Small Invasive Breast Carcinomas in Taiwanese Women

Background: Female Taiwanese breast cancer patients are younger than their Western counterparts. This study examined the predictors of axillary lymph node metastases in Taiwanese women with T1 breast cancer.Methods: Data from 394 Taiwanese women with T1 invasive breast carcinoma were retrospectively reviewed.Results: The data contained 6 T1a, 51 T1b, and 337 T1c breast tumors. The patients ages ranged from 23 to 82 years (mean ± SD, 48.2 ± 11.4 years; median, 46.4 years). Axillary nodal metastases were present in 38.3% of the patients (16.7% in T1a, 35.3% in T1b, and 39.2% in T1c tumors). The patients with nodal metastases had significantly greater body weights and S-phase fractions than those without nodal metastases. Univariate analysis revealed that unfavorable pathology, lymphovascular invasion, S-phase fraction >7%, and nondiploid DNA ploidy were significantly associated with lymph node metastases. Lymphovascular invasion was the only significant variable as the independent predictor in the multiple logistic regression analysis. In the Cox proportional hazards regression analysis, axillary nodal status and lymphovascular invasion were significantly associated with survival.Conclusions: Taiwanese women with small breast cancer displayed a relatively higher incidence of axillary lymph node metastases than Western women. Axillary lymph node dissection or sentinel lymph node biopsy should be conducted on Taiwanese patients with small invasive breast carcinomas, particularly when risk factors exist.     

腹股沟可触及睾丸的隐睾的微创治疗

目的探讨腹股沟可触及睾丸的隐睾的微创治疗方法。方法2007年8月～2008年3月对60例腹股沟区可触及睾丸的隐睾,根据睾丸位置高低,采取经阴囊或腹腔镜辅助下睾丸固定手术。结果经阴囊睾丸固定术24例,睾丸位于外环口与阴囊上极之间,23例固定于阴囊底,1例固定于阴囊上极。经阴囊转腹腔镜睾丸固定术2例,均为右侧,睾丸位于外环口与阴囊上极之间,经隐囊手术睾丸下降位置不满意,转为腹腔镜手术将睾丸固定于阴囊底。经腹腔镜睾丸固定术34例,其中睾丸位于腹股沟内16例（41.1%）,位于近外环口处18例（52.9%）,合并腹股沟斜疝8例（23.5%）,均在腹腔镜下行内环口结扎,术后睾丸固定于阴囊底部。60例B超随访3～6个月,平均4.3月,无睾丸萎缩及回缩,无腹股沟斜疝的发生。结论可触及睾丸的腹股沟隐睾如果能推到阴囊上极,则可选择经阴囊切口的睾丸固定术;如果不能将睾丸推到阴囊上极或经阴囊切口不能将睾丸固定到阴囊底时,可选择腹腔镜手术。2种手术方法睾丸固定位置满意,可作为临床医师的参考手术方式之一。     

Radiofrequency Ablation of Invasive Breast Carcinomas: A Phase II Trial

Background Local ablative therapy of breast cancer represents the next frontier in the minimally invasive breast-conservation treatment. We conducted a phase II trial to evaluate radiofrequency ablation (RFA) of invasive breast carcinomas. Methods Consecutive patients from two Mexican Institutions with invasive breast cancers < 4 cm, with no multicentric tumors and no previous chemotherapy were included in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RFA electrode followed by surgical resection. Routine pathologic analysis and viability evaluation with NADPH-diaphorase stain were performed to assess tumor ablation. Procedure-associated morbidity was recorded. Results Twenty-five patients were included. Mean patient age was 55.3 years (range 42–89 years). Mean tumor size was 2.08 cm (range 0.9–3.8 cm). Fourteen tumors (56%) were <2 cm. The mean ablation time was 11 minutes using a mean power of 35 W. During ablation, the tumors become progressively echogenic that corresponded with the region of severe RFA injury at pathologic examination. Of the 25 patients treated, NADPH stain showed no evidence of viable malignant cells in 19 patients (76%), with significant difference between tumors <2 cm (complete necrosis in 13 of 14 cases, 92.8%) vs. those >2 cm (complete necrosis 6 of 11 cases, 54.5%) (P < .05). No significant morbidity was recorded. Conclusions RFA is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further studies are necessary to optimize the technique and evaluate its future role as local therapy for breast cancer.     

