A 20-year review of pediatric pancreatic tumors.

Pancreatic tumors are rare surgical problems in infants and children. A 20-year audit (1971 to 1991) of this institution showed six patients ranging in age from 3 weeks to 16 years who were operated on for pancreatic neoplasms. Five of these tumors were malignant, bringing the reported experience to 71 cases. This series of malignancies included three solid cystic tumors, one insulin-secreting tumor, and one pancreatoblastoma. The clinical presentations varied: three had abdominal pain, one developed hypoglycemia, and one had an abdominal mass with jaundice. In five of the six patients pancreatic pathology was suspected preoperatively. All were treated primarily with pancreatic resection including one pancreatoduodenectomy. No radiotherapy or chemotherapy was used. The perioperative mortality was 0% with a morbidity of 50%. The long-term results are encouraging, with all patients alive after a mean follow-up of 7.8 years. These data suggest that aggressive surgical therapy is warranted in the management of pediatric pancreatic tumors.     

Ancillary Studies,Including Immunohistochemistry and Molecular Studies,in Pancreatic Cytology

Fine-needle aspiration biopsy of the pancreas is indicated for sampling of solid and cystic masses. Preoperative cytologic diagnosis of pancreatic ductal adenocarcinoma and cystic lesions on cytology can be problematic, and ancillary studies may help confirm diagnosis. Ancillary studies in pancreatic cytology include special stains, immunohistochemistry, mutational analyses of specific genes, cyst fluid analysis of tumor markers and enzymes, and, in some instances, flow cytometry. Proteomics, microRNA sequencing, and whole-exome gene sequencing have been used to illustrate the progression of pancreatic neoplasms and identify key diagnostic markers. This article summarizes recent literature on ancillary studies in pancreatic fine-needle aspiration samples.     

High-Grade Breast Epithelioid Angiosarcoma Secondary to Radiotherapy Metastasizing to the Contralateral Lymph Node: Unusual Presentation and Potential Pitfall

BACKGROUND: Breast angiosarcoma is a rare disease occurring as primary tumour or secondary to lymphoedema or radiotherapy. The more frequent use of breast-conserving therapy and radiotherapy for breast carcinoma explains the increasing diagnosis of these tumours. CASE REPORT: We report a case of a breast epithelioid angiosarcoma which metastasized to the contralateral axillary lymph node, occurring 4 years after breast-conserving therapy with axillary lymph node dissection and radiotherapy. The patient presented skin lesions and an axillary lump (clinically diagnosed as carcinoma relapse and lymph node metastasis). Fine-needle cytology on both lesions and a core needle biopsy of the axillary lump were carried out. Differential diagnosis included carcinoma, malignant melanoma, and angiosarcoma. Immunohistochemistry confirmed the diagnosis of angiosarcoma. CONCLUSIONS: Breast angiosarcoma is a challenge - clinically, radiologically and pathologically - and requires a high index of suspicion in susceptible patients.     

The Role of Intraoperative Radiotherapy in Solid Tumors

Background  Combined multimodality therapy is becoming standard treatment for many solid tumors, but the role of intraoperative radiotherapy in the management of solid tumors remains uncertain. The aim is to review the indication, application, and outcomes of intraoperative radiotherapy in the management of nongynecological solid tumors. Methods  A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1965 and 2008 assessing intraoperative radiotherapy, using the keywords “intraoperative radiotherapy,” “colorectal cancer,” “breast cancer,” “gastric cancer,” “pancreatic cancer,” “soft tissue tumor,” and “surgery.” Only publications in English with available abstracts and regarding adult humans were included, and the evidence was critically evaluated. Results  Our search retrieved 864 publications. After exclusion of nonclinical papers, duplicated papers and exclusion of brachytherapy papers, 77 papers were suitable to assess the current role of intraoperative radiotherapy. The clinical application and evidence base of intraoperative radiotherapy for each cancer is presented. Conclusions  Current studies in all common cancers show an additional benefit in local recurrence rates when intraoperative radiotherapy is included in the multimodal treatment. However, intraoperative radiotherapy may not improve overall survival and has significant morbidity depending on the site of the tumor. Intraoperative radiotherapy does have a role in the multidisciplinary management of solid tumors, but further studies are required to more precisely determine the extent of benefit.     

The role of fine-needle aspiration in the management of solid breast masses

Fine-needle aspiration cytology is a safe, inexpensive, rapid method of establishing the diagnosis of breast cancer in patients with solid, palpable masses. The pathologist must be conservative in his interpretation of malignancy so that positive study results occur only in patients with cancer. We compared the cytologic diagnosis of 140 breast masses with the histologic diagnosis. Seventy of 98 breast cancers were diagnosed by this technique. Because 28 cancers could not be diagnosed with certainty, open biopsy should be performed on all breast masses with nonmalignant cytologic findings.     

