A Validated Model for Identifying Patients Unlikely to Benefit From the 21-Gene Recurrence Score Assay.

BACKGROUND: Predicting recurrence risk and chemotherapy benefit in early-stage breast cancer can be challenging, and Oncotype DX (ODX) is often used to gain insight. However, it is still unclear whether ODX can benefit in all cases. To clarify ODX's usefulness we sought to develop a model using readily available pathologic markers to help clinicians make that determination. PATIENTS AND METHODS: Clinical pathologic data from 221 hormone receptor-positive, HER2-negative invasive breast cancer patients was used to create a model. The model was then validated on a second institution's set of 319 patients. RESULTS: The model has 2 simple rules: low grade and positive progesterone receptor tumors (LG+PR) are low risk, and high grade or low estrogen receptor (ER) (ER < 20%) tumors (HG/LER) are high risk. The TAILORx (Trial Assigning Individualized Options for Treatment (Rx)) trial thresholds of Recurrence Score (RS) ≤ 10, when chemotherapy is of little benefit, and RS ≥ 26 when chemotherapy might be beneficial were used to judge model performance. Impressively, the misclassifications of an HG/LER patient who has an RS ≤ 10 were 0% and 2%, and for LG+PR patients who had an RS ≥ 26 were 0% and 2.6%. In the validation set, 28% (66 of 232) of the indeterminate group (neither in the HG/LER nor the LG+PR groups) had an RS ≤ 10 or an RS ≥ 26; this group might clinically benefit from ODX. CONCLUSION: A simple 2-rule model based on readily available pathologic data was developed and validated, which categorized patients into high and low risk for recurrence. Identification of patients who are unlikely to benefit from ODX testing could result in significant cost avoidance.

Management of aortic valve bypass surgery.

The 3 leading causes of aortic stenosis (AS) in adults are calcific degeneration of a normal trileaflet aortic valve (AV), calcific degeneration of a congenital bicuspid AV, and rheumatic AS. Therapeutic options in patients with severe AS include aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI), or aortic valve bypass (AVB). An AVB involves the placement of a valved conduit between the apex of the left ventricle and the descending thoracic aorta. AVB serves as a useful alternative to treat severe AS in patients deemed high risk for conventional AVR (ie, porcelain aorta, previous cardiac surgery) or TAVI (ie, severe aorto-iliac disease, limited experience, lack of hybrid operating room). Advantages of on-pump AVB include the avoidance of aortic cannulation, cross-clamping, and cardioplegic cardiac arrest. The procedure can also be performed without cardiopulmonary bypass. In this article, the authors review the circulatory physiology, perioperative anesthetic management, the role of intraoperative transesophageal echocardiography, and surgical considerations of AVB surgery through 3 cases.

Diffuse esophageal polyposis: an uncommon occurrence.

The presence of multiple esophageal polyps on endoscopy is a rare entity. Most of the literature cited on this phenomenon is based on case reports and small series. A large proportion of the literature describes one or two polyps, with the majority of polyps occurring in the area of the gastroesophageal junction. We present a case of a 66-year-old woman with a history of gastroesophageal reflux disease that was found to have extensive esophageal polyposis of the mid-esophagus on upper endoscopy. The patient underwent a transhiatal esophagectomy. Final pathology was consistent with extensive polypoid dysplasia in the presence of Barrett's esophagus.

Thoracic disk herniation resulting in acutely progressing paraplegia in a pediatric patient.

BACKGROUND: Thoracic intervertebral disk herniation is an uncommon entity. Acute presentation of this entity in the pediatric population is exceptionally rare. Given the infrequent prevalence, accurate diagnosis of acute symptomatic thoracic disk herniation can be difficult. PURPOSE: The purpose of this article is to describe the presentation of acute nontraumatic thoracic disk herniation in a pediatric patient and the diagnostic workup and surgical management of this rare entity. STUDY DESIGN: This is a case report regarding a pediatric patient with nontraumatic acutely symptomatic thoracic disk herniation. The order of diagnostic studies and method of surgical decompression used are described. Progressive follow-up neurological improvement is detailed in the report. METHODS: A 16-year-old adolescent girl with acutely symptomatic paramedian disk herniation at T10 to T11 underwent left thoracotomy followed by microdiscectomy. Decompression of T10 to T11 was followed by fusion of T10 to T11 with rib strut graft. RESULTS: Postoperatively, the patient recovered near-complete resolution of bilateral lower extremity paralysis and dysesthesias. CONCLUSIONS: Thoracic intervertebral disk herniation is a rare phenomenon. It is a particularly uncommon entity in the pediatric population. As such, the diagnosis and management of thoracic disk herniation can be a considerable challenge. As illustrated in our case report, the clinician's focus should not exclusively rest on lumbar disk pathology as the etiology for such rapidly evolving neuromuscular deficits. Thoracic disk herniation must be included in the differential diagnosis, and appropriate diagnostic workup should be instituted in an expeditious manner. Plain radiographic studies may not delineate the causative factor of pathology, and emergent magnetic resonance imaging can aid in obtaining a timely diagnosis. Early intervention and decompression have been shown to significantly improve functional recovery.

Elastofibroma dorsi: clinicopathologic review of 6 cases.

Elastofibroma dorsi is a rare, benign lesion arising from connective tissue and usually found at the angle of the scapula. Surgical resection is often indicated in the presence of an enlarging mass or when malignancy can not be excluded. Herein we report our most recent case of elastofibroma dorsi and our review of 6 cases from the past 16 years.

Cervical hibernoma demonstrating uptake on Tc-99m lymphoscintigraphy.

A hibernoma is an uncommon, benign tumor composed of brown adipose tissue. It is a rare but documented cause of neck masses. Hibernomas may be first diagnosed not by clinical examination, but incidentally through radiologic tests assessing the metabolic activity of certain tissues. These tumors are by definition benign entities but, given their propensity for growth over time, they require complete extirpation to prevent recurrence. Different radiologic modalities have been used to evaluate hibernomas, including computed tomography scan, magnetic resonance imaging, fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography, and angiography. It is rare for a hibernoma to be discovered through Tc-99m lymphoscintigraphy.