Screening for metastasis in primary breast cancer patients having four or more axillary lymph node involvement: is it really necessary?

PURPOSE: To evaluate the necessity and direct cost effectiveness of screening and staging procedures in breast cancer patients having ≥4 positive axillary lymph nodes and to identify further possible biopathological risk factors associated with increased risk of metastasis. METHODS: We reviewed the demographic and clinicopathological data from the medical records of 1897 newly diagnosed breast cancer patients. Patients having ≥4 positive axillary lymph nodes after primary surgery for breast cancer and who had staging examinations for metastasis were eligible. The impact of staging procedures (thoracoabdominal CT, bone scan etc.) for detecting metastasis, decision of adjuvant treatment and direct costs were analyzed in 329 patients with operable breast cancer. RESULTS: Thirty-five (10.6%) patients were found with metastasis at diagnosis. Seven (20.0%) among them had multiple metastases. Eighteen (51.4%) had lung, 17 (48.6%) bone, and 7 (20.0%) liver metastasis. Twenty-one (60.0%) patients needed further radiological investigation for metastasis confirmation. Treatment decision was changed in 27 (77.1%) patients. No statistically significant risk factor was identified among the metastatic patients by means of conventional demographic and biopathological parameters. The cost of screening was lower when compared to the cost of treatment without any screening procedure. CONCLUSION: Since the conventional clinicopathological data seems not sufficient to define the risk of developing metastasis in breast cancer patients with ≥4 axillary lymph node involvement, all of them should undergo full staging examinations until new parameters based on genomic level are defined. Staging procedures need modification for high risk breast cancer patients.

Do clinical and immunohistochemical findings of pure mucinous breast carcinoma differ from mixed mucinous breast carcinoma?

Mucinous carcinoma of the breast is a relatively rare histologic type with two subtypes: pure and mixed. It has a favourable prognosis with a low risk of axillary metastases. The prognosis for pure mucinous carcinoma (PMC) was much better than for the mixed mucinous carcinoma (MMC). The aim of the study is to determine suitable candidates for breast or axillary conservation in mucinous carcinoma subtypes. The slides of 26 pure and 23 mixed mucinous carcinomas of the breast were evaluated. The clinical, pathological and immunohistochemical features between PMCs and MMCs were compared. MMC displayed greater metastatic potential (p < 0.05), p53 positivity (p < 0.05) and c-erbB-2 positivity (p <0.001) than PMCs. PMCs smaller than 2 cm had less metastatic capacity and extranodal invasion compared to MMCs smaller than 2 cm (p < 0.001 and p < 0.01, respectively). MMCs smaller than 2 cm displayed weaker ER positivity but greater c-erbB-2 positivity than PMCs smaller than 2 cm (p < 0.01). In conclusion, MMC had worse prognostic factors than PMC with both types of mucinous carcinoma showing similar ER and PR positive status. Even if PMCs and especially smaller PMCs display more favourable prognostic features, including less axillary lymph node involvement, it is appropriate to use sentinel lymph node biopsy to make better axillary assessment.

Signet ring cells in fine needle aspiration cytology of breast carcinomas: review of the cytological findings in ten cases identified by histology.

OBJECTIVE: To establish whether the presence of signet ring cells (SRCs) in histology sections of breast carcinoma cases was reflected by their presence in fine needle aspiration cytology (FNAC) smears, correlating to the histological type of breast carcinoma. METHODS: We reviewed the FNAC findings of ten cases that had been diagnosed as primary breast carcinoma with SRCs on histological sections between 1998 and 2007. Slides and histological sections were obtained from the archives of Ege University Hospital. RESULTS: FNA smears were reviewed for the following cytomorphological features: background, cellularity, architecture, nuclear pleomorphism and the presence of SRCs. The background was bloody in eight cases, necrotic in one, and clean in one. There was no mucinous material in any of the cases. Cellularity was prominent in five cases (hypercellular), moderate in three (cellular) and low in two (hypocellular). Loosely cohesive groups of tumour cells of varying size were observed in all cases. A plasmacytoid appearance to some of the tumour cells was seen in all cases and discohesive tumour cells were present in eight. Nuclear pleomorphism was high in six cases and moderate in four. SRCs were observed in seven of the ten cases. Two of these seven cases also had a tubular pattern and one had tumour giant cells. CONCLUSIONS: FNAC should be evaluated carefully regarding the presence of SRCs when cells with a plasmacytoid appearance are observed in either hyper- or hypocellular smears. The presence of single SRCs in FNACs with hypercellularity, high nuclear grade and tubular formation or tumour giant cells may be a clue in favour of ductal carcinoma. The presence of single SRCs in FNACs with hypocellularity and mild to moderate nuclear grade may be suggestive of lobular carcinoma. However, larger studies would be needed to establish the predictive value of the presence of SRCs on FNAC.