Minimally Invasive Ablative Therapies for Invasive Breast Carcinomas: An Overview of Current Literature

Background Minimally invasive treatment may be an alternative to breast-conserving surgery. Methods A structured PubMed, Embase, Cochrane, and Web of Science search was performed. Endpoints studied were feasibility, completeness of ablation, timing of the sentinel node biopsy (SNB), imaging modalities, and treatment-related complications. Results A total of 24 articles were retrieved, and the level of evidence varied (2B-4). Mainly phase II studies with a treat-and-resect protocol were analyzed. Up to 100% completeness of ablation was reported for radiofrequency ablation (RFA), cryosurgery, and focused ultrasound (FUS). The oncologic results need further evaluation. Dynamic contrast enhanced MRI seems to be the best method for monitoring treatment response (77% sensitivity, 100% specificity). Ultrasound is suitable for guiding probes into the tumor. There is no consensus on the timing of the SNB. Conclusions All studies on minimally invasive ablative modalities published so far show that these techniques are feasible and safe. At this stage only T1 tumors should be ablated in a clinical trial setting; it is unclear which of the modalities is most suitable.     

A Phase II Trial of Image-Guided Radiofrequency Ablation of Small Invasive Breast Carcinomas: Use of Saline-Cooled Tip Electrode

Background Local ablative therapy of breast cancer represents the next frontier in the evolution of minimally-invasive breast conservation therapy. We performed this Phase II trial to determine the efficacy and safety of Radiofrequency (RF) ablation of small invasive breast carcinomas. Methods Seventeen patients with biopsy-proven invasive breast cancer, ≤ 1.5 cm in diameter were enrolled in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RF electrode followed by surgical resection. Pathologic and immunohistochemical stains were performed to assess tumor viability. We examined whether loss of ER, PR receptor and pancytokeratin expression following RF ablation would correlate with non-viability. Results Fifteen patients completed the treatment. The mean tumor size was 1.28 cm. The mean ablation time was 21 minutes using a mean power of 35.5 watts. During ablation, the tumors became progressively echogenic that corresponded with the region of severe electrocautery injury at pathological examination. Of the 15 treated patients, NADPH viability staining was available for 14 patients and in 13 (92.8%), there was no evidence of viable malignant cells. ER, PR expression and pancytokeratin immunohistochemistry analysis were unreliable surrogates for determining non-viability. Following RF ablation, 2 patients developed skin puckering. Conclusions RF ablation is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further research is necessary to optimize this image-guided technique and evaluate its future role as the sole local therapy.     

超声引导下麦默通乳腺微创手术的治疗规范

随着高频彩色多普勒超声影像技术的普遍应用,乳腺小肿块的检出越来越多,对乳腺小肿块的定性和切除已经成为当代乳腺外科的新难题。同时,随着对乳腺癌的生物学特性及治疗的认识提高,乳腺癌的术前新辅助治疗逐渐得到认可。如此,新辅助治疗前的病理诊断就显得非常重要,特别是一些关于乳腺癌治疗反应和预后指标的检测     

Image and Pathological Changes after Radiofrequency Ablation of Invasive Breast Cancer: A Pilot Study of Nonsurgical Therapy of Early Breast Cancer

Background

The surgical treatment of early breast cancer has proceeded to less invasive approaches with better cosmetic results. The current study was undertaken to evaluate the clinical and pathological findings after radiofrequency ablation (RFA) without resection for a longer period of time.

Method

A total of 14 patients with breast cancer were enrolled. All patients were diagnosed to have invasive ductal carcinoma, and the median breast tumor size was 12 mm (range, 6–20 mm). Six patients received RFA treatment followed by immediate resection and eight patients without resection. The patients without resection were evaluated by ultrasound, MRI, and the pathological findings of a core needle biopsy after RFA. The removed specimens were examined by hematoxylin-eosin (HE) staining and nicotinamide adenine dinucleotide (NADH) diaphorase staining. The median follow-up of the patients was 39.9 months.

Results

NADH staining was necessary to diagnose complete tumor cell death in the tissue for 3 months after RFA. However, HE staining alone could confirm the effect without NADH staining more than 6 months after RFA. Post-RFA, MRI scans clearly demonstrated the area as a complete ablated lesion in all patients without resection. The ablated area detected by MRI or ultrasound became gradually smaller. All patients that underwent RFA with no resection were alive without relapse.