Fine-needle aspiration cytology, frozen section, and open biopsy: relative significance in diagnosis of musculoskeletal tumors

Fine-needle aspiration cytology (FNAC) is a minimally invasive technique used extensively in diagnosis of various tumors. Frozen section biopsy is known for its usefulness in assessing adequacy of margins of resection intraoperatively. This study assesses the usefulness and significance of these procedures in tumors of musculoskeletal origin. This study includes 91 patients and all the patients were subjected to a preoperative FNAC test on an outpatient basis. An open biopsy was done in every case under appropriate anesthesia and representative tumor tissue was sent for frozen section analysis. Out of 91 patients, FNAC was feasible in 78 patients. Out of the 78 patients aspirated, a type-specific diagnosis was made in 79.5% of cases (62 out of 78). Frozen section was possible in 85 cases. The percentage of specific diagnosis by frozen section in this study is 85.9% (73 out of 85) and overall diagnostic accuracy of 96.5% (82 out of 85). FNAC and frozen section are reliable diagnostic modalities, in the presence of clinico-radiological correlation, in the diagnosis of musculoskeletal tumors.     

Diagnostic accuracy of fine-needle aspiration biopsy versus frozen section in solitary thyroid nodules

Fine-needle aspiration biopsy is widely used in the diagnosis and management of the solitary thyroid nodule. It is the most accurate tool available and decreases the need for ultrasonography and thyroid scanning. In those patients who are selected for surgical treatment by fine-needle aspiration biopsy, it has been advocated as a guide to determining the extent of operation. Frozen section, which usually serves as the surgeon's guide, and fine-needle aspiration biopsy both have varying accuracy rates. Few direct comparisons have been made. We studied 198 aspirates in 198 patients who presented with a solitary nodule and had surgical excision. Fine-needle aspiration biopsy (198 cases) and frozen section (182 cases) were compared with the final histologic diagnosis. Accuracy rates for fine-needle aspiration biopsy and frozen section were 90 percent and 95 percent, respectively. Fine-needle aspiration biopsy detected 43 percent of the cancers and frozen section, 64 percent. There were no false-positive diagnoses with frozen section, but three cases with fine-needle aspiration biopsy. The false-negative diagnosis rate was 5 percent for frozen section and 8.5 percent for fine-needle aspiration biopsy. When the "other" diagnosis category was grouped with the "positive" diagnosis category and a single expert cytopathologist was used to read the cytology report, the sensitivity was increased to 80 percent whereas the accuracy was maintained at 83 percent. We believe that since there were no false-positive diagnosis using frozen section, it can reliably be used as a guide when it reveals malignancy. When the fine-needle aspiration biopsy diagnosis is "positive" or "other," it can guide operation, but only after carefully assessing the wording of the cytology report and the clinical situation. Each modality can provide information missed by the other. We continue to use them as complementary tools in the diagnosis and management of solitary thyroid nodules.     

Salivary gland tumors: a 10-year retrospective study of survival in relation to size, histopathological examination of the tumor, and nodal status

Salivary gland neoplasms represent the most complex and diverse group of tumors encountered by the head and neck oncologist. Their diagnosis and management is complicated by their relative infrequency. The significance of the study was to analyze the different types of salivary gland tumors, the modalities of treatment given, and their varied outcomes in relation with morbidity, prognosis, and survival rate. A total of 436 patients were treated for salivary gland neoplasm at Madras Medical College and Research Institute between 1991 and 2001, and the results were analyzed retrospectively. The patients were between 11 and 72 years of age (mean, 41.5 years), and 334 were male and 102 were female. They were from different socioeconomic groups. Fine-needle aspiration cytology was done for all patients that presented with salivary gland swelling. Univariate analysis was done, the confidence interval and odds ratio were calculated, and the significance was noted. Kaplan-Meier survival analysis was estimated, and the results were analyzed. Pleomorphic adenoma was the most common benign tumor affecting the salivary glands. In our series, 155 patients had malignant parotid gland neoplasms, and 20 patients had cervical lymph node metastasis at the time of presentation. Facial nerve paralysis was noted in 21 cases. The recurrence after total parotidectomy for malignant salivary gland tumors was effectively managed with external beam irradiation in 19 patients. The survival, prognosis, and the mortality rate of the malignant parotid neoplasms and their relation to the sex of the patient, histopathological type of tumor, nodal status, and size of the tumor were analyzed.     

