Comparative analysis of margin status in breast conservation surgery and its correlation with subsequent re-excision findings.

PURPOSE: Breast-conservation surgery (BCS) has become a standard treatment option for invasive breast carcinoma (IBC) and ductal carcinoma in situ (DCIS). The strongest predictor of local recurrence remains the surgical margin status. We evaluated the margin positivity by quantifying the tumor on positive margins and analyzing the histologic factors including type and extent in determining the likelihood of residual disease upon re-excision. METHOD: Retrospective analysis of 210 BCS performed at Mount Sinai Medical Center from the period of January 2011 - December 2017 revealed that 58 had IBC, DCIS, or both, with positive margins that were followed by re-excision. RESULT: The margins had IBC in 18 (31%), DCIS in 32 (55.2%) and both in 8 (13%) cases. Thirty-eight cases (65.5%) were free of carcinoma on re-excision. Of 40 cases with margins positive for DCIS, 16 (40%) had residual DCIS. Of 26 cases with IBC at the margins, and 5 had residual disease (19%). This difference was statistically significant (p = 0.002). Of 21 cases with extensive DCIS, 12 had residual disease (p = 0.02) as compared to only 4 out of 19 without extensive DCIS. None of the cases with clinging/micro-papillary DCIS had residual disease, while 51% of the other types (solid, cribriform, come-do) had residual disease (p = 0.02). The area of DCIS as measured on the involved margin correlated with the amount of residual disease on re-excision (p = 0.03). CONCLUSION: Margins positive for DCIS are more likely to have residual disease on re-excision in comparison to margins positive for only IBC. The type and extent of DCIS appears to influence the likelihood of residual disease.

Intraoperative sentinel lymph node mapping in patients with colon cancer.

BACKGROUND: The sentinel lymph node (SLN) mapping technique has been used in breast cancer and melanoma, and was recently described for colon cancer. METHODS: Thirty-five patients with colon cancer underwent intraoperative SLN mapping. One milliliter of 1% isosulfan blue was injected subserosally around the tumor. The first nodal area that was highlighted with blue was identified as the SLN. All lymph nodes underwent examination with hematoxylin and eosin (H&E) stain. SLNs underwent additional sectioning and were stained with CAM 5.2. RESULTS: Lymphatic mapping adequately identified the SLN in 25 patients (71%). In the 15 cases where the SLNs were negative for metastases, all other non-SLNs were also negative (0% false negative rate). The SLN was the only site of metastases in 6 (17%) of 35 patients. CAM 5.2 staining provided the only evidence of micrometastases in 4 (11%) of 35 patients. CONCLUSIONS: Intraoperative SLN mapping is a feasible technique with a reasonable SLN identification rate (71%). The absence of metastases in the SLNs accurately predicts the status of the non-SLNs. Tumors in 11% of patients were upstaged by the demonstration of micrometastatic involvement, and these patients may benefit from further adjuvant chemotherapy.

Collagenous fibroma (desmoplastic fibroblastoma): a unique presentation as a goiter in an 88-year-old man.

Collagenous fibroma (desmoplastic fibroblastoma) is a recently described entity in the medical literature. This entity has been reported in various locations, including the upper extremities, posterior neck, upper back, lower extremities, abdominal wall, and hip. We report an interesting case of an 88-year-old man who presented with an apparent goiter involving the right anterolateral neck. Histologic studies revealed a well-circumscribed, paucicellular lesion composed of stellate and spindle-shaped fibroblasts separated by bundles of collagen. No mitotic figures, necrosis, or calcification was observed. The stellate and spindle-shaped cells were positive for vimentin and focally positive for desmin, indicating myofibroblastic differentiation. Our case exemplifies the diagnostic difficulties that these tumors may pose from the clinical and radiologic standpoint when they clinically present as a goiter.

An improved method of flexible endoscopic creation of tracheoesophageal fistula for voice restoration.

We present improvements of a previously reported method of tracheoesophageal puncture for voice restoration in postlaryngectomy patients. Our method utilizes a flexible endoscope to enable the tracheoesophageal puncture to be made under direct visualization using only local anesthesia and intravenous sedation. After 3 days, the created tracheoesophageal fistula tract is mature enough to allow placement of a voice prosthesis in the office. This allows the entire procedure to be performed in an outpatient setting with minimal risk.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) as a consequence of neck dissection.

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can have multiple causes. Surgical neck dissections may have an association with this syndrome and represent the basis for this study. A retrospective review of 50 patients undergoing neck dissections was performed to evaluate for the development of hyponatraemia as a consequence of SIADH. Based on the results of this review, a prospective study of 20 consecutive patients undergoing 22 neck dissections was performed to determine the incidence of SIADH. A control group of 25 consecutive patients undergoing major non-neck dissection surgery was also studied. SIADH developed in nine of 50 patients (18 per cent) of our retrospective group with a high incidence of development in those who had jugular vein ligation (JVL) (22 per cent), pre-operative radiation therapy (25 per cent) or squamous cell cancers (32 per cent). SIADH developed in six patients undergoing 22 neck dissections (27 per cent) in our prospective group. A high incidence was also noted for those with JVL (42 per cent), pre-operative radiation therapy (67 per cent) or squamous cell cancer (40 per cent). No patients developed symptomatic hyponatraemia. No patients in the prospective control group developed SIADH. Neck dissection surgery is associated with a significant risk for the development of SIADH. Factors such as jugular vein ligation (JVL), pre-operative radiotherapy and squamous cell cancer appear to increase this risk.