Conclusion

RFA therefore could be an effective alternative to partial mastectomy for early breast cancer. Further research will be necessary to establish the standardization of the indications, as well as the optimal techniques and post treatment evaluation modalities.     

Proximal Ultrasound-Guided Gastrocnemius Recession: A New Ultra-Minimally Invasive Surgical Technique

Selective proximal recession of the medial gastrocnemius head has clear advantages over other approaches and can be performed as a single or combined open procedure for many indications. The purpose of this study was to evaluate the safety and efficacy of a new technique based on ultrasound-guided ultraminimally invasive proximal gastrocnemius recession. We performed a pilot study with 16 cadavers to ensure that the technique was effective and safe; we then prospectively performed gastrocnemius recession in 12 patients (23 cases) with gastrocnemius contracture associated with other indications. We evaluated pre- and postprocedure dorsiflexion, clinical outcomes (based on the visual analog scale and American Orthopedic Foot and Ankle Society scores), and potential complications. We achieved effective release of the proximal medial gastrocnemius tendon in all cases, with no damage to other tissue. Ankle dorsiflexion increased 12° (range 6° to 18°) (p = .05) and was maintained throughout follow-up. The mean preoperative visual analog scale score was 7 (range 5 to 9), which improved to 1 (range 0 to 2) (p = .01). The American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score improved from a mean of 25 (range 20 to 40) to 85 (range 80 to 100) at 6 months and 90 at 12 months (p = .01). No major complications were observed. We considered the technique to be safe and effective for ultrasound-guided ultraminimally invasive proximal-medial gastrocnemius recession using a 1-mm incision in vivo. This novel technique is an alternative to open techniques, with encouraging results and with the potential advantages of reducing pain and obviating lower limb ischemia and deep anesthesia, thus decreasing complications and contraindications and accelerating recovery, although further studies are required.     

99锝m-tetrofosmin乳腺扫描鉴别乳腺包块性质的临床研究

目的探讨99锝m-tetrofosmin乳腺扫描在鉴别可扪及的乳腺包块良恶性质方面的价值.方法 2000年6月至2002年1月在我院临床发现乳腺包块的104例患者接受了99锝m-tetrofosmin乳腺扫描.检查时先经病变对侧肘静脉注射740 MBq显像剂,注射后5、10及20 min 分别采集前位和侧位图像.距阵256×256,每帧记数1～1.5 M,将99锝m-tetrofosmin在乳房局部浓聚视为亲肿瘤显像阳性.全部病例以术后病理结果为金标准,以四格表进行评价分析.结果 99锝m-tetrofosmin在对可扪及的乳腺包块性质进行鉴别诊断时,特异性为84%,敏感性为87%,准确性为86%,阳性预测值为85%,阴性预测值为86%.结论 99锝m-tetrofosmin在对可扪及的乳腺包块进行良恶性质的鉴别时,不失为一种较为准确的方法.     

Ultrasound-Guided Vacuum-Assisted Breast Biopsy System for Diagnosis and Minimally Invasive Excision of Intraductal Papilloma Without Nipple Discharge

Background  

As intraductal papilloma (IP) includes both benign and malignant lesions, it is difficult to decide whether the patient should merely be followed up. The purpose of this study is to validate the ultrasound (US)-guided vacuum-assisted breast biopsy system (Mammotome) for diagnosis and minimally invasive excision of IP.     

Percutaneous Radiofrequency Ablation versus Partial Hepatectomy for Multicentric Small Hepatocellular Carcinomas: A Nonrandomized Comparative Study

Background  

The aim of this study was to compare the results of percutaneous radiofrequency ablation (RFA) with those of partial hepatectomy (PH) in the treatment of multicentric small hepatocellular carcinomas (HCCs). With advances in RFA, it is not known whether the minimally invasive approach with percutaneous RFA could attain comparable survival outcomes but with a lower morbidity in patients with multicentric HCCs.     

