Prognostic Value of Disseminated Tumor Cells in the Bone Marrow of Patients with Operable Primary Breast Cancer: A Long-term Follow-up Study

Background

Detection of disseminated tumor cells (DTC) in primary breast cancer (BC) patients’ bone marrow (BM) seems to be a surrogate marker of tumor spread and an independent prognostic factor for disease-free and overall survival.

Methods

Here we present the largest single-center cohort of patients (n = 1378) with the longest observation time (median 82.0 months). Immunocytochemical staining was performed using murine monoclonal antibody 2E11 with the avidin–biotin complex technique.

Results

At primary surgery, 49 % of patients showed MUC-1 positive cells inside their BM. Patients without BM DTC had significantly more often T1-tumors (P = 0.007) with less often affected axillary lymph nodes (P < 0.001). We observed a significantly higher incidence of distant metastases in DTC positive patients (P < 0.001). This leads to a reduced disease-free survival (P < 0.0001). Furthermore, in DTC positive patients there was a higher mortality rate and, accordingly, a reduced overall survival (P < 0.0001).

Conclusions

Due to the presence of BM DTC, patients with a clinically poorer outcome can be identified at primary surgery. We therefore suggest that DTC analysis can be used as a prognostic factor and monitoring tool in clinical trials. Future study concepts relating to DTC should aim at identification of BC patients who may profit from adjuvant systemic therapy.     

Adenocarcinoma of the Esophagus in the Young

Introduction

Practitioners have noted a striking increase in the number of young patients under the age of 40 years old who develop esophageal adenocarcinoma. The aim of this study was to characterize the presentation, pathology and therapeutic outcome of these young patients.

Methods

The records of patients who presented to the Foregut Surgical Service at the University of Southern California with esophageal adenocarcinoma between 2000 and 2007 were retrospectively reviewed. The presentation, tumor stage and histology, therapy and outcome of the patients under the age of 40 were compared to those ≥40.

Results

Of the 374 patients reviewed, 20 (5 %) were under the age of 40. There were two patients in their second and 18 in their third decade of life. The youngest patient was 25 years old. A history of gastroesophageal reflux disease or Barrett’s esophagus was less common in patients <40 than in those ≥40; 15 and 5 % compared to 61 and 46 %. Similarly, patients <40 had a significantly longer time interval between the onset of symptoms and the diagnosis of their cancer than those ≥40; 4.5 vs. 2 months, p?=?0.04. They also had a higher prevalence of stage IV disease (30 vs. 6 %, p?=?0.0003), a shorter time to recurrence (9.5 vs.19 month, p?=?0.002), and a poorer median survival (17 vs. 43 month, p?=?0.04).

Conclusion

Esophageal adenocarcinoma in patients <40 years old commonly presents with an advanced stage of the disease and an associated poor survival. This is likely due to a low index of suspicion that dysphagia seen in younger patients is due to a malignancy.     

Management of Esophageal Perforation in 120 Consecutive Patients: Clinical Impact of a Structured Treatment Algorithm

Introduction

The therapy of esophageal perforation is still challenging. The aim of this study was to assess the etiology, specific treatment, and outcome of esophageal disruption in order to generate an optimal therapeutic approach to improve patient’s outcome.

Methods

We reviewed the cases of 120 consecutive patients with esophageal perforation treated within 10 years.

Results

Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave’s syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave’s syndrome (p?=?0.005), initial sepsis (p?=?0.002), pleural effusion/empyema (p?=?0.001), mediastinitis (p?=?0.003), peritonitis (p?=?0.001), and redo-surgery (p?=?0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave’s syndrome 33.3 %.

Conclusions

An approach considering etiology and extent of perforation, diagnostic delay, and septic status is required to improve patient’s outcome. Primary repair is feasible in patients without intrinsic esophageal disease and evidence of sepsis. The greater the diagnostic delay, the more the destruction of the esophageal wall especially in the case of septic esophageal disease, thus the stronger the argument for esophagectomy if anatomically and/or oncologically possible.     

Foreign Accent Syndrome: In the ear of the beholder?

Background: The identification of accent type in patients with acquired accent change following brain damage (Foreign Accent Syndrome; FAS), may vary depending on the judge. Aims: This experiment tests the accent identification abilities of naive judges listening to speech samples from FAS patients versus healthy controls. Method & Procedures: A total of 52 naive judges listened to speech samples from speakers of British English, which were presented over audio CD. They were asked to identify the accent type, but were blind as to the identity of the participants vis-a-vis FAS versus control, and foreign versus native UK. Accuracy, variability, and confidence ratings were assessed as a function of participant and of accent type. Outcomes & Results: The naive judges displayed greater accuracy, consistency, and confidence in typing the control versus the FAS accents. There was a positive familiarity effect for the control, but not the FAS accents. Conclusions: The data provide preliminary support for the view that FAS is not exclusively “in the ear of the beholder”.     

Pre‐programmed robotic osteotomies for fibula free flap mandible reconstruction: A preclinical investigation

Bony free flap reconstruction of the facial skeleton remains a challenging area of reconstructive surgery. Despite technological advances that have aided planning and execution of these procedures, surgical inaccuracy is not insignificant. One source of error that has not been wholly addressed is that attributable to a human operator. In this study, we investigate the feasibility and accuracy of performing osteotomies robotically in pre‐programmed fashion for fibula free flap mandible reconstruction as a method to reduce inaccuracies related to human error. A mandibular defect and corresponding free fibula flap reconstruction requiring six osteotomies were designed on a CAD platform. A methodology was developed to translate this virtual surgical plan data to a robot (KUKA, Augsburgs, Germany), which then executed osteotomies on three‐dimensional (3D) printed fibula flaps with the aid of dynamic stereotactic navigation. Using high‐resolution computed tomography, the osteotomized segments were compared to the virtually planned segments in order to measure linear and angular accuracy. A total of 18 robotic osteotomies were performed on three 3D printed fibulas. Compared to the virtual preoperative plan, the average linear variation of the osteotomized segments was 1.3 ± 0.4 mm, and the average angular variation was 4.2 ± 1.7°. This preclinical study demonstrates the feasibility of pre‐programmed robotic osteotomies for free fibula flap mandible reconstruction. Preliminarily, this method exhibits high degrees of linear and angular accuracy, and may be of utility in the development of techniques to further improve surgical accuracy. © 2015 Wiley Periodicals, Inc. Microsurgery 36:246–249, 2016.     

Infections and neutrophils in the pathogenesis of bronchiolitis obliterans syndrome in children after allogeneic stem cell transplantation

It is plausible that infections post‐hematopoietic SCT play a role in the pathogenesis of BOS. A prospective study for children with history, questionnaire, examination, PFTs, and blood counts at one, three, six, nine, 12, 18, and 24 months post‐SCT was conducted. Between September 2009 and September 2011 (n = 39), six developed BOS at 200 days (range 94–282), three patients had probable clinical respiratory infection, and all six had higher neutrophil count compared to non‐BOS patients (4.7 vs. 2.4 at three months and 6.3 vs. 2.9 at six months ×10⁹/L, p = 0.03). Contribution of clinical and subclinical infection needs to be considered in the pathogenesis of BOS.