Progenitor and stem cells for bone and cartilage regeneration.

Research in regenerative medicine is developing at a significantly quick pace. Cell-based bone and cartilage replacement is an evolving therapy aiming at the treatment of patients who suffer from limb amputation, damaged tissues and various bone and cartilage-related disorders. Stem cells are undifferentiated cells with the capability to regenerate into one or more committed cell lineages. Stem cells isolated from multiple sources have been finding widespread use to advance the field of tissue repair. The present review gives a comprehensive overview of the developments in stem cells originating from different tissues and suggests future prospects for functional bone and cartilage tissue regeneration.

Preoperative needle biopsy as a potential quality measure in breast cancer surgery.

Preoperative needle diagnosis (PND) is being considered as a quality measure in breast cancer surgery. This criterion has not been thoroughly evaluated in the literature. The purpose of this study is to assess ease of access to these data and rate of compliance in a tertiary care center. We retrospectively reviewed all our breast cancer cases between July 2006 and July 2007. The data were queried for preoperative needle diagnosis. Charts of patients who did not meet this criterion were reviewed to determine the cause for noncompliance. In the year 2006-2007, 396 breast cancer operations were performed (age range 19-96 years). Of 396 cases, 43 (11%) underwent a surgical procedure without diagnosis of cancer. In 19/396 (5%) cases PND was not feasible due to technical reasons. In 22/396 (5.5%) cases, preoperative needle biopsy did not render a malignant diagnosis: the pathology report was discordant with the radiological or clinical findings, or the needle biopsy result necessitated surgical resection. In only 2 of 396 cases (0.5%) was PND not attempted: an 80-year-old woman with a radiologically and clinically malignant mass, and a 43-year-old woman with a clinical and ultrasonographic suggestion of fibroadenoma. We conclude that data for preoperative needle diagnosis were easily accessible in our center. If this criterion is used as a quality measure in breast cancer surgery, 100% compliance may not be an achievable goal.

Factors correlating with lymph node metastases in patients with T1 breast cancer.

BACKGROUND: Identification of reliable predictors of axillary metastases (ALNM) may be useful in selecting appropriate management for patients with T1-size breast cancer. This study was undertaken to determine the degree of correlation between ALNM and several variables, including age, race, menopausal status, palpability, tumor size, positive margin on initial excision, histology, grade, lymphatic invasion (LI), estrogen receptor status (ER), progesterone receptor status, S-phase, and ploidy. METHODS: Data from 1416 patients with T1 breast cancers treated at Columbia-Presbyterian Medical Center between 1989 and 1998 was reviewed. Patients with multifocal tumors were excluded. RESULTS: Mean patient age was 57.5 years (SD = 12.0); 65% of the patients were postmenopausal. One hundred thirty-one patients with Tla (< or =0.5 cm), 435 with T1b (0.6-1.0 cm), and 850 patients with T1c (1.1-2.0 cm) lesions were studied. The overall rate of ALNM was 23%. AM was identified in 11% of T1a, 15% of T1b, and 29% of T1c patients. Statistically significant factors from univariate analysis were age, palpability, skin changes, tumor size, LI, histology, grade, ER status, and positive margin on initial excision. CONCLUSIONS: Axillary staging by either sentinel lymph node biopsy or level I/II axillary dissection is indicated for most T1 breast cancer patients. Omission of axillary staging can be considered for highly selected patients with T1a cancers.

Breast masses in African American teenage girls.

PURPOSE: The aim of this study was to evaluate the incidence of malignancy in breast lumps excised from African American teenagers. METHODS: The authors reviewed the pathology records at King's County Hospital Center between January 1982 and December 1992. The pathology reports and charts of all patients who had breast masses excised during this period were reviewed. Data for this study were derived from the group of African American and black Caribbean American teenage patients who underwent breast biopsies and whose pathology reports and medical records were available. The age of patients, size of the lesion, and diagnosis were recorded. RESULTS: Medical records from 155 African American and black Caribbean American girls between the ages of 13 and 19 years (inclusive) who underwent breast biopsies between January 1982 and December 1992 were reviewed. Fibroadenoma was the most common diagnosis (127 of 155; 82%). This was followed in frequency by fibrocystic mastopathy (18 of 155; 11.6%) and breast abscess (3 of 155; 2%). None of the patients had a malignancy. Review of tumor registry data from the same time period at Kings County Hospital Center and the University Hospital of Brooklyn showed that the youngest African American or black Caribbean American patient diagnosed with breast cancer was 21 years of age. CONCLUSIONS: The incidence of malignant breast lumps in African American and black Caribbean American teenagers is distinctly low. Conservative treatment in this population is warranted, and diagnosis can be made easily in most cases with either needle aspiration for cytology or core biopsy of any lesions discovered.

