Injection of cryopreserved amniotic membrane and umbilical cord particulate for pressure injuries: a retrospective case series.

INTRODUCTION: PI poses a significant burden to society. Cryopreserved AMUC has potential benefits in managing complex wounds owing to its anti-inflammatory, anti-scarring, and proregenerative properties. AMUC grafts are commonly in sheets, but also come as morselized powders that can be sprinkled or injected. The authors initially used AMUC injection in chronic PIs in March 2017. MATERIALS AND METHODS: This is a single-center, retrospective review of patients with nonhealing PIs treated with AMUC particulate between March 2017 and November 2018. Incidence of wound healing (zero wound volume with complete reepithelialization) was measured at 12, 24, 36, and 52 weeks. RESULTS: Review included 26 PIs (21 patients); of which, 85% were stage 4 PIs, per the NPIAP staging system. After AMUC injection, 14 PIs (54%) achieved complete wound closure at a median of 12.4 weeks (range, 5-52 weeks). Complete wound closure was observed in 7 patients (27%) at 12 weeks, 10 patients (38%) at 24 weeks, 13 patients (50%) at 36 weeks, and 14 patients (54%) at 52 weeks. One patient with vascular issues required amputation; however, no treatment-related adverse events or complications were observed. CONCLUSIONS: These preliminary results suggest that injection of AMUC particulate may be a safe and promising treatment in promoting wound closure of difficult-to-treat PIs.

Proteomic profiling of tear fluid as a promising non-invasive screening test for colon cancer.

BACKGROUND: Current screening options for colorectal cancer (CRC) are either invasive (colonoscopy) or have lower sensitivity to identify pre-malignant lesions (fecal immunochemical test). We proposed to identify protein profiles in tears of patients with both pre-malignant polyps and CRC; these profiles could have potential as a noninvasive screening test. METHOD: Colonoscopy patients were divided into "high risk" group (CRC and tubular adenomatous polyp) and "low risk" (normal and hyperplastic polyps). Tear fluids from patients were analyzed by Liquid Chromatography Mass Spectrometry/Mass Spectrometry. The data were analyzed for protein expression, protein-protein interaction and gene set enrichment. RESULTS: The results showed 80 proteins (18 up-regulated and 62 down-regulated) significantly differentiated in "high-risk" compared to "low-risk"; Twenty-eight of these show protein-protein interactions, 9 of which were associated with pathways demonstrated to be altered in CRC patients. CONCLUSION: Our pilot data, though limited, demonstrated tear protein profiling could distinguish the groups of patients with and without colon lesions.

Association of tobacco and alcohol use with earlier development of colorectal pathology: should screening guidelines be modified to include these risk factors?

BACKGROUND: Current guidelines for colorectal cancer (CRC) screening recommend initial screening at 50 years of age for normal-risk patients. Alcohol and tobacco use can be associated with an earlier onset of CRC and possibly polyps. METHODS: We reviewed all colonoscopies performed at our institution from January to December 2007. Patient data were collected on age, sex, tobacco and alcohol history, and the presence of colon lesions. RESULTS: Our data included 663 patients (643 men and 20 women) with a mean age of 60.7 years (range 23-89 years); 68.5% were current/former tobacco users, 53.7% were current/former alcohol users, 37.6% had used both, and 21.7% had used neither. Colonoscopy findings were as follows 64% of patients had no lesions, 30.6% had tubular polyps, 3.5% had villous polyps, and 2% had cancer. The current use of tobacco, alcohol, or both was associated with the early development of colon pathology (ie, 66.9 years, 61.1 years, and 59.2 years [P < .05], respectively). In nonusers, the mean age was 67.7 years. CONCLUSIONS: Our work confirms that the use of alcohol and tobacco is associated with an earlier onset of colon pathology. Consideration should be given to modifying screening guidelines to include these habits as "high-risk" factors.

A report of laryngeal adenocystic carcinoma metastatic to the spleen and the role of splenectomy in the management of metastatic disease: a case report.