Granulomatous mastitis: imaging findings with histopathologic correlation.

OBJECTIVE: The purpose of this study is to evaluate the mammographic and ultrasonographic characteristics of granulomatous mastitis and to correlate the imaging features with the histologic findings. MATERIALS-METHODS: 15 patients with diagnosis of idiopathic granulomatous mastitis were examined with mammography and ultrasonography. The clinical, pathologic and imaging features were retrospectively reviewed and correlated in all patients. RESULTS: Mammographic examination showed an asymmetric density with no distinct margins in 8 patients and an ill-defined mass in 3 patients. In 4 cases, no abnormal finding was detected on the mammography. Sonographic examination demonstrated an irregular mass with tubular connections in 5 patients, single or multiple hypoechoic tubular/nodular structures in 6, and focally or segmentally decreased parenchymal echogenity with acoustic shadowing in 4 patients. The imaging findings suggested a malignant tumor in 7 patients, while an inflammatory process or intraductal papilloma was considered in the differential diagnosis of the other patients. CONCLUSION: Granulomatous mastitis usually presents with clinical findings mimicking a carcinoma. The most common mammographic appearance of the lesion is an asymmetrically increased density, which is not characteristic for this entity. Sonographic patterns of the disease are varied and appear to relate to the histologic features. Findings include a mass-like appearance, tubular/nodular hypoechoic structures and focal decreased parenchmal echogenicity with acoustic shadowing. With awareness of the findings granulomatous mastitis can be considered in the differential diagnosis.

Effect of polyethylene glycol 4000 on adhesion formation following thyroid surgery in rats.

BACKGROUND & OBJECTIVES: Difficulties in dissection encountered during reoperative thyroid surgery could be minimised by preventing formation of adhesions in the operative field. We studied the prevention of adhesion formation in rats after thyroid surgery by using polyethylene glycol 4000 (PEG 4000). METHODS: Twenty two rats in two equal groups were studied. Right hemithyroidectomy was performed in both groups with 0.9 per cent saline being instilled in the operative field in the control group and PEG 4000 solution in the study group. After 10 days, all rats were re-explored and the remaining thyroid tissue of the right lobe was excised. The specimens were scored according to the thickness of the connective tissue over the remainder of the thyroid gland. RESULTS: The connective tissue thickness over the remaining tissue of the thyroid gland in the control and study groups was 272.04 +/- 77.10 and 172.90 +/- 48.92 microns respectively. The decrease of the connective tissue thickness over the remainder of thyroid gland in the study group was significant (P < 0.05). INTERPRETATION & CONCLUSION: In this animal model although application of PEG 4000 did not completely prevent adhesion formation, a significantly decreased amount of adhesions was found.

Effects of somatostatin analogues and vitamin C on bacterial translocation in an experimental intestinal obstruction model of rats.

The passage of viable endogenous bacteria and their products across the intact intestinal mucosal barrier, disseminating to the mesenteric lymph nodes, peritoneal cavity, spleen, liver, and circulation, is defined as bacterial translocation. Intestinal obstruction induces bacterial translocation due to mucosal disruption, motility dysfunction, and increased intestinal volume, leading to bacterial overgrowth. In a rat model of intestinal obstruction, the effects of both high-dose vitamin C (350 microg/kg), an antioxidant agent known to have a cytoprotective effect in ischemia-reperfusion injury, and somatostatin (20 microg/kg), a gastrointestinal antisecretory agent, in preventing bacterial translocation were studied. Both intestinal and liver samples from the rats was observed, and it was found that the rate of bacterial translocation was 100% in the control group, and only 43% for the rats who were given intraperitoneal vitamin C and somatostatin. The difference was statistically significant. In conclusion, we are convinced that vitamin C and somatostatin analogues may have protective effects against bacterial translocation in mechanical bowel obstruction.