Rectal carcinoma metastatic to the thyroid gland.

Clinically evident metastases to the thyroid gland are rarely found antemortem. A case of a 59-year-old woman with a history of rectal carcinoma, who presented with low back pain and a mass in the right lobe of her thyroid gland, is presented. The tumour of the thyroid was found to be metastatic adenocarcinoma from her previous rectal cancer. Other synchronous metastases were noted in her lumbar spine and kidneys. The clinical finding of metastases to the thyroid gland is rare, particularly from a colorectal primary. One must consider, however, the possibility of a tumour of the thyroid gland representing a secondary malignancy in any patient with a prior history of cancer.

Inguinal lymph node metastases from adenocarcinoma of the rectum.

This study is a retrospective review of 18 patients treated from 1964 to 1990 with inguinal lymph node metastases from rectal adenocarcinoma. Statistical analyses were performed to determine the effects of sex, disease-free interval, extent of inguinal lymph node metastases, and the presence of extranodal disease upon survival. The mean age of patients was 61 years (range 32 to 87). Lymph node metastases were unilateral in 12 patients and bilateral in 6. All 18 patients developed disease at loco-regional sites (pelvis/perineum) either synchronous or metachronous to their development of inguinal lymph node metastases. Survival from the time of diagnosis of inguinal lymph node metastases ranged from 2 to 54 months (median 13.5). There was no statistically significant difference in survival for unilateral versus bilateral inguinal metastases (P = 0.37). The median survival when inguinal lymph node metastases occurred > or = 12 months from diagnosis of the primary tumor was 16 months and 10.5 months when metastases occurred < 12 months after the diagnosis of the primary tumor (P = 0.033). The median survival for patients with isolated metachronous inguinal lymph node metastases was 20 months versus 12 months for patients who developed metachronous inguinal metastases concurrent with other areas of disease (P = 0.045). Although patients with disease-free intervals > or = 12 months and those with isolated inguinal metastases had statistically significant longer median survivals, the overall survival remains poor and all patients died with disease.

Endoscopic laser treatment for palliation of colorectal adenocarcinoma.

Fifty-three patients were treated for palliation with endoscopic neodymium yttrium aluminum garnet (Nd:YAG) laser for colorectal carcinoma at Roswell Park Cancer Institute. There were 25 females and 28 males. The mean age of the patients was 76 years. Thirty-eight tumours were primary and 15 recurrent. The level of the lesions from the anal verge ranged from 2 to 50 cm, with a mean of 10 cm. Eighty-four percent of the lesions were rectal carcinomas within 15 cm of the anal verge. Lesion length ranged from 1.5 to 12 cm with a mean of 5 cm. The number of laser treatments ranged from 1 to 17 with a mean of 3. The duration of treatments ranged from 25 to 90 min with a mean of 35 min. The mean number of joules per treatment was 5093. Eight patients (15%) developed complications. There were no mortalities. The success rate for treating bleeding, the most frequent presenting symptom, was 93%. The overall success rate of patients improved by laser treatment was 79%. Patients who were improved by therapy had a median survival of 18 months versus those not improved who had a median survival of 3 months (P = 0.01). The use of the Nd:YAG laser for palliative treatment of patients with colorectal carcinoma is safe, effective and associated with no mortality.

Granular cell tumor of the breast.

Granular cell tumors are rare tumors occasionally located in the breast. They are generally benign, but can mimic breast carcinoma thus complicating diagnosis and treatment. The etiology of these tumors remains obscure, but may be neurogenic in origin. We report a case of granular cell tumor of the breast and present a review of the topic.

Risk factors for breast cancer.

Despite the numerous risk factors for the development of breast cancer that have been investigated, only a few demonstrate a clear association with breast cancer development. Female gender and increasing age are the most important factors, followed by factors involving a woman's menstrual, reproductive, and family history. The risks related to menstruation and reproduction are probably related to the duration of estrogenic breast stimulation. The relationship of family history and breast cancer risk is unclear, but there may be a true genetic basis. The previous occurrence of breast cancer (invasive or in situ), the presence of proliferative pathological changes, especially with atypia, and the presence of other malignancies (e.g., primary ovarian and endometrial cancer) are histological risk factors for the development of new or recurrent breast cancer. Radiation exposure, the use of exogenous estrogens (both estrogen replacement therapy and oral contraceptives), diet (especially fat consumption), and alcohol intake may all play a role in cancer risk. Certain medications as well as patient demographics may also have a weak association. Cigarette smoking, caffeine consumption, and stress presently have little support for an association with breast cancer risk. It should be noted that in only one in four patients can breast cancer be accounted for by the known risk factors. This demonstrates that although presently known risk factors may help in screening for the early detection of breast carcinoma, in its possible prevention by modulation of influenceable factors, and in advising patients about their risks, these factors are merely strong associations with breast cancer incidence and not actual causations. The mechanisms of the development of breast cancer are as yet unknown.

Horseshoe anomaly of the appendix: a previously undescribed entity.

Anomalies of the appendix are extremely rare. The case presented here has not been previously described and is that of a "horseshoe" appendix in a 33-year-old man with sigmoid diverticulitis. This appendiceal variant cannot be classified into any of the existing categories of appendiceal anomalies.