A tattoo pigmented node and breast cancer.

Over the last decade, the axillary SLNB has replaced routine ALND for clinical staging in early breast cancer. Studies describe a potential pitfall in the identification of a true sentinel node during surgery due to lymph node pigmentation secondary to migration of tattoo dye. These pigmented "pseudo-sentinel" nodes, if located superficially in the axilla, may mimic the blue sentinel node on visual inspection, therefore missing the true sentinel node and potentially understaging the patient. Here, we present a case report of a breast cancer patient with a tattoo and discuss the importance of tattoo pigment in the LN (Fig. 1, Ref. 8).

Margin width is not predictive of residual disease on re-excision in breast conserving therapy.

BACKGROUND: There is lack of consensus regarding re-excision in breast-conserving therapy (BCT) and close margins. We hypothesize that margin width does not predict residual disease. METHODS: The cancer registry was queried from 2003 to 2008 for patients with BCT who underwent re-excision for <2-mm margins. Factors associated with additional disease were evaluated. RESULTS: One thousand eight hundred forty-three patients underwent BCT. Our re-excision rate was 42%. Clinicopathologic factors from 228 patients were analyzed. One hundred five patients (46%) had additional disease; of those, 58% had BCT and 42% mastectomy. One hundred twenty-three (54%) had no additional disease; of those 82% had BCT and 18% mastectomy. Of the 66 patients who underwent mastectomy, 44 (67%) had residual disease; of the 161 who had BCT, 61 (38%) had residual disease (P < 0.01). On univariate analysis, margin width did not correlate with residual disease. Multifocality, non-invasive histology, increasing number of close margins, and higher grade predicted additional disease (P < 0.05). On multivariate analysis, only number of close margins remained significant. CONCLUSIONS: Margin width does not predict additional disease. This challenges the practice of using this to select re-excision candidates. Our data suggest that tumor behavior and extent of disease, defined by volume of residual disease and invasiveness of histology, play a more significant role.

The importance of pre-operative needle core breast biopsy results on resected tissue volume, margin status, and cosmesis.

PURPOSE: This study aimed to evaluate the relationship between pre-operative image-guided large needle core biopsy (LNCB) histopathology results and surgical resection volumes in breast conserving surgery (BCS), with attention to both margin status and cosmetic outcome. METHODS: Breast volumes (BV) were calculated using the elliptical cone based formula on mammography images for each patient. Initial resected volume (IRV), final resected volume (FRV), and resected volume ratio (RVR) were calculated and compared according to histopathological diagnosis and cosmetic outcomes. Final pathology results were classified as benign, high risk lesion (HRL), ductal carcinoma in situ (DCIS), or invasive cancer. The cosmetic results were graded based on the Harvard breast cosmesis grading scale. RESULTS: A total of 217 women underwent BCS by the same experienced breast surgeon. The resected volumes (mean, cm3) were higher among patients who underwent LNCB than those who did not (54.3 vs 26.5 ;p=0.005). The LNCB diagnoses were 16% benign, 19% HRLs, 16% DCIS, and 49% invasive cancers. Reexcision rates were 15.6% and 25.8% for DCIS and invasive cancer, respectively. Cosmesis was excellent in 79.8%. Age, pathological tumor size, IRV and FRV were different among the benign, HRLs and carcinoma groups (p= 0.001). CONCLUSION: The diagnosis of carcinoma by LNCB leads to the planning of a wider resection, but the need for reexcision is no different than less resection. HRLs are best approached with diagnostic excision, as there is no strong evidence that larger resections reduce the incidence of involved resection margins.

Preoperative MDCT evaluation of congenital lung anomalies in children: comparison of axial, multiplanar, and 3D images.

