Metastatic squamous cell carcinoma of the mediastinum with unknown primary tumor.

Although metastatic carcinoma from an unknown primary tumor is known to occur, the combination of squamous cell carcinoma histologic findings and a mediastinal location is quite unusual. The evaluation of a case of a patient with a posterior mediastinal mass, eventually shown to be metastatic squamous cell carcinoma of the mediastinum with unknown primary tumor, is described herein. Resection of the lymph node mass was performed and was followed by chemoradiation for presumed lung cancer.

Intraoperative lymphatic mapping for non-small cell lung cancer: the sentinel node technique.

BACKGROUND: The purpose of the study was to determine the accuracy and role of the sentinel node technique in patients with non-small cell lung cancer. METHODS: This study was carried out on 36 consecutive patients undergoing lung resection. Peritumoral tissue was infiltrated with isosulfan blue dye and the first lymph node to stain was identified as a sentinel node. Sensitivity and specificity of the sentinel node in predicting the status of other lymph node stations were determined. RESULTS: Seventeen patients had sentinel lymph nodes. In 9 of these 17 cases neither the sentinel node nor any other lymph node contained metastatic carcinoma. In 5 cases the sentinel node was in the mediastinum and documented unexpected N2 disease. In 19 patients no sentinel node was found. Final lymph node statuses were N0 in 13 patients, N1 in 5, and N2 in 1. CONCLUSIONS: The use of isosulfan blue for intraoperative lymphatic mapping is feasible. The specificity in our experience was good; 9 of 9 patients with negative sentinel nodes were found to be N0 on the final pathology report. Unexpected N2 disease was found in 5 patients. The accumulation of further experience will determine the role of the sentinel node technique in patients with non-small cell lung cancer.

Gastric bypass for morbid obesity: a standard surgical technique by consensus.

BACKGROUND: The gastric bypass operation has evolved since 1966 when it was first introduced. The purpose of this study was to determine the present state of gastric bypass by consensus among the members of the American Society for Bariatric Surgery (ASBS). METHOD: A questionnaire was sent to all members of the ASBS. Forty-three percent responded reporting over 41,200 cases. RESULTS: Results were analyzed by using chi2 tests with a null hypothesis. Surgeons agreed on several technical aspects, preferring a vertical to a horizontal stapleline; estimating, rather than measuring, the pouch volume at an average of 22 cc. Few surgeons divide the short gastric vessels, and only 25% of surgeons polled use a restrictive ring or band proximal to the gastroenterostomy. Most surgeons calibrate the gastroenterostomy, reporting a preferred average diameter of 12.3cm. There was no consensus regarding forming the gastroenterostomy, 58% preferring hand-sewn and 42% stapled anastomoses. There was no consensus regarding dividing the gastric pouch from the bypassed stomach: CONCLUSION: The preferred gastric bypass is vertical, with the pouch estimated at 20-25 cc, and the gastroenterostomy calibrated at 12 mm diameter. The short gastric vessels need not be divided, and restrictive bands or rings are not preferred. This technique of gastric bypass should be used as the control procedure when modifications are tested in future trials. Randomized prospective studies are suggested to probe the benefits of division of the stomach pouch from the bypassed stomach.

Association of human papillomavirus and colon neoplasms.

Human papillomavirus has been shown to be associated with squamous carcinomas. We evaluated benign and malignant colon tissues for the presence of human papillomavirus infection to determine if a similar relationship exists between human papillomavirus and colon neoplasms. Colon tissues were screened using an immunohistochemical technique to detect human papillomavirus antigen. In situ DNA hybridization was then performed on those tissues that yielded positive results by immunohistochemistry. Groups were compared using chi 2 analysis. Human papillomavirus antigen was present in 23% of normal colon specimens, 60% of benign tumors, and 97% of carcinomas. Human papilloma viral genome was demonstrated in 27% of benign tumors and in nearly 43% of all carcinomas tested. These data indicate that human papillomavirus infects the columnar mucosa of the colon, and that an association exists between human papillomavirus and colon neoplasia.

Feasibility of breast-conserving therapy for younger women with breast cancer.

OBJECTIVE: To determine if breast-conserving therapy (BCT) consisting of segmentectomy, axillary lymph node dissection, and postoperative irradiation is a feasible approach to breast cancer in younger women, whose breast tissue is dense and whose tumors can be difficult to detect and successfully excise. DESIGN AND PATIENTS: We studied BCT in 59 women 35 years old or younger (mean age, 31.7 years) treated for breast cancer since 1982. Ninety percent of their cancers were palpable; 44% were not visible by mammography. Most (93%) had T1 or T2 lesions (< or = 5 cm). Invasive ductal carcinoma was the predominant histologic diagnosis (68%). RESULTS: Segmentectomy with axillary dissection was the initial operative procedure for 39 (66%) of the 59 patients; of these, 21 (54%) had microscopically positive segmentectomy margins. Nine patients (23%) with diffusely positive segmentectomy margins and four patients (13%) with local recurrences after BCT required conversion to mastectomy. Three patients (8%) underwent reexcision to achieve negative margins. The 39 patients required a total of 22 additional surgical procedures for local control. Thirty-three (56%) of the 59 patients underwent mastectomy during the mean 68-month follow-up period; 20 (34%) underwent mastectomy as the initial definitive treatment. Reasons for primary mastectomy included multifocality or multicentricity (35%), large tumor size (30%), patient preference (15%), and occult primary tumor (10%). During the same time period, 474 (64%) of 745 women older than 35 years underwent BCT as treatment of breast cancer. Two percent required conversion to mastectomy and 1% required repeated excision. Twenty-four patients (5%) required mastectomy for local recurrence after BCT. After excluding mastectomies performed because of patient preference, significantly fewer older women required mastectomy to achieve local control (21% vs 50%, P < .001). CONCLUSIONS: Breast-conserving therapy is significantly more difficult in younger women despite surgeon and patient commitment. Patients and physicians should be encouraged to consider BCT but should be aware of the potential difficulty in obtaining adequate local control and the possible need for additional operative procedures.

