Axillary sentinel node biopsy after neoadjuvant chemotherapy.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear. PATIENTS AND METHODS: Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively. RESULTS: SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus 2 cm, and extra-sentinel node extension.

Gastric metastasis of malignant fibrous histiocytoma presenting as gastrointestinal bleeding.

Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. With only 4 cases described in the available English literature up to now, gastric metastasis of MFH is extremely rare. Among them only one case has been reported to lead to gastrointestinal bleeding. We report the case of a 55-year-old woman who underwent total gastrectomy, 14 months after resection of an MFH from the right side of retroperitoneum. The neoplasm was detected at the time of diagnostic workup for upper gastrointestinal bleeding. The resected specimen contained multiple polypoid nodular lesions which were located in the greater curvature. The clinical and pathological characteristics of gastric metastasis of MFH are presented herein with review of literature.

Prognostic and predictive factors after surgical treatment for locally recurrent rectal cancer: a single institute experience.

OBJECTIVE: Resection of locally recurrent rectal cancer (LRRC) after curative resection represents a difficult problem and a surgical challenge. The aim of this study was to evaluate the results of resecting the local recurrence of rectal cancer and to analyze factors that might predict curative resection and those that affect survival. PATIENTS AND METHODS: A retrospective review was performed in 50 patients who underwent surgical exploration with intent to cure LRRC between April 1998 and April 2005. All of the patients had previously undergone resection of primary rectal adenocarcinoma. Of these patients' charts, operation and pathology reports were reviewed. Primary tumor and treatment details, hospital of initial treatment and TNM stage were registered. The following data were collected concerning the detection of the local recurrence; date of recurrence, symptoms at the time of presentation and diagnostic work-up. Perioperative complication and date of discharge were also gathered. The recurrent tumors were classified as not fixed (F0), fixed at one site (F1) and fixed to two or more sites (F2) according to the preoperative and peroperative findings. Microscopic involvement of surgical margins and localization of recurrence were noted based on pathology reports. RESULTS: The median time interval between resection of primary tumor and surgery for locally recurrent disease was 24 (4-113) months. In a statistical analysis, initial surgery, complaints of patients, increasing number of sites of the recurrent tumor fixation in the pelvis, location of the recurrent tumor were associated with curative surgery. Curative, negative resection margins were obtained in 24 (48%) of patients; in these patients a median survival of 28 months was achieved, compared to 12 months (p=0.01) in patients with either microscopic or gross residual disease. Primary operation and CEA level at recurrence were also found to be important factors associated with improved survival. There was no operative mortality and, the complication rate was 24%. CONCLUSIONS: This study demonstrated that many patients with LRRC can be resected with negative margins. The type of primary surgery, symptoms, location, and fixity of recurrent tumor are associated with the increased possibility of carrying out curative resection. Previous surgery and curative surgery are significant predictors of both disease-specific survival and overall survival.

Primary ovarian cancer presenting with axillary lymph node metastases: a report of two cases.

BACKGROUND: Axillary lymph node metastasis of primary ovarian cancer is rare. CASE I: A 74-year-old woman presented with a 2 x 2 cm hard, mobile mass in the right axilla. She had a history of stage IIIA epithelial ovarian cancer which was diagnosed and treated four years previously. A right lateral wall involvement of the rectum was detected in abdominal tomography. A right axillary lymph node dissection and low anterior resection of the rectum were performed. Histopathologic examination showed ovarian epithelial serous papillary adenocarcinoma metastases to axillary lymph node and the rectum. CASE 2: A 38-year-old woman presented with a 3 x 2 cm hard, mobile mass in the right axilla. She was treated surgically and by systemic chemotherapy with a diagnosis of stage IIIA epithelial ovarian cancer two years previously. A trucut biopsy was taken from the enlarged axillary lymph node, and histopathological examination revealed metastases of primary ovarian cancer. Complete axillary lymph node dissection was performed and metastases of ovarian papillary adenocarcinoma were found in 11 of the 30 lymph nodes. CONCLUSION: Supradiaphragmatic lymph node involvement of primary ovarian cancer is very rare. We report here two cases presenting with axillary metastases of ovarian cancer.

Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett's esophagus.

