Phyllodes Tumors of the Breast (the Egyptian Experience).

Phyllodes tumors (PT) are rare fibroepithelial lesions, about 0.3-0.5% of all breast tumors. This study is an evaluation of patient characteristics, clinicopathologic features, diagnostic tools, therapeutic options, risk factors for recurrence, and distant metastasis and follow-up findings in patients with PTs. One hundred twenty-seven patients with pathologically proved PTs in the National Cancer Institute, Cairo University, Egypt, from January 2011 to January 2016 were reviewed and analyzed. Sixty patients presented with benign PTs (47.2%), 34 had borderline PTs (26.8%), and 33 had malignant PTs (26%). The mean follow-up period was approximately 36 months; local recurrence occurred in 34 patients, 9 benign cases (14.5%), 11 borderlines (32.4%), and 14 malignant PTs (42.4%). Mastectomy was the most commonly used surgery in recurrent cases (61.4%). Axillary staging was performed in 31 cases (24.4%); only 2 cases showed positive nodal metastasis (6.5%) and were of the malignant subtype. Distant metastasis occurred in 12 patients, 4 with borderline PTs, and 8 with malignant PTs. The most common site for metastasis was the lungs and bones. Adjuvant radiotherapy was applied in 9 patients, 2 in borderline phyllodes, and 7 in malignant phyllodes; post-radiotherapy recurrence occurred in 5 malignant phyllodes patients. Chemotherapy was employed in 10 metastatic patients (4 with borderline and 6 with malignant phyllodes); excision with clear margins is important to reduce the local recurrence. Routine axillary staging should not be done. The adjuvant radiation therapy is still controversial. Local recurrence can develop even after appropriate surgery. Therefore, close follow-up is mandatory.

Pulmonary manifestations in a group of patients with Behcet's disease.

AIM: In this study we investigated the frequency and characteristics of pulmonary manifestations in a group of patients with Behcet's disease (BD) who were admitted to Cairo University Hospital. METHODS: Fifteen patients were included in our study, 14 men (93.3%) and one woman (6.66%).Their mean age was 30.06 ± 9.8 years and the mean age of onset of BD was 23.7 ± 5.54 years. All patients were subjected to full history taking, clinical examination, plain chest X-ray and helical computed tomography (CT) study of the chest. RESULTS: Pulmonary involvements were detected in 11 patients with BD, 73.3% of cases: 10 men (90.9%) and one woman (9.09%).Their mean age was 28.8 ± 8.07, the mean age of onset of BD was 23.2 ± 5.59 years and the mean disease duration until lung manifestations appear was 3.7 ± 4.8 years. The main pulmonary and constitutional symptoms in these 11 patients were as follows: dyspnea 81.8%, cough 63.6%, weight loss 63.6%, chest tightness 54.5%, hemoptysis 45%, massive hemoptysis 27.2%, fever 36.3% and expectoration 36.3. Analysis of both vascular and parenchymal lung lesions in helical CT scan in the 11 patients with BD were as follows: pulmonary artery aneurysm (PAA) occurred in 5/11 patients (45.4%), pulmonary nodules occurred in 3/11 patients (27.2%), pleural effusion occurred in 3/11 patients (27.2%), pulmonary embolism and infarction occurred in 1/11 patients (9.09%) and pneumonitis occurred in 1/11 patients (9.09%). CONCLUSION: The higher frequency of pulmonary manifestations in our patients (73.3%) and the higher frequency of PAA (33.3%) could be related to the fact that this study was conducted on a group of patients who were admitted to the hospital with more severe illnesses.

Stepladder reconstructive options in post-ablative complex surgical defects in the head and neck.