A clinicopthologic study of a rare clinical entity mimicking breast carcinoma: idiopathic granulomatous mastitis.

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast clinically simulating carcinoma. The purpose of this report is to review the clinicopathological features of this clinical entity in a series of 18 cases diagnosed in our institute. The notes of patients and the slides of the biopsy specimens of 18 cases with IGM were reviewed. Special stains for organisms and immunohistochemistry for T and B markers using the primary antibody was done. The diagnosis of IGM was made according to the criteria of Kessler and Wolloch. All but two patients were of reproductive age and all were parous. The main clinical finding was a unilateral, firm, discrete mass. All patients underwent excisional biopsy and recurrence was seen in three patients. In two of these patients who had recurrences, the prolactin level was high and reexcision combined with antiprolactinemic therapy was performed. The third patient was treated by reexcision and oral prednisone. There was granulomatous inflammation, centered mainly on breast lobules in all patients. T cell domination was observed. Exclusion of the other causes of a granulomatous lesion is necessary to make the diagnosis of IGM. The treatment of choice is unclear. Because of the clinical concern of malignancy, fine-needle aspiration cytology or core biopsy can be useful in some cases. To differentiate it from other granulomatous lesions, incisional biopsy or surgical excision of the lesion is necessary. In patients with delayed wound healing or recurrence after excisional biopsy, or those patients who have had an incisional biopsy only, if prolactin level is normal, reexcision and oral prednisone usage may be curative. In patients with a high prolactin level who have recurrence, medical treatment to control prolactin level may be useful in the management of these women.

Hydroxyethyl starch solution: is it a new alternative way of treatment in bacterial translocation?

In this experimental study, the effects of mannitol and hydroxyethyl starch solution (HES) on bacterial translocation were evaluated in a rat model of simple mechanical bowel obstruction. The mechanical bowel obstruction was created by ligation of the ileum 1 cm proximal to the ileocecal valve. Excluding the control group (n = 7), the rats were given 2 ml of mannitol or 2 ml of 6% hydroxyethyl starch solution intraperitoneally during the procedure. Relaparotomy was made and segmental ileal resection, total mesenteric lymph node excision and removal of tissue sample of liver were performed 24 h after the mechanical bowel obstruction, both for histopathological and microbiological examination. The rates of colony formation in the mesenteric lymph nodes after the mechanical bowel obstruction were 71% (5/7) in control animals, 43% (3/7) in animals given mannitol and only 14% (1/7) in animals given HES. In the liver samples observed for the bacterial translocation, the corresponding figures were 14% (1/7), 28% (2/7) and 0% (0/7) respectively. The difference between hydroxyethyl starch solution and control groups were statistically significant (P<0.04). The bacterial population/g tissue obtained from intraluminal bacterial cultures of the ileum was also depressed in hydroxyethyl starch solution group when compared to the control (P<0.03). As a result, we confirmed that hydroxyethyl starch solution, a plasma volume expander, depressed the bacterial translocation to the mesenteric lymph nodes and liver and also reduced intraluminal bacterial overgrowth in the simple mechanical bowel obstruction model of rats. We believe that hydroxyethyl starch solution may be an alternative therapeutic agent for the pre-operative fluid resuscitation in simple mechanical bowel obstruction.

Esophagocoloplasty in the management of postcorrosive strictures of the esophagus.

BACKGROUND/AIMS: Esophageal replacement therapy has developed an increasing role in the management of severe esophageal strictures due to caustic ingestion. The aim of this study is to discuss methods of reconstruction and results of them in corrosive esophagitis at our Institute. METHODOLOGY: Thirty-three patients underwent 34 esophagocoloplasties for benign strictures of the esophagus over a 17-year period. The left colon was used in 8 patients, the right colon in 3 patients, and the right colon with the terminal ileum in 23 patients. RESULTS: Three patients died in the first postoperative month, and there was an overall mortality rate of 9%. The most severe complication was graft necrosis (2 patients). The remainder of the patients survived without any deleterious complications. CONCLUSION: Esophageal replacement therapy using the right colon with the terminal ileum is superior to the modalities in terms of the continuity of peristalsis of the interposed bowel segment with an intact ileocecal valve, which decreases the hazard of regurgitation from the colon. It is also easier to perform an anastomosis between the ileum and the cervical esophagus from the point of view of surgical manipulation.