OBJECTIVE: The objective of our study was to compare the preoperative diagnostic accuracy of axial, multiplanar, and 3D MDCT images for evaluating congenital lung anomalies in pediatric patients and to assess the potential added diagnostic value of multiplanar and 3D MDCT images in this setting. MATERIALS AND METHODS: We used our hospital information system to identify all consecutive pediatric patients younger than 18 years who had undergone preoperative MDCT angiography and had a pathologically proven congenital lung anomaly between June 2005 and February 2010. Each MDCT examination was reviewed independently by two experienced pediatric radiologists for the types, location, associated mass effect, and associated anomalous vessels of congenital lung anomalies on axial, multiplanar, and 3D MDCT images. The final diagnosis was determined by surgical and pathologic findings. Diagnostic accuracy, confidence level of diagnosis (scale of 1-3: 1 = highest confidence and 3 = lowest), perceived added diagnostic value of multiplanar or 3D MDCT images (scale of 1-5: 5 = highest added diagnostic value and 1 = lowest), and interobserver kappa agreement were evaluated. RESULTS: The final study cohort consisted of 46 pediatric patients (28 males and 18 females; mean age, 5.6 ± 6 [SD] months; range, 1 day-50 months). Histopathologic diagnoses included congenital pulmonary airway malformation (n = 19, 41%), sequestration (n = 15, 33%), congenital lobar emphysema (n = 7, 15%), and bronchogenic cyst (n = 5, 11%). Both independent reviewers correctly diagnosed types, location, associated mass effect, and associated anomalous arteries of all congenital lung anomalies with high accuracy (100%) and confidence level (mean confidence level < 1.2) on each type of image display (axial, multiplanar, and 3D). However, for the detection of anomalous veins, multiplanar and 3D images were associated with greater diagnostic accuracy and higher confidence level than axial images alone. Specifically, diagnostic accuracy for the detection of anomalous veins (n = 15; 33%) was 60% (9/15 cases) for axial MDCT images, 80% (12/15) for multiplanar MDCT images, and 100% (15/15) for 3D MDCT images (Friedman test, p = 0.011). Confidence levels for the detection of anomalous veins were significantly higher with 3D MDCT images (mean level = 1.0) and multiplanar MDCT images (mean level = 1.5) compared with axial MDCT images alone (mean level = 2.6) (Friedman test, p < 0.01). Both multiplanar and 3D MDCT images were found to provide added diagnostic value for accurately detecting anomalous veins associated with congenial lung anomalies (paired Student t tests, p < 0.012). CONCLUSION: Axial MDCT images allow accurate diagnosis of the types, location, associated mass effect, and anomalous arteries of congenital lung anomalies, but supplemental multiplanar and 3D MDCT images add diagnostic value for the evaluation of congenital lung lesions associated with anomalous veins.

MDCT for computerized volumetry of pneumothoraces in pediatric patients.

RATIONALE AND OBJECTIVES: Our purpose in this study was to develop an automated computer-aided volumetry (CAV) scheme for quantifying pneumothorax in multidetector computed tomography (MDCT) images for pediatric patients and to investigate the imaging parameters that may affect its accuracy. MATERIALS AND METHODS: Fifty-eight consecutive pediatric patients (mean age 12 ± 6 years) with pneumothorax who underwent MDCT for evaluation were collected retrospectively for this study. All cases were imaged by a 16- or 64-MDCT scanner with weight-based kilovoltage, low-dose tube current, 1.0-1.5 pitch, 0.6-5.0 mm slice thickness, and a B70f (sharp) or B31f (soft) reconstruction kernel. Sixty-three pneumothoraces ≥1 mL were visually identified in the left (n = 30) and right (n = 33) lungs. Each identified pneumothorax was contoured manually on an Amira workstation V4.1.1 (Mercury Computer Systems, Chelmsford, MA) by two radiologists in consensus. The computerized volumes of the pneumothoraces were determined by application of our CAV scheme. The accuracy of our automated CAV scheme was evaluated by comparison between computerized volumetry and manual volumetry, for the total volume of pneumothoraces in the left and right lungs. RESULTS: The mean difference between the computerized volumetry and the manual volumetry for all 63 pneumothoraces ≥1 mL was 8.2%. For pneumothoraces ≥10 mL, ≥50 mL, and ≥200 mL, the mean differences were 7.7% (n = 57), 7.3% (n = 33), and 6.4% (n = 13), respectively. The correlation coefficient was 0.99 between the computerized volume and the manual volume of pneumothoraces. Bland-Altman analysis showed that computerized volumetry has a mean difference of -5.1% compared to manual volumetry. For all pneumothoraces ≥10 mL, the mean differences for slice thickness ≤1.25 mm, = 1.5 mm, and = 5.0 mm were 6.1% (n = 28), 3.5% (n = 10), and 12.2% (n = 19), respectively. For the two reconstruction kernels, B70f and B31f, the mean differences were 6.3% (n = 42, B70f) and 11.7% (n = 15, B31f), respectively. CONCLUSION: Our automated CAV scheme provides an accurate measurement of pneumothorax volume in MDCT images of pediatric patients. For accurate volumetric quantification of pneumothorax in children in MDCT images by use of the automated CAV scheme, we recommended reconstruction parameters based on a slice thickness ≤1.5 mm and the reconstruction kernel B70f.