Inguinal herniation justifies sigmoidoscopy.

Controversy exists concerning the association of inguinal hernia and colonic carcinoma and, more specifically, whether the development of an inguinal hernia justifies sigmoidoscopy. To study the role of endoscopic screening in cases of inguinal hernia, we prospectively evaluated 464 patients with inguinal hernia over a 54-month period with flexible sigmoidoscopy. Each patient was over the age of 40 and male. Sigmoidoscopy documented polyps (97 patients, 21 percent) and carcinoma (22 patients, 5 percent). Multiple neoplasms were observed in 6 percent (7 of 119 patients). Occult blood was detected in the fecal specimens of 8 percent of the total group of patients, but in only 13 percent of the patients with polyps or carcinomas. A normal examination occurred in only 38 percent of the total group. By using the presence of an inguinal hernia in patients older than 40 years of age as an indication for sigmoidoscopy, we found that more than one of every four patients had an asymptomatic, concurrent malignant or premalignant colonic lesion. Flexible sigmoidoscopy should be used for screening colonic neoplasms in patients with inguinal hernia.

Confirmation of the association of human papillomavirus with human colon cancer.

The human papillomavirus (HPV) has been shown to be associated with neoplasms of the human colon using immunohistochemistry and in situ hybridization. We now report our use of the polymerase chain reaction and Southern blotting to investigate that same association. We selected 38 carcinomas, 21 adenomas, and 24 normal mucosal samples for the current study. Tissue sections were prepared, and then DNA was extracted and subjected to 40 cycles of amplification using Thermus aquaticus DNA polymerase and a set of degenerate primers. Amplified products were analyzed by agarose gel electrophoresis and Southern blotting. The L1 region of the HPV genome was identified in 13 of 38 carcinomas (32%), 8 of 21 adenomas (38%), and 2 of 24 normal biopsy specimens (8%). These observations validate our previous results and confirm the presence of HPV in human colon mucosa and tumors of that mucosa.

Immunohistochemical demonstration of human papilloma virus antigen in human colon neoplasms.

The presence of human papilloma virus (HPV) has recently been demonstrated in colon tumors, but the incidence of HPV infection in normal colon mucosa or in benign or malignant neoplasms of the mucosa is unknown. We studied both neoplastic and normal human colon tissue for the presence of HPV antigen using immunohistochemical techniques. Ninety colon specimens were studied. Three consecutive series of normal colon mucosa (N = 30), single benign tubulovillous adenomas (N = 30), and invasive carcinomas (N = 30) were selected and confirmed histologically. Formalin-fixed paraffin-embedded samples of each tissue were prepared using immunohistochemical techniques and resultant slides were read blindly and graded simply as positive or negative for HPV antigen. The presence of HPV antigen varied dramatically between groups, with 97% of the invasive carcinomas, 60% of the benign tubulovillous adenomas, and 23% of the normal mucosa positive for HPV antigen. Groups were statistically significant using chi 2 analysis (P less than 0.001). We conclude that an association exists between the human colon neoplasia and the presence of HPV antigen. This may suggest an etiologic role of the virus in colon cancer.

Lymphatic mapping and sentinel lymphadenectomy for breast cancer.

OBJECTIVE: The authors report the feasibility and accuracy of intraoperative lymphatic mapping with sentinel lymphadenectomy in patients with breast cancer. SUMMARY BACKGROUND DATA: Axillary lymph node dissection (ALND) for breast cancer generally is accepted for its staging and prognostic value, but the extent of dissection remains controversial. Blind lymph node sampling or level I dissection may miss some nodal metastases, but ALND may result in lymphedema. In melanoma, intraoperative lymph node mapping with sentinel lymphadenectomy is an effective and minimally invasive alternative to ALND for identifying nodes containing metastases. METHODS: One hundred seventy-four mapping procedures were performed using a vital dye injected at the primary breast cancer site. Axillary lymphatics were identified and followed to the first ("sentinel") node, which was selectively excised before ALND. RESULTS: Sentinel nodes were identified in 114 of 174 (65.5%) procedures and accurately predicted axillary nodal status in 109 of 114 (95.6%) cases. There was a definite learning curve, and all false-negative sentinel nodes occurred in the first part of the study; sentinel nodes identified in the last 87 procedures were 100% predictive. In 16 of 42 (38.0%) clinically negative/pathologically positive axillae, the sentinel node was the only tumor-involved lymph node identified. The anatomic location of the sentinel node was examined in the 54 most recent procedures; ten cases had only level II nodal metastases that could have been missed by sampling or low (level I) axillary dissection. CONCLUSIONS: This experience indicates that intraoperative lymphatic mapping can accurately identify the sentinel node--i.e., the axillary lymph node most likely to contain breast cancer metastases--in some patients. The technique could enhance staging accuracy and, with further refinements and experience, might alter the role of ALND.