The evaluation and follow-up of patients with Ta,Tcis, and T1 bladder cancer

Summary Endoscopic evaluation and transurethral resection are the most important steps in the management of patients with bladder cancer. While multifocality is primarily a prognostic factor with respect to tumor recurrence, tumor grade and depth of invasion are prognostic regarding progression in stage. Transurethral resection biopsies of the prostate should always been obtained in patients with high grade tumors. Follow-up of patients should be individualized: patients with risk for progression, but not necessarily for recurrence, should be followed more closely than patients with low-grade tumors and low risk for progression. In this setting cytology is especially helpful because most high-grade tumors will be detected by cytology. Intravesical therapy is indicated in patients with high-grade tumors, carcinoma in-situ and multiple low grade tumors. While there is a growing body of evidence that BCG is superior to intravesical chemotherapy, one also has to take into account the more frequent and more serious side effects of BCG when compared with mitomycin C or thiotepa.     

Metastatic rhinosporidioma in a child

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It commonly affects nasal mucosa and conjunctiva. Subcutaneous disease is unusual and it is often mistaken for soft-tissue sarcoma. Such tumoral rhinosporidiosis has never been reported in children. This report describes, for the first time, an 11-year-old girl who presented with nasal polyp and multiple metastatic swellings of rhinosporidial origin. Fine-needle aspiration cytology and histopathology were diagnostic. Surgical excision, followed by dapsone therapy, was found to be useful.     

Conservatively aggressive management with bilateral Wilms' tumors.

Radical Primary Excision, up to and including bilateral nephrectomy with renal allotransplantation, has been advocated for bilateral Wilms' tumors. Since 1953 we have treated nine children with bilateral Wilms' tumors. Only two of them died of their malignancies; both had primary radical excision and received less than the currently recommended dosaes of radiotherapy and chemotherapy.More recently, we have excised the more involved kidney and treated the less involved side with radiotherapy and multiple courses of chemotherapy. We have termed this conservatively aggressive management; it has resulted in no evidence of residual malignancy in any of the six children so treated. Three of these six patients were left with residual benign rhabdomyomas. These results suggest that this less radical approach to bilateral Wilms' tumors is an effective method of management.     

Treatment strategy for malignant solid tumors in childhood

The prognosis for children with malignant solid tumors has improved dramatically in Japan. During the last two decades, various groups have conducted sequential studies of the treatment of children with neuroblastoma, Wilms' tumor, and hepatoblastoma. Most institutes participated in nonrandomized trials designed to evaluate the safety and efficacy of combination chemotherapy, surgery, and radiotherapy in each group study and treated children with these tumors The results are reviewed and areas for future investigation are identified.     

Ependymomas

Opinion statement Optimal management of ependymomas includes surgical resection and evaluation of the extent of central nervous system involvement using cerebrospinal fluid cytology and craniospinal contrast-enhanced MRI. In instances of measurable residual disease, reoperation should be considered because survival of patients with ependymomas is significantly improved by performance of a complete resection. In patients not considered for further surgery and with residual disease, limited-field radiotherapy is usually administered. The role of craniospinal irradiation in patients with local disease and no evidence of metastasis is controversial because most tumor recurrences are local and at the site of the primary tumor. No clear role for adjuvant chemotherapy has been demonstrated. When used, chemotherapy for ependymomas has been administered primarily to children aged younger than 3 years as adjuvant therapy and to patients with recurrent disease who are not considered surgical candidates as salvage therapy. Recurrent ependymomas are managed by reoperation of tumors that are surgically accessible, by radiotherapy if not previously administered, and by salvage chemotherapy. The role of stereotactic radiotherapy administered as radiosurgery or brachytherapy is unclear because all reports are anecdotal. Because salvage chemotherapy is not curative, no standard therapy exists, and a variety of chemotherapy agents and drug schedules have been investigated.     

Fine-needle aspiration of diffuse cervical lymphadenopathy in patients with acquired immunodeficiency syndrome

Although diffuse cervical lymphadenopathy is one of the earliest and most common findings in patients with AIDS, the appropriate diagnostic approach in these patients has yet to be determined. Fine-needle aspiration (FNA) was performed on 26 patients with AIDS in order to evaluate the role of FNA in patients with diffuse cervical adenopathy. Specimens were sent for cytology, bacterial culture, fungal culture, and acid-fast smear and culture. Ten patients had positive findings, including toxoplasmosis, histoplasmosis, tuberculosis, atypical mycobacterium, and methicillin-resistant staphylococcal infection. All patients with either unilateral adenopathy or lymph nodes 3 cm or larger had positive aspirates. A statistically significant difference between patients with lymph nodes smaller than 2 cm and those with nodes larger than 2 cm was found. Fine-needle aspiration of a representative node in patients with AIDS may allow prompt diagnosis of diffuse lymphadenopathy. Rapid initiation of appropriate treatment can lead to symptomatic improvement. The need for excisional biopsy of involved lymph nodes may be obviated. Fine-needle aspiration is recommended as a diagnostic tool in selected patients with diffuse cervical lymphadenopathy and AIDS.     

