DCIS of the breast: The value of preoperative MRI.

INTRODUCTION: Ductal carcinoma in situ (DCIS) of the breast is commonly treated surgically. The intent of this study was to evaluate whether preoperative MRI could add to mammography in predicting the extent of the disease. METHODS: A series of patients with DCIS attending our surgical clinic for preoperative assessment were offered MRI as part of a prospective study. The extent of the disease indicated by mammography and MRI was compared with histopathology after definitive treatment. The null hypothesis was that MRI does not add to mammography in accurately predicting disease extent. RESULTS: Fifty patients make up the basis of this report. Mammography was concordant with the pathology in 31/50. MRI and mammography combined were concordant in 43/50. This is a statistically significant difference (P = 0.01, Fisher's exact test). Upstaging to mastectomy by MRI was correct in 7/8 patients, but downstaging was correct in only 2/4. CONCLUSIONS: The null hypothesis is rejected. MRI does add to mammography in accurately predicting the extent of DCIS. Upstaging by MRI is usually reliable.

Laparoscopic adrenalectomy for phaeochromocytoma: a case series.

AIM: To describe our 13-year experience in laparoscopic adrenalectomy for phaeochromocytoma. METHOD: We performed a retrospective analysis of case notes of 29 patients who underwent laparoscopic adrenalectomy for phaeochromocytoma between 2000 and 2013. RESULTS: Twenty-nine patients (16 female), aged 16 to 67 years, underwent laparoscopic adrenalectomy for phaeochromocytoma. All patients were treated preoperatively with alpha-blocking agents. 80% were prescribed additional preoperative antihypertensive agents. 90% received antihypertensive agents intraoperatively. All patients received intraoperative magnesium sulphate for haemodynamic stabilisation. The mean operative time was 160 minutes. Nearly all of the patients experienced haemodynamic stability during surgery. Two patients required conversion to open adrenalectomy, due to severe intraoperative hypertension during tumour handling, and due to extensive intra-abdominal adhesions. Postoperative complications were minimal, and included blood loss, superior epigastric artery damage, and cellulitis at the laparoscopic port site. There was no perioperative mortality. The median length of stay postoperatively was 4 days. 24% were prescribed antihypertensive medication on discharge. CONCLUSION: In our experience, favourable perioperative outcomes were achieved, demonstrating that laparoscopic adrenalectomy for phaeochromocytoma is a safe and effective procedure in the setting of experienced and skilled surgical, anaesthetic and medical teams delivering the perioperative care.

International multi-institutional management and outcome of melanoma patients with positive sentinel lymph nodes in more than one nodal basin.

BACKGROUND: Melanoma patients with palpable nodal disease in more than one basin have a worse prognosis than those with single-basin disease. Little is known about the outcome of patients with microscopically positive nodal disease in more than one basin, or how they are currently managed at tertiary referral centers. METHODS: We identified 97 patients with positive sentinel lymph nodes (SLNs) in more than one lymph node basin from 1994 to 2010 from three tertiary care centers. Clinical and pathologic outcome variables were analyzed. RESULTS: Ninety-seven patients (72 men, 25 women) were identified with at least one positive SLN in at least two node basins. Most primary tumors were truncal (68, 70 %) followed by extremity (16, 17 %) and head/neck (13, 13 %). The median Breslow depth was 3.2 mm (range 0.8-12 mm), and 49 (51 %) were ulcerated. The most frequently involved nodal basins were the axilla (112, 57 %), neck (40, 20 %), and groin (24, 12 %). Seventy-seven percent (153 of 198) of all positive SLN basins underwent completion lymph node dissection (CLND). Most patients (54, 56 %) developed recurrent disease, with a median time to recurrence of 20 months. The majority of first recurrences were distant (42, 43 %), followed by regional nonnodal metastases (17, 18 %) and regional nodal metastases (16, 16 %). There was no significant difference in median overall survival between CLND versus no-CLND groups (45 vs. 30 months, respectively). CONCLUSIONS: Most melanoma patients with more than one SLN-positive basin are currently managed with CLND. Outcomes after CLND and no CLND are similarly poor; therefore, consideration of close nodal observation may be more appropriate.

Surgical outcomes following laparoscopic adrenalectomy for treatment of Conn's syndrome (primary hyperaldosteronism) between 1999 and 2006.

BACKGROUND: Primary hyperaldosteronism is a recognised cause of secondary hypertension with its aetiology most commonly due to a secreting aldosterone adenoma of the adrenal gland. Laparoscopic resection of the adrenal tumour has now become the accepted form of intervention. The aim of this study was to assess the effectiveness of such procedures performed by one surgeon over a 7-year period. METHOD: An observational study was conducted in respect of 33 patients who underwent adrenalectomies for primary hyperaldosteronism between 1999-2006. Information on blood pressure, electrolytes, medications, histology, patient characteristics and patients' perception of benefit was gathered via clinical notes and a patient questionnaire. RESULTS: 33 patients were reviewed. The mean follow-up was 38.4 months. Blood pressure and number of medications all had statistically significant decreases. Systolic blood pressure decreased from 146 mmHg preoperatively to 130 mmHg at final follow-up (p<0.00005). Diastolic blood pressure decreased from 91.0 mmHg preoperatively to 81.5 mmHg (p<0.00005). There was also a significant decrease in number of blood pressure medications from 2.3 preoperatively to 1.0 on average (p<0.00005). Only one patient required potassium at final review. Overall 36% had clinical cure and 50% had significant improvement in terms of blood pressure and medications requirements. CONCLUSION: The results suggest unilateral laparoscopic adrenalectomy is an effective tool in treatment for benign primary hyperaldosteronism caused by aldosterone secreting adenomas.