BACKGROUND: Reconstruction of head and neck defects can pose many challenges to the reconstructive head and neck surgeon. Achieving the best cosmetic and functional results without compromising the safety of oncologic surgery are the primary reconstructive goals. Speech and articulation are particularly important in oral reconstructive procedures. In addition, preservation of the integrity and function of the donor sites should always be considered in all reconstructive procedures. AIM OF THE STUDY: The aim of the study is to evaluate different reconstructive options in complex defects of the head and neck region after resection of malignant tumours. The feasibility of the reconstructive ladder starting from simple techniques such as local flaps and skin grafts up to free flaps will be assessed. PATIENTS AND METHODS: In this study we evaluated different reconstructive procedures used in 50 patients with complex head and neck defects undertaken at the department of surgery at the National Cancer Institute between July 2003 and December 2007. RESULTS: The average age of patients was 52 years and the range was 26-67 years. Most of the tumours were either squamous cell carcinoma (74 %) or Basal cell carcinoma (20 %). Tumour sites included the nose (6 %), lip (10 %), cheek (12 %) scalp (6 %) as well as mucosal defects of the oral cavity (40 %) and the hypopharynx (20 %). We used local flaps and skin grafts in reconstruction in 36 % of cases and pedicled flaps in 32% while free flaps were used in 32 % of cases. Complications occurred in 32 % of patients of which total flaps loss constituted 6 % and partial flap loss 4 %. Minor complications such as oro-cutaneous fistulae, wound infection, seroma and haematoma were noticed in 22 % and all of them were treated conservatively. The final functional and aesthetic results were satisfactory in 60% of cases while poor results were encountered in patients who suffered some degree of flap loss. KEY WORDS: Head and neck reconstruction - Pedicled flaps - Free flaps.

Gastrointestinal stromal tumors (GIST) of the stomach: retrospective experience with surgical resection at the National Cancer Institute.

BACKGROUND: Gastric GISTs account for more than half of all gastrointestinal stromal tumors and represent less than 5% of all gastric tumors. The peak age for harboring GIST of the stomach is around 60 years and a slight male preponderance is reported. These tumors are identified by expression of CD117 or CD34 antigen. Symptoms at presentation usually include bleeding, abdominal pain or abdominal mass. Endoscopically, they typically appear as a submucosal mass with or without ulceration and on CT scans an extragastric mass is usually seen. Complete surgical resection provides the only chance for cure, with only 1-2 cm free margins needed. However, local recurrence and/or metastases supervene in almost half the patients treated with surgery alone, even when no gross residual is left. Thereby imatinib mesylate was advocated as an adjuvant to surgery, which appears to have improved disease-free and overall survival. AIM OF THE WORK: The aim of this work was to assess clinico-pathological features of gastrointestinal stromal tumors (GIST) of the stomach and to appraise the results of treatment by surgery in patients treated at the National Cancer Institute (NCI) of Cairo between January 2002 and December 2007. PATIENTS AND METHODS: Nineteen patients with histologically and immuno-histochemically proven GIST of the stomach were treated by surgery at the NCI during the 6-year study period. Preoperative assessment included detailed history, clinical examination, full laboratory tests, endoscopy, abdominal ultrasound and CT. General medical assessment included chest X-ray, ECG and echocardiography. RESULTS: The patients' age ranged from 26 to 77 years with a median of 51 years. Obvious male/female preponderance was noticed (68.4% to 31.6%). Tumors were located at the upper 1/3 in 42.1%, at the middle 1/3 in 31.6% and at the lower 1/3 in 26.3%. The most common clinical presentation was related to bleeding (hematemesis, melena or anaemia) and was seen in 63.2%. No tumors were labeled as very low or low risk while there were 52.6% intermediate risk and 47.4% high risk. Wedge resection was carried out in 15.8%, partial gastrectomy in 37.8%, total gastrectomy in 5.2%, extended gastric resection in 21.1% and only biopsy in 5.2%. Lymphadenectomy was carried out in 5/19 patients to reveal negative lymph nodes in all five. Complications occurred in 73.7% of patients and only 1 case of early postoperative mortality was recorded. Two patients were lost to follow-up. The remaining 16 patients were followed-up for a period ranging from 6-34 months with a mean of 19.5+/-5.6 months and they were all alive by the end of the study, 10 were free of disease and 6 showed disease recurrence. CONCLUSION: Gastric GIST can present with vague and non specific clinical picture. Therefore, thorough clinical and radiological evaluation and preoperative endoscopy and biopsy are essential to reach the diagnosis and to assess the risk for metastasis. The clinical outcome of these tumors is influenced by completeness of tumor extirpation while avoiding tumor rupture, and by the tumor malignant potential. Accordingly for tumors with adverse factors, multimodal therapy with adjuvant imatinib or one of its successors should be considered in order to improve overall and disease-free survival.

Multidisciplinary approach to wilms' tumor: a retrospective analytical study of 53 patients.