Screening of asymptomatic children for tuberculosis is a lateral chest radiograph routinely indicated?

RATIONALE AND OBJECTIVES: The aim of this study was to determine whether a lateral chest radiograph provides additional diagnostic information to a posteroanterior (PA) radiograph in the screening of asymptomatic children with positive purified protein derivative (PPD) skin tests in a nonendemic area. MATERIALS AND METHODS: This was an Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant, retrospective study of 605 consecutive pediatric patients (294 males, 311 females; mean age, 10.8 ± 5.2 years) with positive PPD skin test results, who underwent PA and lateral chest radiographs between July 2003 and May 2009 at a tertiary care pediatric hospital in a nonendemic area for tuberculosis (TB). Two pediatric radiologists independently reviewed each chest radiograph for evidence of abnormalities that may be indicative of acute or chronic TB infection. The reviewers first analyzed the PA radiograph alone and subsequently evaluated the PA and the lateral radiograph together to determine whether any observed abnormality was identified only on the lateral radiograph. When an abnormality was detected on both PA and lateral radiographs, the reviewers determined whether the abnormality on the lateral radiograph changed the reviewer's decision based on the PA radiograph alone. Assessment of nonconcordance between PA and lateral chest radiographs for each reviewer was evaluated by the McNemar test of matched binary pairs. Agreement between reviewers for detecting abnormalities on radiographs was evaluated by using the kappa (κ) statistic. RESULTS: The frequency of an abnormal chest radiograph related to TB was 1.8% (11/605). The PA radiograph showed abnormalities in all 11 (100%) children with radiographic abnormalities. Lateral radiographs showed abnormalities related to TB in 2 (18.2%) of 11 cases found to be abnormal on PA radiographs. Nine (81.8%) of 11 abnormalities on PA radiographs were not detected on the lateral chest radiographs. There was statistical evidence of nonconcordance between PA and lateral chest radiographs in detecting TB-related abnormalities for reviewer 1 (P < .001) and reviewer 2 (P = .004). In cases with abnormalities observed on both PA and lateral radiographs, there were no cases in which information obtained from the lateral chest radiograph resulted in a change in interpretation based on the PA radiograph alone. A high level of agreement was observed between the two independent reviewers in detecting TB-related abnormalities on PA radiographs (κ = 0.84, P < .001). CONCLUSIONS: A PA radiograph alone is sufficient for TB screening of asymptomatic pediatric patients with positive PPD skin test results in an area non-endemic for TB.

Streptococcus milleri group pleuropulmonary infection in children: computed tomographic findings and clinical features.

