Immunohistochemical expression of sex steroid hormone receptors, cell cycle regulators and angiogenesis factors in intraductal papillary mucinous neoplasms: an explorative study.

AIM: The objectives of our explorative study were to (i) evaluate the immunohistochemical expression of sex steroid hormone receptors (estrogen receptor a [ERα], estrogen receptor ß [ERß], progesterone receptor [PR] and androgen receptor [AR]), angiogenesis factors (vascular endothelial growth factor [VEGF] and inhibitor of differentiation/DNA synthesis 1 [Id-1]) and cell-cycle regulators (cyclin D1, p16 and p27) in intraductal papillary mucinous neoplasms (IPMNs) in comparison to normal adjacent pancreatic tissues and (ii) assess their correlation with the grade and histological sub-type of those lesions. MATERIALS AND METHODS: Paraffin-embedded specimens from 12 consecutive patients with IPMNs were immunostained for the studied markers and staining quantification was assessed by an image analysis system. RESULTS: AR H-score and cyclin D1 H-score were significantly higher in the IPMN lesions (0.86±0.33 vs. 0.57±0.12 in the normal tissue, p=0.010 and 0.47±0.23 vs. 0.21±0.20 in the normal tissue, p=0.019, respectively). No significant differences were noted regarding the expression of ERα, ERß, PR, p16, p27, VEGF, Id-1 or MVD. Moreover, no significant associations were found between the expression of studied markers and grade or histological subtype. CONCLUSION: Our study showed higher expression of AR and cyclin D1 in IPMNs compared to normal pancreatic ducts without any association between AR and cyclin D1 expression and IPMNs' grade or subtype.

Cyclin D1, p16(INK) (4A) and p27(Kip1) in pancreatic adenocarcinoma: assessing prognostic implications through quantitative image analysis.

The prognostic significance of cyclin D1, p16(INK) (4A) and p27(Kip1) expression has been documented in several human malignancies; however, their prognostic potential in pancreatic adenocarcinoma is still unclear. This study aimed to assess the correlation of the aforementioned molecules with clinicopathological parameters and prognosis. Sixty patients with pancreatic ductal adenocarcinoma underwent surgical resection at a single institution; immunohistochemical staining of the studied markers was quantified by Ιmage analysis system. Cyclin D1 overexpression was positively associated with grade, neural infiltration and vascular invasion, whereas p27 positively correlated with age. Higher cyclin D1 expression indicated poorer survival (adjusted HR = 9.75, 95%CI: 1.48-64.31, p = 0.018, increment: one unit in H-score), whereas a marginal trend toward an association between p16 positivity and improved survival was observed (adjusted HR = 0.58, 95%CI: 0.32-1.05, p = 0.072 regarding positive vs negative cases). No significant association with overall survival was noted regarding p27. In conclusion, cyclin D1 overexpression and possibly p16 loss of expression in pancreatic adenocarcinoma seem to be adverse prognostic factors, whereas p27 expression did not seem to possess such prognostic properties. Further validation of the present findings in studies encompassing larger samples seems to be needed.

Downgrading BIRADS 3 to BIRADS 2 category using a computer-aided microcalcification analysis and risk assessment system for early breast cancer.

This paper explores the potential of a computer-aided diagnosis system to discriminate the real benign microcalcifications among a specific subset of 109 patients with BIRADS 3 mammograms who had undergone biopsy, thus making it possible to downgrade them to BIRADS 2 category. The system detected and quantified critical features of microcalcifications and classified them on a risk percentage scale for malignancy. The system successfully detected all cancers. Nevertheless, it suggested biopsy for 11/15 atypical lesions. Finally, the system characterized as definitely benign (BIRADS 2) 29/88 benign lesions, previously assigned to BIRADS 3, and thus achieved a reduction of 33% in unnecessary biopsies.

Psychiatric disorder associated with vacuum-assisted breast biopsy clip placement: a case report.

INTRODUCTION: Vacuum-assisted breast biopsy is a minimally invasive technique that has been used increasingly in the treatment of mammographically detected, non-palpable breast lesions. Clip placement at the biopsy site is standard practice after vacuum-assisted breast biopsy. CASE PRESENTATION: We present the case of a 62-year-old woman with suspicious microcalcifications in her left breast. The patient was informed about vacuum-assisted breast biopsy, including clip placement. During the course of taking the patient's history, she communicated excellently, her demeanor was normal, she disclosed no intake of psychiatric medication and had not been diagnosed with any psychiatric disorders. Subsequently, the patient underwent vacuum-assisted breast biopsy (11 G) under local anesthesia. A clip was placed at the biopsy site. The pathological diagnosis was of sclerosing adenosis. At the 6-month mammographic follow-up, the radiologist mentioned the existence of the metallic clip in her breast. Subsequently, the woman presented complaining about "being spied [upon] by an implanted clip in [her] breast" and repeatedly requested the removal of the clip. The patient was referred to the specialized psychiatrist of our breast unit for evaluation. The Mental State Examination found that systematized paranoid ideas of persecutory type dominated her daily routines. At the time, she believed that the implanted clip was one of several pieces of equipment being used to keep her under surveillance, the other equipment being her telephone, cameras and television. Quite surprisingly, she had never had a consultation with a mental health professional. The patient appeared depressed and her insight into her condition was impaired. The prevalent diagnosis was schizotypal disorder, whereas the differential diagnosis comprised delusional disorder of persecutory type, affective disorder with psychotic features or comorbid delusional disorder with major depression. CONCLUSION: This is the first report of a psychiatric disorder being brought to the fore using a vacuum-assisted breast biopsy clip. Vacuum-assisted breast biopsy, and breast biopsy in general, represent a significant experience, encompassing anxiety and pain; it may thus aggravate psychiatric conditions. Apart from these well-established factors, other aspects, such as the clip, may occasionally become significant. In a modern breast unit, the evaluation of patients should be multidisciplinary. A psychiatrist may be needed for optimal management of anxiety-related issues, as well as for the detection of psychiatric disorders.

Modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system.

HYPOTHESIS: The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN: Prospective study. SETTING: University surgical department. PATIENTS: Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES: Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS: The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS: In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Sutureless open low anterior resection with total mesorectal excision for rectal cancer with the use of the electrothermal bipolar vessel sealing system.

BACKGROUND: There is no report of electrothermal bipolar vessel sealer utilization in rectal surgery. The objective here was to evaluate the results of the use of this device in open low anterior resection for rectal cancer regarding reduction of operative time, hemostasis, and postoperative complications compared with the conventional technique. An additional aim was to describe and standardize this operative technique. MATERIAL/METHODS: All open low anterior resections with total mesorectal excision for rectal cancer performed by the same surgical team from January 2003 to December 2003 were reviewed. Patients were divided in two groups: those operated with the classic technique (group A) and those with a bipolar vessel sealer (group B). Main outcomes measured were operative and hospitalization time, intraoperative blood loss, postoperative drainage volume and duration, postoperative complications, perioperative blood transfusions, and final outcome. RESULTS: Forty-one patients were included (group A: 19, group B: 22). The groups were similar in demographics, TNM classification, number of lymph nodes dissected, complications, blood transfusions, hospital stay, and outcome. Comparing group B with group A, operative time (171+/-10 vs. 203+/-20 min, p=0.002), intraoperative blood loss (20+/-6 vs. 60+/-4 ml, p=0.04), drainage volume (70+/-8 vs. 120+/-10 ml, p=0.001), and drainage duration (1.7+/-0.3 vs. 2.6+/-0.2 days, p=0.01) were significantly reduced. CONCLUSIONS: The bipolar vessel sealer is a safe and effective adjunct for low anterior resection. The device simplifies the procedure while achieving efficient hemostasis and results in reduced operative time, intraoperative blood loss, and drainage volume and duration.

The use of spray electrocautery to control presacral bleeding: a report of four cases.

Bleeding originating from the presacral venous plexus during pelvic operations is difficult to control, constituting a potentially life-threatening complication. Although suture ligatures, packing, and placement of tacks are established hemostatic techniques, they are often proved to be ineffective. We report a simple novel technique using spray diathermy for managing this severe complication. We have applied our method in four patients, two undergoing low anterior resection, and the others undergoing abdominoperineal resection for rectal cancer, that manifested severe presacral bleeding during rectal mobilization. Electrocautery at spray setting was applied slightly above the target bleeders at the presacral fascia, delivering a high-frequency electrical current in combination with drainage suction. In all cases, the method resulted in successful hemostasis. Applying spray electrocautery is a simple and effective method for controlling presacral bleeding. The advantages of using such a method instead of conventional hemostatic techniques include the option of varying the degree of haemostatic effect by altering the frequency and the volume of electric current.

Contraindications of sentinel lymph node biopsy: are there any really?

BACKGROUND: One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient. METHODS: In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery. RESULTS: Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure. CONCLUSION: When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer.

Electrothermal bipolar vessel sealing system is a safe and time-saving alternative to classic suture ligation in total thyroidectomy.

BACKGROUND: Total thyroidectomy is associated with minimal morbidity. The electrothermal bipolar vessel sealing system is an adjunct to the surgical technique, recently made available to thyroid surgery. METHODS: This is a prospective randomized trial of total thyroidectomies performed in single unit from July 2003 to May 2004. Patients were randomly assigned in two groups: group A (n = 90), total thyroidectomy with the classic suture ligation technique; and group B (n = 94), total thyroidectomy with the use of the electrothermal bipolar vessel sealing system. RESULTS: Operative time was significantly reduced in group B by 14 minutes (mean difference, 14.3 +/- 4.2 minutes, 95% CI, 5.88-22.6 minutes). No statistically significant differences were found in postoperative complications, postoperative serum calcium measurements, or hospital stay between the two groups. CONCLUSIONS: The electrothermal bipolar vessel sealing system is a safe and useful, time-saving adjunct for total thyroidectomy.

Intra-arterial bolus octreotide administration during Whipple procedure in patients with fragile pancreas: a novel technique for safer pancreaticojejunostomy.

BACKGROUND AND OBJECTIVES: Leakage from the pancreaticojujenostomy is the most serious complication of Whipple. Pancreatic fistula rate is higher in cases of fragile pancreas often seen in duodenal carcinomas and carcinomas of the ampulla of Vater. Octreotide administration has been used for the prevention of fistula formation through the subcutaneous route. Due to its physiologic effects to the pancreatic parenchyma the intra-arterial administration of octreotide could provide tissue hardening that allows for a technically easier anastomosis while maintaining its protective role for fistula formation. METHODS: Octreotide was injected directly into the distal part of the gastroduodenal artery (GDA) in four patients undergoing Whipple for histologically proven periampullary cancer. RESULTS: Tissue hardening after octreotide administration was evident not only in surgeons' hands but in the intra-operative ultrasound as well. The three patients were discharged on day 9, 11, and 13; they had an uneventful postoperative course, while one patient had a minor bile leak from the choledojejunal anastomosis and was discharged on day 22. CONCLUSIONS: The intra-arterial administration of octreotide during Whipple is a safe procedure and provides tissue hardening thus making the performance of the anastomosis technically easier. The actual benefit in terms of morbidity, mortality, and fistula rate are to be further evaluated.