INTRODUCTION: Adenoid cystic carcinoma (ACC) of the larynx is a rare malignancy characterized by an indolent course and late pulmonary metastases. Metastases from the larynx to the spleen are an unusual event. In the present report, we discuss a patient with adenoid cystic carcinoma of the larynx metastatic to the spleen. A review of the literature did not yield any other such incidents. We review the clinical presentation and course of adenoid cystic carcinoma, as well as the role of splenectomy for metastases. CASE PRESENTATION: We present a case of laryngeal adenoid cystic carcinoma in a 26-year-old Caucasian man treated with total laryngectomy and ionizing radiation. He initially developed asynchronous pulmonary metastases, which were resected. Our patient subsequently presented with a symptomatic splenic lesion consistent with metastatic disease, for which he underwent laparoscopic splenectomy. CONCLUSIONS: Splenectomy might be indicated for isolated metastases. A splenectomy effectively addresses symptoms and serves as a cytoreduction modality.

Association of tobacco and alcohol use with earlier development of colorectal cancer: should we modify screening guidelines?

BACKGROUND: Current guidelines recommend initial colorectal cancer screening at age 50 years for average-risk patients. Alcohol and tobacco use can be associated with earlier onset of colorectal cancer. We hypothesized an earlier age at diagnosis and/or more advanced stage in patients with these habits. METHODS: We queried our tumor registry for colorectal cancer diagnosed between January 1997 and December 2006. Data were analyzed to evaluate effects of alcohol and tobacco use. RESULTS: Of 335 colorectal cancer patients, 81% used tobacco, 51% used alcohol, 45% used both, and 14% used neither. Current tobacco and alcohol use were associated with younger ages at onset of colorectal cancer. Thirteen of 332 patients were diagnosed with colorectal cancer before age 50 years. All had exposure to alcohol and tobacco. Fifty-four percent (7/13) of these patients presented at stage 3/4 compared with 34% of the overall population. CONCLUSIONS: Modification of screening guidelines to include these habits as "high-risk" factors may be indicated.

Prevention of nausea and vomiting following breast surgery.

BACKGROUND: The purpose of this study was to determine the rate of nausea and vomiting in women following breast surgery (PONV) under general anesthesia (GA), before and after the introduction of a standardized prophylactic anti-emetic (AE) regimen. METHODS: We performed a retrospective review of eligible patients, between July 2001 and March 2003. Patients operated on before September 2002 had standard preoperative care (old cohort [OC]); patients operated on after September 2002 were treated prophylactically with oral dronabinol 5 mg and rectal prochlorperazine 25 mg (new cohort [NC]). Data were collected from hospital records regarding age, diagnosis, comorbid conditions, previous anesthesia history, anesthesia and operative details, episodes PONV, and use of AE. The rate and severity of PONV was calculated for both cohorts. RESULTS: Two hundred forty-two patients were studied: 127 patients in the OC and 115 patients in the NC. The median age was 56 years (range 32 to 65). The rate of nausea and vomiting were significantly better in the patients treated prophylactically with dronabinol and prochlorperazine (59% vs. 15%, P < .0001 and 29% vs. 3%, P < .0001). Twenty patients in the OC were given some prophylactic AE treatment and 12 (60%) of them required further treatment; only 12 of 109 patients (11%) in the NC required further AE treatment (P < .0001). CONCLUSION: PONV is a significant problem in breast surgical patients. Preoperative treatment with dronabinol and prochlorperazine significantly reduced the number and severity of episodes of PONV.

Surgical benefits conveyed by biopsy site marking system using ultrasound localization.

