Congenital palatal fistula: an embryological enigma?

Cleft palate can present in varying degrees of severity. Based on the development of the palate, the minimal expression is a posterior cleft. Submucous clefting is well described, and the reason for it is also postulated. However, a congenital hard palate fistula, with a normally developed posterior palate (with its full complement of mesodermal element), is extremely rare and difficult to explain embryologically. We document a case of this nature and review various embryological theories in an attempt to explain this occurrence.     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.     

Breast Cancer in the Elderly: Is MRI Helpful?

Appropriate use of magnetic resonance imaging (MRI) in elderly breast cancer (BC) patients remains unclear; we sought to identify the indications and implications of MRI use in our elderly BC population. Women 70 years of age or older at first BC diagnosis with an MRI performed at our institution either perioperatively or in follow‐up were included from a prospectively maintained database from 2000 to 2010. Univariate logistic regression was used to test associations with disease identified by MRI only (additional ipsilateral, contralateral, or new cancer) following perioperative MRI. 305 BCs were imaged in 286 patients. 133 were imaged with MRI in the perioperative setting alone, 88 had only follow‐up MRIs after BC treatment, and 65 had both. Indications for perioperative MRI include: extent of disease evaluation (181; 91%); occult primary (10; 5%); high‐risk screening (5; 3%); and abnormal physical exam with negative conventional imaging (2; 1%). Disease identified by MRI only for occult primary cases was 4/10 (40%; 95% confidence interval: 12.2–73.8%) and 14/181 (7.7%; 95% confidence interval: 4.3–12.6%) for perioperative MRIs performed for extent of disease evaluation. Analysis of imaging and tumor characteristics failed to find significant predictors of disease identified by MRI only. A total of 369 post‐treatment follow‐up MRIs were performed in 148 patients with a median of 2 MRIs per patient (range 1–8), with seven cases of disease identified by MRI only (1.9%; 95% confidence interval: 0.8–3.9%). MRI had the greatest benefit in women presenting with an occult primary cancer and minimal additional benefit in elderly patients with BC undergoing MRI imaging for extent of disease evaluation or in post‐treatment surveillance.     

Round Gel Breast Implants or Anatomic Gel Breast Implants: Which is the Best Choice?

Background  

Since their introduction in 1993, anatomic implants have been popularized by numerous surgeons, but very little literature compares the precise indications, advantages, and disadvantages between round implants and anatomic implants.     

Breast myiasis: Are we prepared for the correct diagnosis?

Cutaneous myiasis is an endemic infestation in Latin America and Africa. Many unusual sites of larval infection can cause diagnostic confusion, especially if the patient is not from an endemic area. In the breast, the furuncular aspect suggests some differential diagnosis. We report a case of an 84-year-old patient with an ulcerated lesion on the right breast, who was referred to the reference service to exclude malignancy. Considering the clinical aspects and after further evaluation with imaging methods, she was diagnosed with myiasis. This study reinforces the importance of differential diagnosis of myiasis in patients that come from endemic areas.     

Secondary Angiosarcoma of the Breast: Can Imaging Findings Aid in the Diagnosis?

Abstract:  Secondary angiosarcomas, although rare, are aggressive tumors that can develop in breast tissue that has undergone prior radiation therapy. We present three cases of secondary angiosarcoma of the breast in the setting of prior breast irradiation. Imaging findings include cutaneous nodules and progressive skin or trabecular thickening in an area of the breast separate from the patient's original breast carcinoma. These imaging findings may enable the radiologist to suggest this diagnosis, even when the clinical presentation is more benign.     

Primary Angiosarcoma of the Breast: Do Enlarged Axillary Nodes Matter?

Primary angiosarcoma of the breast is a rare and aggressive malignancy that is typically seen in premenopausal patients. The tumor's spread occurs predominantly through the bloodstream; involvement of the lymphatics is unusual. We present a case of breast angiosarcoma presenting with enlarged axillary lymph nodes treated with a modified mastectomy and axillary lymph node dissection. Pathology found no tumor in the lymph nodes. Based on this experience and data from the literature, we suggest evaluation of the sentinel nodes prior to potentially morbid standard level 1 and 2 axillary lymph node clearance.     

On the origin of the toughness of mineralized tissue: microcracking or crack bridging?

Two major mechanisms that could potentially be responsible for toughening in mineralized tissues, such as bone and dentin, have been identified-microcracking and crack bridging. While evidence has been reported for both mechanisms, there has been no consensus thus far on which mechanism plays the dominant role in toughening these materials. In the present study, we seek to present definitive experimental evidence supporting crack bridging, rather than microcracking, as the most significant mechanism of toughening in cortical bone and dentin. In vitro fracture toughness experiments were conducted to measure the variation of the fracture resistance with crack extension [resistance-curve (R-curve) behavior] for both materials with special attention paid to changes in the sample compliance. Because these two toughening mechanisms induce opposite effects on the sample compliance, such experiments allow for the definitive determination of the dominant toughening mechanism, which in the present study was found to be crack bridging for microstructurally large crack sizes. The results of this work are of relevance from the perspective of developing a micromechanistic framework for understanding fracture behavior of mineralized tissue and in predicting failure in vivo.     

Macrophages in Breast Cancer: Do Involution Macrophages Account for the Poor Prognosis of Pregnancy-Associated Breast Cancer?

Macrophage influx is associated with negative outcomes for women with breast cancer and has been demonstrated to be required for metastasis of mammary tumors in mouse models. Pregnancy-associated breast cancer is characterized by particularly poor outcomes, however the reasons remain obscure. Recently, post-pregnancy mammary involution has been characterized as having a wound healing signature. We have proposed the involution-hypothesis, which states that the wound healing microenvironment of the involuting gland is tumor promotional. Macrophage influx is one of the prominent features of the involuting gland, identifying the macrophage a potential instigator of tumor progression and a novel target for breast cancer treatment and prevention. Financial Support: This work was supported in part by grants from The Avon and Mary Kay Ash Foundations, and DOD BC060531 to PS and a DOD Predoctoral Grant BC073482 to JO.     

The origin of information: are IUGA-specific patient information leaflets the answer?

Introduction  

In contemporary practice, patients should be partners in their care; unfortunately, we frequently find patients with unclear information regarding their conditions.