and restenosis of the sphincteroplasty. A delay in the clearance of dye from the dorsal pancreatic duct after endoscopic retrograde cholangiopancreatography was utilized to determine minor papilla stenosis. In the future, secretin ultrasound tests should prove of value in assessing minor papilla stenosis. Once the diagnosis is made, sphincteroplasty of the minor papilla is the most logical procedure because of the good results obtained. In the present study, pancreaticojejunostomy provided good duct decompression as well.

Management of pancreatic trauma.

Between 1974 and 1984, 25 patients with pancreatic trauma were seen at three Regina hospitals. Eighteen had blunt injuries and 7 penetrating injuries. The mean injury severity score was 37 and the mean age 24.5 years. Management was nonoperative in six patients. Of the 19 treated surgically, 14 underwent laparotomy and drainage, 2 laparotomy without drainage and 3 pancreatic resection. Complications related to pancreatic injury occurred in 11 patients. One patient died. The results of this series suggest that the majority of patients with pancreatic injuries can be treated by laparotomy and drainage with a low mortality, but the complication rate is high. In select patients, visualization of the pancreatic duct may allow the surgeon to perform definitive surgical management at the initial procedure.