OBJECTIVE: Streptococcus milleri group streptococci have recently been increasingly recognized as important pulmonary pathogens, but their imaging features have not been well documented in children. We have recently observed a number of cases of this infection among pediatric patients at our tertiary care, children's hospital. Our purpose was to investigate the computed tomographic (CT) findings and clinical features of S. milleri group pleuropulmonary infection in children. MATERIALS AND METHODS: We used our hospital information system to identify all consecutive pediatric patients (<18 years of age) who had both a microbiologically proven S. milleri group infection and a chest CT scan between December 1996 and May 2009. Each scan was systemically reviewed by 2 pediatric radiologists for pleural and lung parenchymal abnormalities. Pleural effusions were classified as either simple or complex and correlated with results of pleural fluid analysis. Computed tomographic findings were compared with chest radiographic findings in the subset of patients who underwent radiography within 24 hours of CT. Microbiological data, risk factors, immune status, patient management, and clinical outcome were systematically reviewed. RESULTS: The final study cohort consisted of 15 children (6 boys and 9 girls), ranging in age from 4.2 years to 17.7 years (mean, 10.8 years). All patients were immunocompetent without recognized risk factors for this infection. Thirteen pleural effusions were identified in 10 (67%) of the 15 patients, including 10 complex and 3 simple pleural effusions. All complex effusions at CT were consistent with empyemas by pleural fluid analysis. Lung parenchymal abnormalities were identified in 7 (47%) of the 15 patients, including lung abscess in 4 patients, consolidation in 2, and multiple bilateral pulmonary nodules and lung abscesses in 1. In the subset of 7 patients with comparison radiographs, radiographic and CT findings were concordant for the detection of lung abnormalities, except one case in which consolidation was diagnosed on chest radiography, whereas CT scan showed a lung abscess. Radiographs detected all 4 complex pleural effusions seen on CT scan, although it was not possible to characterize the effusions as simple or complex on the radiographs. Interventional procedures were required in all 15 patients, most commonly thoracentesis (n = 11) and chest tube drainage (n = 9). CONCLUSIONS: In children with S. milleri group pleuropulmonary infection, CT often demonstrates complex pleural effusions and lung abscesses, which usually require interventional procedures for effective treatment.

Validation of breast cancer nomograms for predicting the non-sentinel lymph node metastases after a positive sentinel lymph node biopsy in a multi-center study.

OBJECTIVE: In the study, our aim was to evaluate the predictability of four different nomograms on non-sentinel lymph node metastases (NSLNM) in breast cancer (BC) patients with positive sentinel lymph node (SLN) biopsy in a multi-center study. METHODS: We identified 607 patients who had a positive SLN biopsy and completion axillary lymph node dissection (CALND) at seven different BC treatment centers in Turkey. The BC nomograms developed by the Memorial Sloan Kettering Cancer Center (MSKCC), Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. Area under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for each nomogram and values greater than 0.70 were accepted as demonstrating good discrimination. RESULTS: Two hundred and eighty-seven patients (287) of 607 patients (47.2%) had a positive axillary NSLNM. The AUC values were 0.705, 0.711, 0.730, and 0.582 for the MSKCC, Cambridge, Stanford, and Tenon models, respectively. On the multivariate analysis; overall metastasis size (OMS), lymphovascular invasion (LVI), and proportion of positive SLN to total SLN were found statistically significant. We created a formula to predict the NSLNM in our patient population and the AUC value of this formula was 0.8023. CONCLUSIONS: The MSKCC, Cambridge, and Stanford nomograms were good discriminators of NSLNM in SLN positive BC patients in this study. A newly created formula in this study needs to be validated in prospective studies in different patient populations. A nomogram to predict NSLNM in patients with positive SLN biopsy developed at one institution should be used with caution.

Models for predicting non-sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system.

BACKGROUND: Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non-sentinel nodes and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. To predict non-SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created. METHOD: This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non-SLN involvement in patients with SLN positive breast cancer. RESULT: There are several published scoring systems that contain different parameters to estimate the rate of non-SLN metastases in SLN positive patients. We reviewed Memorial Sloan-Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non-SLN status accurately. The other three models have not yet been verified in outside institutions. CONCLUSION: Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.

The predicted probability of having positive non-sentinel lymph nodes in patients who received neoadjuvant chemotherapy for large operable breast cancer.