早期浸润性乳腺癌保乳与全乳腺切除手术远期疗效评价：Meta分析结果

目的 系统评价早期浸润性乳腺癌保乳(breast-conserving therapy,BCT)与全乳腺切除手术(mastectomy therapy,MT)的远期疗效.方法 采用Cochrane系统评价方法, 检索Cochrane图书馆临床对照试验数据库、PubMed、EMBASE、Cancer Lit等数据库,2名评价员独立提取信息并评价文献质量后交叉比对,评价指标包括随访结束时死亡人数、局部复发率及总复发率,采用RevMan 4.2.2软件进行Meta分析.结果 共有6篇文献进入Meta分析,累积样本含量3 933例.BCT组与MT组随访结束时死亡人数差异无统计学意义(OR=1.05,95% CI: 0.93～1.19,P=0.45),而BCT组局部复发率(OR=1.64,95% CI: 1.10～2.44,P=0.01)及总复发率(OR=1.42,95% CI: 1.22～1.64,P<0.01)明显高于MT组.结论 对于早期浸润性乳腺癌,行BCT与MT患者长期预后相当,但BCT患者术后局部复发率明显升高,需引起注意.     

Accurate Prediction of the Amount of In Situ Tumor in Palpable Breast Cancers by Core Needle Biopsy: Implications for Neoadjuvant Therapy

Background: Neoadjuvant chemotherapy facilitates breast conservation in stage II breast cancer patients, whose primary tumors are assumed to be invasive because they are palpable. However, chemotherapy may not be indicated in the minority of patients whose clinically T2 tumors are completely or predominantly in situ. Almost all previous studies of core needle biopsy in breast cancer have been concerned with nonpalpable, mammographically detected tumors, and none have evaluated its ability to quantitatively determine the amounts of in situ and invasive disease.Methods: From September, 1992 to December, 1997, core needle biopsy was performed on all patients presenting to the Kings County Hospital Breast Clinic with palpable breast masses. Carcinoma was present in both core needle biopsy samples and surgical specimens subsequently obtained from 95 of 99 patients. Each specimen was evaluated for tumor type, histologic grade, and the amounts of in situ and invasive carcinoma it contained, and the results from surgical and core needle biopsy specimens from the same patients were then compared.Results: The surgical specimens of 14 patients had completely or predominantly in situ disease. Completely or predominantly invasive disease was present in 67 specimens, and the remaining 14 had significant amounts of both. The high level of agreement between the amounts of in situ and invasive disease in core needle biopsy and surgical specimens is indicated by Pearson and intraclass correlation coefficients of 0.91 (P < .001 and < .00001, respectively). Tumor type was correctly predicted by core needle biopsy in each case. Variables among these patients, including primary tumor size, interval between biopsy and surgery, or administration of neoadjuvant systemic therapy, did not alter agreement between core needle biopsy and surgical specimens.Conclusions: Core needle biopsy can identify palpable breast tumors that are predominantly or completely in situ, and, thus, avoid unnecessary neoadjuvant chemotherapy. It also can demonstrate that a tumor is predominantly invasive, but cannot rule out small invasive foci. For that purpose, complete surgical excision of the tumor is required.     

A Modified Triple Test for Palpable Breast Masses: The Value of Ultrasound and Core Needle Biopsy

Background

The original triple test score (TTS)—clinical examination, mammogram, and fine-needle aspiration (FNA) biopsy—has long been used to evaluate palpable breast masses. We modified the original TTS to include ultrasound (US) and core biopsy to determine their role in evaluating palpable breast masses.

Methods

A retrospective chart review of 320 female patients was performed. We developed a modified triple test score (mTTS) that included physical examination, mammogram and/or US, and FNA and/or core biopsy. For the examination and imaging score, 1–3 points were given for low, moderate, or high suspicion. Biopsy scores were characterized as benign, atypical, or malignant. Final outcome was determined by open biopsy or follow-up greater than 1 year.

Results

Physical examination was 92 % accurate (95 % confidence interval [CI] 0.89–0.96, p < 0.0001) at predicting whether a mass was benign or malignant. Imaging was 88 % accurate (95 % CI 0.84–0.92, p < 0.0001) and needle biopsy was 95 % accurate (95 % CI 0.92–0.98, p < 0.0001). The modified triple test was 99 % accurate (95 % CI 0.98–1.00, p < 0.0001). Each 1-point increment in the mTTS was associated with an increased risk of cancer, with an odds ratio of 9.73 (CI 5.16–18.4, p < 0.0001). For 150 patients, we compared the original TTS with the mTTS. US and core biopsy changed the scores of 24 patients; only three changed clinical management.