Accurate prediction of the amount of in situ tumor in palpable breast cancers by core needle biopsy: implications for neoadjuvant therapy.

BACKGROUND: Neoadjuvant chemotherapy facilitates breast conservation in stage II breast cancer patients, whose primary tumors are assumed to be invasive because they are palpable. However, chemotherapy may not be indicated in the minority of patients whose clinically T2 tumors are completely or predominantly in situ. Almost all previous studies of core needle biopsy in breast cancer have been concerned with nonpalpable, mammographically detected tumors, and none have evaluated its ability to quantitatively determine the amounts of in situ and invasive disease. METHODS: From September, 1992 to December, 1997, core needle biopsy was performed on all patients presenting to the Kings County Hospital Breast Clinic with palpable breast masses. Carcinoma was present in both core needle biopsy samples and surgical specimens subsequently obtained from 95 of 99 patients. Each specimen was evaluated for tumor type, histologic grade, and the amounts of in situ and invasive carcinoma it contained, and the results from surgical and core needle biopsy specimens from the same patients were then compared. RESULTS: The surgical specimens of 14 patients had completely or predominantly in situ disease. Completely or predominantly invasive disease was present in 67 specimens, and the remaining 14 had significant amounts of both. The high level of agreement between the amounts of in situ and invasive disease in core needle biopsy and surgical specimens is indicated by Pearson and intraclass correlation coefficients of 0.91 (P < .001 and < .00001, respectively). Tumor type was correctly predicted by core needle biopsy in each case. Variables among these patients, including primary tumor size, interval between biopsy and surgery, or administration of neoadjuvant systemic therapy, did not alter agreement between core needle biopsy and surgical specimens. CONCLUSIONS: Core needle biopsy can identify palpable breast tumors that are predominantly or completely in situ, and, thus, avoid unnecessary neoadjuvant chemotherapy. It also can demonstrate that a tumor is predominantly invasive, but cannot rule out small invasive foci. For that purpose, complete surgical excision of the tumor is required.

Is race a poor prognostic factor in breast cancer?

BACKGROUND: African American breast cancer patients have a higher mortality rate than their Caucasian counterparts. The purpose of this study was to evaluate whether race is a poor prognostic factor in breast cancer survival after multiple other prognostic factors are taken into account. STUDY DESIGN: The tumor registry data from two institutions between the years 1982 and 1995 were combined for the analysis. A total of 1,745 patients, including 1,297 African American and 448 Caucasian women, were available for analysis. Race, age, income, stage, histologic findings, type of operation, and treating institution were evaluated as possible key prognostic variables. RESULTS: In a univariate Cox proportional hazards regression analysis, African American patients with breast cancer were 1.27 times more likely to die than Caucasians when death from disease was measured (p = 0.01, 95% confidence interval 1.03 to 1.47). When all factors were included in a Cox regression analysis, only the stage of disease at diagnosis, age, and whether the patient had a therapeutic surgical treatment were statistically significant. Race, income, hospital, and histologic findings were not significant, although they were significant when used in a univariate analysis. CONCLUSIONS: Poor survival of African American breast cancer patients seems to be related to their advanced stage at presentation and young age. To improve survival in these women, efforts should be concentrated on aggressive screening at a young age to detect the disease at an earlier stage.

Age at presentation of African-American and Caucasian breast cancer patients.

BACKGROUND: The purpose of this study was to compare the age at presentation of Black-American (Caribbean-American and African-American) and Caucasian breast cancer patients. STUDY DESIGN: We reviewed the records of all breast cancer patients seen at King's County Hospital Center and SUNY Health Science Center at Brooklyn between 1982 and 1995. The patients were stratified based on ethnicity. Age distribution, median, and mean ages are compared for Black-American and Caucasian patients. RESULTS: The median age, mean age, and standard deviation for 1,632 African-American patients was 54, 54.17, and 13.11 years, respectively, whereas for 671 Caucasians patients it was 62, 60.35, and 13.85 years, respectively. Using the Student's t-test for equality of means there is a statistically significant difference in the mean age of presentation for the 2 ethnic groups with a p < 0.001 and a 95% confidence interval for difference (4.960, 7.405). More than one-third (37.7%) of Black-American breast cancer patients present younger than 50 years of age compared with 24.7% for Caucasians. CONCLUSIONS: The younger age at presentation of Black-American breast cancer patients ought to be considered while setting screening guidelines for that group of women.

Diagnostic delay in breast disease: a system analysis of a public urban hospital.