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication for the regression of Barrett's esophagus in gastroesophageal reflux disease remains controversial. The aim of this study, therefore, was to review endoscopic findings and clinical changes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease, particularly for patients with Barrett's esophagus. METHODS: From September 1995 through June 2004, 127 patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication. All the patients had clinical and endoscopic follow-up evaluation. We further analyzed the course of 37 consecutive patients with Barrett's esophagus (29% of all laparoscopic fundoplications performed in our institution) using endoscopic surveillance with appropriate biopsies and histologic evaluation. The median follow-up period for all the patients after fundoplication was 34 months (range, 3-108 months). The median follow-up period for the patients with Barrett's esophagus was 19 months (range, 3-76 months). RESULTS: During the 9-year period, 70 women (55 %) and 57 (45%) men were treated with laparoscopic Nissen fundoplication. The median age of these patients was 42 years (range, 7-81 years). The clinical results were considered excellent for 67 patients (53%), good for 51 patients (40%), fair for 7 patients (6%), and poor for 2 patients (1%). Endoscopic surveillance showed regression of the macroscopic columnar segment in 23 patients with Barrett's esophagus (62%). Regression at a histopathologic level occurred for 15 patients (40%). The histopathology remained unchanged for 14 patients with Barrett's esophagus (38%). CONCLUSION: Laparoscopic Nissen fundoplication effectively controls intestinal metaplasia and clinical symptoms in the majority of patients with Barrett's esophagus.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer.

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (0.2 cm). Five patients had isolated tumor cells detected by IHC (

The role of sentinel lymph node biopsy with blue dye alone in breast cancer patients with excisional biopsy.

PURPOSE: Sentinel lymph node biopsy (SLNB) appears to offer an excellent alternative method to routine axillary lymph node dissection for staging patients with breast cancer. The aim of this study is to evaluate the effect of excisional biopsy on identification and false negative rate of sentinel lymph node biopsy with blue dye alone in breast cancer patients with clinically negative axilla. MATERIAL AND METHODS: From March 1998 to March 2003, 266 consecutive sentinel lymph node biopsies (SLNB) were performed using isosulfan blue dye alone. Patients were divided into two groups. One hundred and four patients (39.1%) had previously undergone an excisional biopsy (Group I); in 162 patients (60.9%), pre-operative diagnosis was obtained by either fine-needle aspiration biopsy (FNAB) or core biopsy (Group II). Following sentinel lymph node biopsy, all patients had axillary lymph node dissection (ALND). Data concerning patients, sentinel lymph nodes and the status of the axilla were collected and compared using Fisher's exact test. A p value of less than 0.05 was considered statistically significant. RESULTS: The sentinel lymph node was successfully identified by blue dye in 94.3% (251/266) of patients. Mean lymph nodes removed from the axilla was 19 (range 11-36) and the mean number of sentinel nodes was 2 (range 1-5). The identification and false negative rate were unrelated to size, type or location of the tumour, or a previous surgical biopsy. CONCLUSIONS: SLNB with blue dye for evaluation of the axilla is a rapid and accurate technique that provides increased efficacy in the detection of lymphatic metastasis when careful pathologic evaluation with serial sections is performed. The risk-benefit analysis of lymphatic mapping with blue dye provides improvement in staging, with reduced morbidity and hospital stay, and the elimination of general anaesthesia. The technique may also be used safely and accurately in breast cancer patients with excisional biopsy.

Breast conserving surgery after primary chemotherapy in locally advanced breast cancer.

PURPOSE: Primary chemotherapy is being given in the treatment of locally advanced breast cancers (LABC), but a major concern is local recurrence after therapy. The aim of this study was to assess the role of breast conserving surgery (BCS) in patients with locally advanced breast cancer. MATERIAL AND METHODS: Twenty-eight patients, presenting LABC (T any, N 012, M0) were treated with primary chemotherapy comprising of cyclophosphamide, doxorubicin and fluorouracil and then BCS followed by radiotherapy were examined between the years 1992-2002 retrospectively. Before neoadjuvant chemotherapy, seven patients (25%) were Stage IIB, 19 patients (68%) Stage IIIA and two patients (7%) Stage IIIB. Survival times and curves were established according to the Kaplan-Meier method and compared by means of the log-rank test. The chi-square test and log rank test were performed for univariate statistical analysis of each prognostic factor. P values in multivariate analysis were carried out by the Cox's proportional hazards regression model. All p values were two-sided in tests and p values <0.05 were considered significant. RESULTS: Clinical down staging was obtained in 25 (89%) of patients. Three (11%) patients had complete clinical response, 22 (78%) patients with partial response and 3 (11%) had stable disease. The primary tumour could not be palpated after chemotherapy in 6 (21%) of 28 patients presenting with palpable mass, therefore needle localization was performed for BCS. Median follow-up was 51.9 months (ranging 10 to 118 months). Local recurrence was detected in 4 (14%) patients. Distant metastasis developed in 5 (18%) patients. Three of the patients died of distant metastases and two of them are alive at 49 months. Five-year survival rate was 66%. Statistically, there were no significant factors in terms of local recurrence. Histological grade and menopause status were significantly associated with overall survival (p = 0.018) and nuclear grade was the one significant factor on distant disease-free survival in univariate analysis (p = 0.006). In multivariate analysis, there were no significant factors in terms of overall and distant disease-free survival CONCLUSIONS: Negative margin is more important than the clinical and histological parameters, such as pretreatment stage, clinical response rate, ER and PR in terms of local recurrence. BCS can be performed safely by achieving free surgical margin in patients who have small sized tumour and with either N2 axillary involvement or skin invasion.