The accuracy of the nomogram in women with positive sentinel nodes following neoadjuvant chemotherapy (NCT) is unknown. The aim of this study was to evaluate the accuracy of the nomogram in patients receiving NCT. Between December 1999 and December 2005, we identified 233 patients who had a positive sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection at Magee-Womens Hospital of University of Pittsburgh Medical Center. Thirty-two patients (14%) had presented with clinically N0 breast cancer (BC) for which NCT was administered. The computerised BC nomogram was used to calculate the probability of non-sentinel node metastases utilising tumour size before NCT and after NCT for the same patient. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve (ROC). The median patient age was 51.5 (range: 39-66) years in the NCT group of patients. Twelve patients (37%) had positive axillary non-sentinel lymph nodes (NSLNs). The nomogram was first validated in our institution for 201 patients without NCT and the predicted accuracy of the nomogram by the AUC was 0.73. The area under the ROC was identical regardless of whether pre- or posttreatment tumour size was used to determine predicted probability of NSLN metastases (0.66). The predictive accuracy of the nomogram was found to have less power for patients receiving NCT (0.66) than the non-NCT group of patients.

Centralized medical monitoring in phase III clinical trials: the National Surgical Adjuvant Breast and Bowel Project (NSABP) experience.

BACKGROUND: There is a need for data quality assurance procedures in phase III cancer trials. At the National Surgical Adjuvant Breast and Bowel Project (NSABP) 'real-time' systems have been developed for quality assurance and study monitoring: (1) manual review and triage of data forms by data managers at the time of submission; (2) computerized edit checking of all submitted data forms; (3) systematic review of eligibility, treatment compliance and toxicity in the first 100 patients of a new protocol; (4) prospective centralized medical review of all reported serious adverse events, treatment failures, second primary cancers and deaths; (5) quarterly review and approval of study summary data files by project statistician; and (6) on-site auditing. PURPOSE: To assess the utility of an additional final comprehensive review of all patient records to confirm eligibility, disease status and vital status prior to manuscript submission. METHODS: Four phase III NSABP studies, which had been monitored using the triage-based quality assurance program described above, were selected for analysis (n = 7972). Charts for 5965 patients were identified that had not been previously medically reviewed for protocol events of recurrence, second primary cancer or death. Submitted source documents and data forms of these 5965 NSABP patient records underwent medical review to verify patient eligibility, disease status and vital status. RESULTS: This final comprehensive review found no additional treatment failures or deaths, identified seven additional cases of ineligibility, was time-intensive requiring enormous use of expensive resources, and was therefore judged not to add significantly to the integrity of the database. LIMITATIONS: Our findings are influenced by the procedures the NSABP employs for quality assurance and study monitoring for Phase III clinical trials and may have limited generalizability to other settings. CONCLUSION: In the presence of multiple quality assurance and data monitoring systems, the rare discrepancies found between the data forms and source documentation does not support the routine use of a final comprehensive chart review for phase III trials at the NSABP Biostatistical Center.

The prevalence of benign breast disease in women with polycystic ovary syndrome: a review of a 12-year follow-up.

A cross-sectional study of benign breast disease (BBD) was conducted to determine the actual prevalence and follow-up importance of BBD among women with polycystic ovary syndrome (PCOS) in conjunction with an ongoing prospective cohort study. The present study involved a subset of the original group of 244 women with a diagnosis of PCOS and 244 control women matched by age and race. A total of 240 women (116 cases and 124 controls) were included in the present analysis. The majority of women in each group were Caucasians (93 and 96%, respectively). The median age was 46 years in the cases and 47 years in the controls. Screening mammography begins at the age of 40 and has been carried out in 69% of cases and 66% of controls since the study began. Family history of breast disease was observed in 27 cases of both the groups (p > 0.05). Neither fibrocystic breast disease, lump thickening, calcification, fibroadenoma, pain, redness, discharge nor hyperplasia showed a significantly higher prevalence rate in cases than in controls. Eleven (9%) women with PCOS and 21 (17%) controls underwent diagnostic or curative surgery (relative risk: 0.56). These results, in contrast to the previously published literature, do not allow us to conclude that there is a higher risk for BBD among women with PCOS, and the proportion of women with a positive family history of breast cancer was significantly greater in women with PCOS compared with controls. Our observation is that having PCOS does not appear to affect surgeons' decisions to remove BBD.