Conclusions

For patients with a palpable breast mass and a mTTS score of 3–4, no further assessment is necessary. Those with a mTTS of 8–9 can proceed to definitive therapy. Patients with a mTTS of 5–7 require further assessment. US and/or core biopsy added little to the accuracy or predictive value of the original TTS.     

A Multicentered, Randomized, Controlled Trial Comparing Radioguided Seed Localization to Standard Wire Localization for Nonpalpable, Invasive and in situ Breast Carcinomas

Background

Studies suggest radioguided seed localization (RSL) yields fewer positive margins than wire-guided localization (WL). The goal of this study is to determine whether RSL is superior to WL.

Methods

Women with confirmed invasive or ductal carcinoma in situ (DCIS) undergoing localization and breast conserving surgery were enrolled. Outcomes measured include positive margin and reoperation rates, specimen weight, operative and localization times, and surgeon and radiologist ranking of procedural difficulty.

Results

Randomization was centralized, concealed, and stratified by surgeon with 153 patients in the WL group and 152 in RSL group. Localizations were performed using either ultrasound (70%) or mammographic guidance (30%). Pathology was either DCIS (18%) or invasive carcinoma (82%). Procedures were performed at 3 sites, by 7 surgeons. Only difference found for patient and tumor characteristics was more multifocal disease in RSL group. Using intention-to-treat analysis, there were no differences in positive margins rates for RSL (10.5%) and WL (11.8%), (P = .99) or for positive or close margins (<1 mm) (RSL 19% and WL 22%; P = .61). Mean operative time (minutes) was shorter for RSL (RSL 19.4 vs WL 22.2; P < .001). Specimen volume, weight, reoperation and localization times were similar. Surgeons ranked the seed technique as easier (P = .008), while radiologists ranked them similarly. Patient’s pain rankings during wire localization were higher (P = .038).

Conclusions

In contrast to other trials positive margin and reoperation rates were similar for RSL and WL. However, for RSL operative times were shorter, and the technique was preferred by surgeons, making it an acceptable method for localization.     

Suture-Free and Mesh Reinforced Small Intestinal Anstomoses: A Feasibility Study in Rabbits

ABSTRACT

Introduction: Anastomotic leakage still remains a major complication in general surgery. Beside general risk factors, the ideal method of anastomotic technique has not been found until now. The aim of the present study was to analyze wound healing in suture-free small intestine anastomoses using fibrin glue with and without mesh-reinforcement. Methods: Laparotomy and four different types of small bowel anastomoses were performed in 32 chinchilla rabbits. Standard hand-sewn anastomoses (CG), suture-free glued anastomoses (FG) with and without mesh reinforcement using two different types of meshes [Vicryl-mesh (VM) and Surgisis (SM)]. Animals were sacrificed after 5 and 21 days. Bursting pressure, collagen type I/III ratio, and matrix-metalloproteinase 2, 9, and 13 were analyzed. Results: None of the animals died due to an anastomotic leakage. All animals in the long term group with Surgisis mesh died due to a mechanical bowel obstruction based on a distinctive stenosis of the anastomosis. The bursting pressures did significantly differed in animals with fibrin glue alone compared to animals with Vicryl-mesh reinforcement (p < 0.05). Histological examination revealed statistically significant differences (p < 0.05) in the values for MMP-2 (VM < SM), MMP-9 (VM < CG), and MMP-13 (CG < SM, VM < FG, and VM < SM). However, collagen type I/III ratios were not significantly different between groups. Conclusions: Our results suggest that a mesh reinforced glued anastomosis is technically feasible. Furthermore, mesh-reinforcement using VM increased the integrity and simplified the technique of suture-free anastomoses.     

Multiple Basal Cell Carcinomas Developed After Radiation Therapy for Tinea Capitis: A Case Report

Development of skin neoplasms is the most important complication of radiation therapy. There are contradictive reports about the type of these neoplasms. Squamous cell carcinomas are considered the most frequent tumors arising on chronic radiodermatitis areas, but recent studies have demonstrated that the type of neoplasm occurring in response to ionizing radiation exposure depends on several factors. Herein we report a patient who had received low-dose radiation for the treatment of tinea capitis and developed multiple basal cell carcinomas in the radiated areas after a long latent period of 53 years.