AIM OF THE WORK: The aim of this work was to assess the epidemiologic aspects, clinico-pathological features and the results of multidisciplinary treatment of Wilms' tumor (WT) in pediatric patients treated at the National Cancer Institute (NCI), Cairo University, between January 2002 and December 2004. PATIENTS AND METHODS: This study included 53 patients, all under the age of 16 years, with previously untreated WT. Initial evaluation of all patients comprised laboratory investigations and radiological assessment which included chest X-ray and CT, abdomino-pelvic ultrasonography and CT. Doppler study of the renal vein and vena cava and bone scan were done when needed. Neoadjuvant chemotherapy was given to patients suffering from poor general condition, extensive tumor thrombus in the renal vein, irresectable and bilateral (stage V) nephroblastoma. Otherwise, up-front nephrectomy was the standard therapeutic approach in this study. RESULTS: The age of the patients ranged from 2 to 108 months with a mean of 39.9 months (+/-22.56). Males and females were almost equal in number (50.9% and 49.1% respectively). Tumors were located in the left kidney in 52.8%, right kidney in 41.5% and bilaterally in only 5.7% of the cases. An abdominal mass was the most common clinical presentation (77.4%). Favorable histology was found in 86.3% while unfavorable histology was elicited in 13.7% of the cases. Congenital anomalies were recorded in 4 patients. Stage I and III were the most common (29.4% each), followed by stage II and IV (17.7% each), and finally by stage V (5.9%). Neoadjuvant chemotherapy was given to 27 cases while up-front nephrectomy was undertaken in 26 cases. Intra-operative spillage occurred in 12% of patients who had preoperative chemotherapy and 31% of those who had upfront nephrectomy. Postoperative abdominal radiotherapy was given to 32 patients. Twenty five patients underwent renal bed irradiation only, while in the other 7 whole abdominal irradiation was used. Additional chest bath (1200 cGy) was given to 7 patients. Complete remission (CR) was achieved in 74%, while death during neoadjuvant therapy took place in 4% of the cases. Disease progression during treatment was noticed in 8%. These patients were all treated with radio- and chemotherapy. Fatal outcome supervened in 75% of these, whereas in 25%, CR could be accomplished. Relapse after remission occurred in 14%. A 2nd CR could be achieved in 28.5% with a survival rate of 21.4%. Patients who relapsed >12 months after 1st CR had a 14 month-survival rate of 37.5% compared to 0% in those who relapsed <12 months after 1st CR. Disease-free survival (DFS) at 2 years was 82.4%, while overall survival (OAS) at 2 years was 78.9%. Therapy-related complications were mainly related to chemotherapy in 49% of patients and surgery in 5.9%. CONCLUSION: Tight communication between the surgical, the medical and the radiation oncologists, together with the pathologist, is indispensable for better management of WT patients. Regional lymph node biopsy and accurate marking of residual disease are essential components of surgical treatment and heroic surgical attempts are unnecessary. Neoadjuvant chemotherapy, which is still a fertile source of debate, could possibly help to avoid excessive post-operative radiotherapy and its potential complications. Tumor stage and age of patient were found to affect the results of treatment of Wilms' tumor; but the only statistically significant determinant of prognosis was histologic differentiation. Finally, further studies including molecular markers are needed to augment therapy for the blastemal predominance subtype or for favorable histology associated with loss of heterozygosity (LOA) at chromosomes 1p and 16q aiming at improved survival. KEY WORDS: Wilms' tumor - Nephroblastoma.

Oncoplastic resection of retroareolar breast cancer: central quadrantectomy and reconstruction by local skin-glandular flap.