Epidemiology, morbidity, mortality and treatment of lightning injuries in a Turkish burns units.

Deaths from lightning injuries are infrequent--0.2-0.8 per million per year. The victims are mostly young, active people who are struck during various outdoor activities in the summer months. From November 1975 to October 1998; 22 lightning burns were treated in Ankara Numune Teaching and Research Hospital. The mean age of the patients was 32.9 (12-65) years, the female/male ratio 9/13 and the mean duration of hospital stay 15.4 (1-62) days. The commonest clinical symptoms were confusion, amnesia (5 patients), neurological dysfunction (2 patients), cystitis (4 patients), and cardiac arrhythmias (1 patient). There were no deaths. Sixteen surgical procedures were carried out on 14 patients; this was significantly fewer than from any other cause of burns. The commonest long-term complication was chronic pain. Because complications are frequently seen in lightning injuries, our results revealed that patients should be hospitalised and treated as soon as possible after the accident with fluid resuscitation, cardiac resuscitation, tetanus prophylaxis and antibiotics where necessary.

Self-expandable metallic stent therapy of esophagojejunal stricture in a stapled anastomosis: a case report and review of the literature.

The introduction of the stapler apparatus has provided safe and effective gastrointestinal anastomotic surgical operations for most surgeons. However, the major disadvantage of stapler surgery is an increased risk of anastomotic stricture formation. Treatment of this kind of stricture is performed mainly by using endoscopic balloon dilators. However, this therapy may fail or the patient may become reactive or uncooperative during dilatation sessions. Herein, we present a case to show the successful and uncomplicated insertion of a self-expanding metallic stent into an esophagojejunal anastomotic stricture which developed 1 month after total gastrectomy and stapled esophagojejunal anastomosis in a patient with gastric carcinoma. This is the 3rd report in the literature.

Outcome and quality of life of patients with acute pancreatitis requiring intensive care.

BACKGROUND: Patients with severe acute pancreatitis often require intensive care unit (ICU) admission, have multiple complications, spend weeks to months in the hospital, and consume a large amount of resources. The aim of this study was to evaluate the ICU course, costs, mortality, and quality of life of patients who require ICU admission for acute pancreatitis. METHODS: Patients with acute pancreatitis requiring ICU admission were identified retrospectively. Data regarding in-hospital morbidity, mortality, and hospital costs were obtained. Long-term quality of life was assessed using the Short Form-36 Health Survey (SF-36). RESULTS: Fifty-two patients were identified. There were 31 men and 21 women: the mean age was 53 years (range, 22-89). The most common causes of acute pancreatitis were gallstones (44%) and alcoholism (17%). Pulmonary failure (52% required mechanical ventilation) and renal failure (21% required dialysis) were common. There were 39 (75%) hospital survivors and 13 (25%) nonsurvivors. In the first 24 h, the mean Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 10 +/- 6 in survivors and 16 +/- 4 in the nonsurvivors (<0.01). Mean length of ICU (15 +/- 18 and 28 +/- 31 days) and hospital (40 +/- 34 and 38 +/- 34 days) stays were similar in survivors and nonsurvivors, respectively (NS). The mean hospital cost for survivors was $83,611 +/- 88,434 and that for nonsurvivors was $136,730 +/- 95,045 (P = 0. 09). The estimated cost to obtain one hospital survivor was $129,188. Of the 39 hospital survivors, 5 died later, 21 completed the SF-36, and 13 were lost to follow-up. Long-term quality of life (SF-36) was similar to that of an age-matched population. Twenty of twenty-one felt their general health was at least as good as it had been 1 year previously. CONCLUSIONS: Patients with severe acute pancreatitis need prolonged ICU and hospital stays. APACHE II may be a good predictor of outcome; further, prospective evaluation is needed. Although resource utilization is high, most patients survive and have good long-term quality of life.