BACKGROUND: With vacuum-assisted biopsy technology all, or most, of a breast lesion may be removed during the initial biopsy; in such cases a metallic marker is often inserted at the site of the biopsy for future localization. The aim of this study was to evaluate the efficacy and impact of the Gel Mark Ultra biopsy site marking system (SenoRx, Aliso Viejo, CA) on the practice of needle localization breast biopsy. METHODS: We retrospectively analyzed the experience of 45 general surgeons across the United States in a variety of practice settings using the Gel Mark Ultra clip. Imaging-guided biopsy technique, localization quality, surgeon confidence, and margin status were assessed and compared against the broad data reported in the literature. RESULTS: A total of 432 records of patients who underwent imaging-guided breast biopsy with placement of Gel Mark Ultra clip were reviewed. Of these, 63 (15%) patients required definitive surgical intervention, for which 41 cases were localized with ultrasound and assessed for margin clearance. Clear margins were achieved in 37 (90%) of the 41 cases. These results are statistically superior (P < .01) to positive margins rates reported in the literature. CONCLUSIONS: The Gel Mark Ultra biopsy site marking system is a new localization device that provides a safe and effective alternative to traditional localization methods with a significant reduction in the percentage of positive margins, as well as advantages in terms of surgical approach, time, and patient comfort.

Antigen binding of human IgG Fabs mediate ERK-associated proliferation of human breast cancer cells.

Serum-circulating antibody can be linked to poor outcomes in some cancer patients. To investigate the role of human antibodies in regulating tumor cell growth, we constructed a recombinant cDNA expression library of human IgG Fab from a patient with breast cancer. Clones were screened from the library with breast tumor cell lysate. Sequence analysis of the clones showed somatic hypermutations when compared to their closest VH/VL germ-line genes. Initial characterizations focused on five clones. All tested clones displayed stronger binding to antigen derived from primary breast cancers and established breast cancer cell lines than to normal breast tissues. In vitro functional studies showed that four out of five tested clones could stimulate the growth of MDA-MB-231 breast cancer cell lines, and one out of five was able to promote MCF-7 cell growth as well. Involvement of ERK2 pathway was observed. By 1H-NMR spectra and Western blot analysis, it was evident that two tested antibody Fabs are capable of interacting with sialic acid. Our study suggests a possible role for human antibody in promoting tumor cell growth by direct binding of IgG Fab to breast tumor antigen. Such studies prompt speculation regarding the role of serum antibodies in mediating tumor growth as well as their contribution to disease progression.

Intraoperative subareolar radioisotope injection for immediate sentinel lymph node biopsy.

OBJECTIVE: To determine the identification of sentinel lymph node biopsy (SLNB) in breast cancer patients after intraoperative injection of unfiltered technetium-99m sulfur colloid (Tc-99) and blue dye. BACKGROUND: SLNB guided by a combination of radioisotope and blue dye injection yields the best identification rates in breast cancer patients. Radioisotope is given preoperatively, without local anesthesia, whereas blue dye is given intraoperatively. We hypothesized that, because of the rapid drainage noted with the subareolar injection technique of radioisotope, intraoperative injection would be feasible and less painful for SLN localization in breast cancer patients. METHODS: Intraoperative injection of Tc-99 and confirmation blue dye was performed using the subareolar technique for SLNB in patients with operable breast cancer. The time lapse between injection and axillary incision, the background count, the preincision and ex vivo counts of the hot nodes, and the axillary bed counts were documented. The identification rate was recorded. RESULTS: Ninety-six SLNB procedures were done in 88 patients with breast cancer employing intraoperative subareolar injection technique for both radioisotope (all 96 procedures) and blue dye (93 procedures) injections. Ninety-three (97%) procedures had successful identification; all SLNs were hot; 91 (of 93 procedures with blue dye) were blue and hot. The mean time from radioisotope injection to incision was 19.9 minutes (SD 8.5 minutes). The mean highest 10 second count was 88,544 (SD 55,954). Three of 96 (3%) patients with failure of localization had previous excisional biopsies: 1 circumareolar and 2 upper outer quadrant incisions that may have disrupted the lymphatic flow. CONCLUSION: Intraoperative subareolar injection of radioisotope rapidly drains to the SLNs and allows immediate staging of the axilla, avoiding the need to coordinate diagnostic services and a painful preoperative procedure.

Touch preparation of breast core needle specimens is a new method for same-day diagnosis.