BACKGROUND: Patients with central breast neoplasms account for 5 to 20% of breast cancer cases and, for a long time, they have been denied Breast Conservation Surgery (BCS) and conventionally treated with mastectomy. The high incidence of Nipple-Areola-Complex (NAC) involvement usually associated with these tumors necessitates nipple and areolar resection together with an adequate safety margin around the tumor, which yields an unacceptable cosmetic result. With the help of Oncoplastic Surgical Techniques, BCS can be offered to these patients. In this study central quadrantectomy and breast reconstruction by an infero-laterally based pedicled flap were evaluated. PATIENTS AND METHODS: This study comprised 23 women with central breast tumors treated at the National Cancer Institute (NCI), Cairo University and at the Aswan Cancer Center, Egyptian Ministry of Health. Their ages ranged from 31 to 62 years (mean: 48.4+/-10.2 years). Twenty-two had a palpable mass, while only 1 had Paget's disease of the nipple without mass. The size of their tumors ranged from 4 to 33 m (mean: 16.9+/-8.6mm). Only 9 women showed clinical suspicion of NAC involvement in the form of nipple retraction. Seventeen cases had their tumors strictly in the retro-areolar region, while 5 had tumors extending for a maximum of 1.5 cm beyond the areolar edge. All patients underwent central quadrantectomy with NAC resection removing a cylinder of breast tissue reaching down to the pectoral muscle together with axillary dissection. Advancement of an infero-laterally based skin-glandular flap was then carried out. All patients received adjuvant radiotherapy with or without chemotherapy or hormonal therapy. RESULTS: Fourteen patients showed pathological evidence of nipple infiltration (60.8%). The free safety margin (SM) ranged from 9 to 13 mm (mean: 10.2+/-0.9 mm). This could be accomplished from the first attempt in 18 patients;however, in 5 patients a second wider excision was needed to obtain an adequate margin. Positive axillary nodes were found in 10 / 23 patients (43.5%). The procedure lasted a mean time of 195+/-12.7 minutes and blood loss was estimated at a mean of 225+/-64.8 mL. Hospital stay ranged from 2 to 10 days (median: 4 days). Post-operatively, superficial flap sloughing occurred in 2 / 23 patients and full thickness sloughing in 1 /23 patients. Cosmetic results were evaluated by both patient and surgeon according to a scoring system and were found excellent in 26.1%, good in 34.8%, satisfactory in 30.4%, poor in 8.7% and very poor in none. The procedure did not delay the start of adjuvant treatment nor did it hamper clinical and mammographic follow-up. CONCLUSION: Oncoplastic techniques have succeeded in expanding the role of BCS to retro-areolar tumors. Central quadrantectomy with repair by a skin-glandular flap is a relatively simple procedure that yields very satisfactory cosmetic results with minimal complications and it may be considered as one of the noteworthy therapeutic options for patients with central breast tumors.

Expanding the role of breast conservation surgery by immediate volume replacement with the latissimus dorsi flap.

INTRODUCTION: Many women with early breast cancer are treated with Mastectomy, instead of Breast Conservation Surgery (BCS), for fear of suboptimal tumor removal or cosmetic failure due to volume and shape loss. These women can be satisfactorily treated by BCS and immediate volume replacement. Synchronous breast augmentation by the autologous Latissimus Dorsi (LD) Muscle or Myocutaneous Flaps in the treatment of relatively large and/or retroareolar breast tumors was investigated in this study held at the National Cancer Institute of Cairo University and at the Aswan Cancer Center. PATIENTS AND METHODS: Between October 2000 and March 2003, 29 patients with histologically proven breast cancer were treated by BCS and immediate volume replacement with LD muscle or myocutaneous flaps. Patients' age ranged from 32 to 57 years. Tumors' size ranged from 28 to 69mm. Axillary dissections revealed positive lymph glands in 58.6% of cases. Tumor location was in the central quadrant in 45%, in the upper quadrants in 41% and in the lower quadrants in 14% of cases. The LD myocutaneous flap was used in 21 cases while, in the remaining 8 cases, only the LD muscle was needed. RESULTS: The median size of the lumpectomy specimen was 219cm3. The safety margins obtained ranged between 9 and 28mm. The mean combined operating time was 238 minutes. The mean blood loss was 320ml and no patient required blood transfusion. The median hospital stay was 5 days. Persistent seroma in the back occurred in 52% of patients, requiring a median of 5 weekly aspirations. No sepsis or flap viability problems were encountered. Cosmetic results were satisfactory in 69% of patients. Only 17% showed some asymmetry in size, 7% some discrepancy in skin color and 7% a mild difference in Nipple Areola Complex (NAC) level. CONCLUSION: Mastectomy can be avoided in a large number of women with small breast/tumor ratio or retroareolar tumors. Immediate volume replacement with LD flap can extend the role of BCS to these patients. This can be achieved without compromising the adequacy of resection, with minimal morbidity, very satisfactory cosmetic results, no need for prosthesis or contra lateral mammaplasty and no effect on postoperative clinical or radiological follow-up.