Thymidine labeling index: prognostic role in breast cancer.

The aim of this study is to evaluate the prognostic role of thymidine labeling index in patients with breast cancer. Cellular proliferation rates in 155 breast cancer specimens were investigated by 3H-thymidine labeling index (3H-TLI). Median age was 47 years (range: 23-76). At presentation, 11 patients (7.1%) had stage I disease, 76 (49%) had stage II, 64 (41.3%) had stage III disease, and 4 (2.6%) had metastatic involvement. Patients were placed in 2 groups based on their proliferative indices. The cut-off level was assigned as the median TLI value of the whole group. Correlations between proliferative activity of the tumors based on 3H-TLI levels and various previously established prognostic factors, as well as the influence of proliferative activity on survival as a clinical outcome, were analyzed. The mean and median TLI values for the whole group of patients were 4.36 +/- 4.96% and 2.76% (range: 0-23.6), respectively. There was a significant association of nuclear grade with TLI (P = 0.04). Patients who were alive with no sign of disease at the final follow-up examination had a significantly lower median TLI rate than those who were either alive with disease or those who had eventually died with disease progression (3.7% versus 1.9%, respectively; P = 0.04). Patients with locally advanced disease (N2 + N3 involvement) had a significantly higher median TLI rate than those with local nodal involvement (N1) (3.4% versus 1.7%, respectively, P = 0.026). Furthermore, TLI levels showed a significant association with overall survival in patients with node-negative disease (P = 0.02). Based on the results of this study, it can be concluded that TLI plays a significant prognostic role in a subset of patients with node-negative breast cancer. Furthermore, TLI appears to have a predictive value for the clinical outcome of patients with breast cancer. These findings may justify a more aggressive therapeutic approach in patients with high TLI levels. Further large-scale, prospective studies are required before a definite conclusion can be reached.reached.

Laparoscopic treatment of mesenteric cysts.

Mesenteric cysts are rare intraabdominal tumors. We review the diagnosis, laparoscopic management, patient's outcome and follow-up of evaluation for three cases of mesenteric cyst that presented to Istanbul University, Istanbul Medical School, Department of Surgery, from 1999 to 2002. All of the patients presented with nonspecific abdominal symptoms such as constipation, abdominal discomfort, and anorexia. Preoperative evaluation for differentiating mesenteric cyst from malignancy is made by abdominal ultrasound and computed tomography. The procedure was completed laparoscopically using three trocars in three patients. In one patient retroperitoneal resection was performed. There were no intraoperative or postoperative complications. The follow-up periods ranged from 6 to 36 months, and there were no recurrences. Currently, the surgical treatment of mesenteric cyst should be performed by laparoscopy, which offers significant advantages in terms of reduced morbidity and hospital stay. For appropriate cases in which cyst arises from mesenterium of colon, the retroperitoneal approach should be applied.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome.

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Surgical treatment of hepatic hydatid disease.

The results of surgery in 38 patients with hepatic hydatid disease are described. Cystectomy was done in four patients with small peripheral cysts. For them the mean postoperative stay was 8.2 days. Partial cystectomy, introflexion and omentoplasty were performed in 28 patients with uncomplicated large cysts. The mean postoperative stay for these patients was 8.6 days. One patient in this group died of massive hemorrhage and disseminated intravascular coagulation. Exploration of the common bile duct and choledochoduodenostomy were required in three patients who had large cysts complicated by rupture into the biliary tree. This complication resulted in a mean postoperative stay of 11.5 days. Three patients who had cysts complicated by pyogenic infection were treated with tube drainage. They were discharged with their tubes in place after a mean hospital stay of 26.5 days. Hydrogen peroxide 10% was used as a scolicidal agent and was successful in preventing dissemination. All patients underwent ultrasonography 3 months after surgery, and 28 (74%) were followed up by annual examination. There was no recurrence after a mean follow-up of 2.7 years. The results suggest that surgical treatment of hepatic hydatid disease should be governed by the size, location and complications of the cyst. The combination of partial cystectomy, introflexion and omentoplasty was safe and effective therapy for patients with large hepatic cysts uncomplicated by pyogenic infection.

[Stomach cancer following gastroenterostomy]. / Magenkarzinom nach Gastroenterostomie.

Treatment was applied to 279 cases of gastric carcinoma at the authors' hospital, within a period of six years. Fourteen of these patients (five per cent) had received surgical treatment for peptic ulcer, between seven and 44 years back (23.6 years on average). Bilateral truncular vagotomy and pyloroplasty had been applied as primary operation to 6.9 per cent. The remaining 93.1 per cent had undergone either exclusive gastrojejunostomy or, in addition, partial gastrectomy. Partial or residual resection of the stomach could be performed on six patients only.