BACKGROUND: Touch preparation cytology (TPC) has proven to be a quick and accurate intraoperative diagnostic tool for excisional breast biopsy, margins and sentinel nodes. We hypothesized that TPC of core needle biopsy (CNB) specimens can provide a same-day diagnosis in the outpatient setting. METHODS: Outpatients presenting with breast lesions underwent TPC of biopsy cores performed by biopsy gun or vacuum-assisted CNB. The TPC results were compared with the final diagnosis of CNB specimens. RESULTS: In all, 199 CNB and TP were performed between August 1997 and October 2002. Twenty-nine percent of lesions were malignant. Touch preparation was deferred in 21% of cases. In the remaining 157 evaluable cases, TPC had an accuracy of 89% and a false negative rate of 26%. The sensitivity, specificity, positive predictive value and negative predictive value of TPC were 74%, 97%, 93%, and 86% respectively. CONCLUSIONS: Touch preparation cytology on CNB can be performed simply in the outpatient setting. Collaboration between the surgeon and pathologist allows TP to be an accurate means of same-day pathological determination.

Clip migration in stereotactic biopsy.

BACKGROUND: Needle localization breast biopsy (NLBB) is the standard for removal of breast lesions after vacuum assisted core biopsy (VACB). Disadvantages include a miss rate of 0% to 22%, a positive margin rate of approximately 50%, and vasovagal reactions (approximately 20%). We hypothesized that clip migration after VACB is clinically significant and may contribute to the positive margin rates seen after NLBB. METHODS: We performed a retrospective review of postbiopsy films in patients who had undergone VACB with stereotactic clip placement for abnormal mammograms. We measured the distance between the clip and the biopsy site in standard two view mammograms. The location of the biopsy air pocket was confirmed using the prebiopsy calcification site. The Pythagorean Theorem was used to calculate the distance the clip moved within the breast. Pathology reports on NLBB or intraoperative hematoma-directed ultrasound-guided breast biopsy (HUG, which localizes by US the VACB site) were reviewed to assess margin status. RESULTS: In all, 165 postbiopsy mammograms on patients who had VACB with clip placement were reviewed. In 93 evaluable cases, the mean distance the clip moved was 13.5 mm +/- 1.6 mm, SEM (95% CI = 10.3 mm to 16.7 mm). Range of migration was 0 to 78.3 mm. The median was 9.5 mm. In 21.5% of patients the clip was more than 20 mm from the targeted site. Migration of the clip did not change with the age of the patient, the size of the breast or location within the breast. In the subgroup of patients with cancer, margin positivity (including those with close margins) after NLBB was 60% versus 0% in the HUG group. CONCLUSIONS: Significant clip migration after VACB may contribute to the high positive margin status of standard NLBBs. Surgeons cannot rely on needle localization of the clip alone and must be cognizant of potential clip migration. HUG as an alternative biopsy technique after VACB eliminates operator dependency on clip location and may have superior results in margin status.

Intraoperative touch preparation for sentinel lymph node biopsy: a 4-year experience.

BACKGROUND: The optimal technique for intraoperative pathologic examination of sentinel lymph nodes (SLNs) is still controversial. Recent small series report sensitivity between 60% and 100% for various techniques. The aim of this study was to evaluate our long-term experience with touch preparation cytology (TPC) and frozen section (FS) in the intraoperative examination of SLNs for breast cancer. METHODS: A total of 247 patients with operable breast cancer underwent an SLN biopsy for staging of the axilla. The SLN was identified by (99m)Tc-labeled sulfur colloid unfiltered dye, blue dye, or both and dissected, and then intraoperative TPC or FS and permanent section, or both, were performed. RESULTS: A total of 479 SLNs were submitted for TPC and permanent hematoxylin and eosin. A total of 68 SLNs were positive by hematoxylin and eosin; 65 SLNs were positive by TPC, with a false-negative rate of 5.8%. The sensitivity for TPC was 94.2%, with a false-positive rate of 0.2%. A total of 165 SLNs were submitted for FS, with a sensitivity of 85.7% and a specificity of 98.6%. The false-positive rate was 1.4%, with a false-negative rate of 15.8%. CONCLUSIONS: In a large series, TPC is as accurate as FS but is simpler and faster in the detection of intraoperative metastasis in SLNs for breast cancer.