OBJECTIVE: To analyze the diagnostic process in 146 women referred to a breast clinic in an urban setting between January 1, 1994, and December 31, 1996. DESIGN: We devised the "diagnostic delay index (DDI)," defined as the time between the medical system's awareness of a diagnostic need and the completion of the diagnostic process. The time awaiting breast clinic consultation and the diagnostic events experienced--including clinic visits, imaging studies, and biopsies--were recorded. We stratified patients in 2 pathways (palpable masses and mammogram-identified lesions) and by benign or malignant outcome. RESULTS: Patients in pathways 1 (n = 85) and 2 (n=61) had a mean (+/-SD) DDI of 68.4 (+/-46.9) days and 71.9 (+/-35.2) days, respectively. Patients in both pathways who had a malignant outcome had a significantly lower DDI than those who had a benign outcome (47.5+/-30.9 days vs 78.6+/-42.6) (P<.001); this advantage was most pronounced in patients with palpable lumps. The average patient waited more than 3 weeks for both an initial clinic consultation and operating room access. Quartile analysis of the DDI revealed statistically significant differences in clinic access time, number of visits, diagnostic events per visit, and operating room access time. Regression analysis demonstrates the relationship between DDI and measured process variables: DDI= -21.11+0.09 age+1.86 pathway-12.18 outcome+1.08 clinic access+11.91 visits+0.94 operating room access (R2=61.5%). CONCLUSIONS: In a public hospital, diagnostic delay is related to inadequate access to surgical consultation and a delay in operating room access. Regression analysis demonstrates the relationships between these components of system diagnostic delay and suggests strategies for reducing the DDI.

Chemotherapy is a safe and effective initial therapy for infected malignant breast and chest wall ulcers.

BACKGROUND AND OBJECTIVES: Locally advanced breast cancers may form large, infected skin ulcers, which were traditionally treated with radiation therapy. Neoadjuvant chemotherapy is now standard treatment for locally advanced breast cancer. METHODS: The response of 33 patients with ulcerated breast cancer to primary chemotherapy was retrospectively analyzed. Antibiotics were not used in primary treatment. Tumor and ulcer responses were evaluated independently. RESULTS: Chemotherapy alone healed 18 of these ulcers. Neither responding nor refractory patients developed sepsis during this treatment. CONCLUSIONS: Chemotherapy is safe and effective treatment for patients with infected malignant breast ulcers and does not cause systemic sepsis.

[Mitral commissurotomy with extracorporeal circulation. Apropos of 200 cases with a median survival of 15 years]. / Commissurotomie mitrale sous CEC. A propos de 200 cas avec un suivi moyen de 15 ans.

This is a retrospective study of 200 patients, with long-term results operated upon from October 1965 to July 1984. 83% women, 17% men. The mean age was 42.40 +/- 11.03 years. In 87% mitral stenosis was pure and 13% systolic murmur was heard. 60% were in classes III and IV and 40% in classes I and II (NYHA). Hemodynamically mean C.W.P. was 21 +/- 6.27 mm Hg and mean P.A. pressure 30 +/- 9.5 mm Hg. Right anterior thoracotomy was done in every case with canulation of femoral artery and V.C. extracorporeal circulation consisted of a bubble oxgenation (RYGG) and a Roller Pump. In 88.5% both commissures were opened and in 11.5% only the anterolateral commissure. In 58% both papillary muscles were incised, in 15% anterolateral and in 13% posteromedial papillary muscles were incised. In 17% valves or commissures were decalcified. In 5.5% a thrombus was removed from the auricle. Postoperative mortality was 0%. 13% of patients experienced a postoperative complication: 4% hemothorax, 2.5% gaz embolism without sequela, 0.5% lower extremity embolism, 3% pulmonary embolism, 2% phlebitis and 1% gastrointestinal haemorrhage. Postoperatively in 75% of cases no murmur was heard, and in 25% a systolic murmur was found over pericardium. 167 patients were assessed at a mean interval of 129.88 months. 11 patients died at a mean interval of 98.56 +/- 48.56 months with non cardiac cause in 9 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Resection and debridement of chest-wall tumors and general aspects of reconstruction.

The main criterion for adequate local control of a chest-wall malignancy remains wide excision. With the available techniques of skeletal and soft-tissue reconstruction, even large lesions can be resected with safe margins. The primary purpose is to achieve a curative resection, although a significant number of symptomatic patients can benefit from palliative resection provided by such procedures. A key element in the success in treating chest-wall tumors is a multidisciplinary approach by all participating physicians, namely the thoracic surgeon, the plastic and reconstructive surgeon, the radiotherapist, and the medical oncologist.