Granulomatous mastitis diagnosed and followed up by fine-needle aspiration cytology,and successfully treated by corticosteroid therapy: Report of a case

A 36-year-old woman presented to our hospital with a rapidly growing lump in her left breast. Fine-needle aspiration (FNA) cytology of the mass revealed many epithelioid cells admixed with multinucleated Langhans-type giant cells, neutrophils, lymphocytes, and stromal cells, leading to a diagnosis of granulomatous mastitis. This report describes the clinical course of this patient in whom granulomatous mastitis was successfully treated with corticosteroid therapy. Special reference is made to the usefulness of FNA cytology in the diagnosis and follow-up of this disease.     

腹腔镜技术诊治小儿腹部实体肿瘤12例报告

目的探讨腹腔镜手术诊治小儿腹部实体肿瘤的价值. 方法 1999年8月～2004年4月,12例腹部实体肿瘤患儿(平均年龄6岁2个月)B超、CT、MRI和IVP等影像学检查,骨髓穿刺细胞学检查和24小时尿VMA、NSE、血AFP等肿瘤标记物检测均未能明确诊断,均接受腹腔镜手术. 结果 11例腹腔镜下成功切取组织做出病理诊断, 其中4例改开放手术切除肿瘤.1例卵巢癌术后二次探查为阴性发现. 结论腹腔镜手术对小儿腹部恶性肿瘤的诊断、分期、可切除性判断和肿瘤复发与转移的评估有着重要作用.     

Choroid plexus tumors: report of 7 cases in a single institution

The management of seven patients with choroid plexus tumors, 4 adults and 3 children (mean age 17.5 years) at our institution was reviewed. There were 4 cases of papilloma and 3 of carcinoma located in the lateral ventricle in 1 case, the third ventricle in 1 case, and the fourth ventricle in 5 cases. Total surgical excision was attempted in all patients. Total resection was achieved in three patients, resulting in no deficit in two and persistence of preoperative dysphagia in one. There was no recurrence after total resection. Subtotal resection was achieved in four patients, one of whom underwent second surgery resulting in total resection, and one patient died of respiratory disturbance after the third operation because of regrowth of the tumor. Complete excision could not be achieved in 3 of the 5 tumors located in the fourth ventricle because of extension to the brainstem. The median survival was 59.5 months for patients with papilloma, and 67.7 months for those with carcinoma. Adjuvant therapy was also required for carcinoma, one patient was treated by radiotherapy, and two by radiotherapy plus chemotherapy. Only one patient with papilloma was treated by radiotherapy plus chemotherapy postoperatively.     

Focal midbrain tumors in children.

The clinical and neuroradiological features of focal midbrain tumors in 12 children are described, and the results of their surgical management are presented. Patients with a focal midbrain tumor usually exhibit either symptoms and signs of raised intracranial pressure caused by an obstructive hydrocephalus (50%) or symptoms and signs caused by pressure on the tegmentum and cerebral peduncles. The lesions are confined to the tectal plate or tegmentum with possible extension upward to the thalamus and downward to the pons, displacing but not invading these structures. The edges of the tumor are well defined, and the large majority have a solid consistency with intense regular enhancement after intravenous contrast. Radical resection is hardly ever feasible in brain stem tumors, but in this series, significant reduction of the tumor mass was obtained in 75% of the patients, with no surgical mortality and minimal surgical morbidity and with the majority of patients showing clinical improvement postoperatively. All tumors were nonpilocytic, low-grade astrocytomas. Six patients received adjunctive radiotherapy. The mean follow-up period is 2.5 years, and all patients are alive and doing well. We conclude that focal midbrain tumors in children appear to be a distinct subgroup of brain stem tumors and are very amenable to surgical resection with an excellent long-term prognosis.     

Fine-needle aspiration cytology for diagnosis and management of palpable breast mass

BACKGROUND: The present study aims to clarify the use, in a developing country, of fine-needle aspiration cytology (FNA) instead of open biopsy as a cost-saving, reliable initial diagnostic and management tool for patients with breast mass. METHODS: A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profiles and pathological results. RESULTS: Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%). CONCLUSIONS: Fine-needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one-third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non-invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.     

Evaluation of postoperative intratumoral injection of bleomycin for craniopharyngioma in children

Total excision is the treatment of choice in preventing the relapse of craniopharyngioma, but for tumors involving an extensive area, it is often associated with increased risks of complications. The efficacy of postoperative radiotherapy has not yet been established. The authors have performed minimal tumor excision followed by intensive injection of bleomycin into the remaining tumor as postoperative adjuvant therapy in seven children with craniopharyngioma. Long-term outcome in the children with cystic-type tumors containing little or no solid tissue has proven the regimen to be more advantageous than total excision.