Detection of circulating epithelial cells after surgery for benign breast disease.

BACKGROUND: Cytokeratins are predominantly expressed in epithelial cells and their malignant counterparts. Ultrasensitive methods for cytokeratin messenger RNAs (mRNAs) can detect rare circulating tumor cells consistent with hematogenous dissemination in epithelial-derived malignancies, including breast carcinomas. Intraoperative tumor-cell shedding may contribute to this process; this hypothesis is based on the assumption that only tumor cells can be mobilized during surgical manipulation. METHODS AND RESULTS: The present study addresses this issue by using cytokeratin 19 mRNA detection by reverse transcription-polymerase chain reaction (RT-PCR) in preoperative and postoperative blood samples from 54 patients undergoing excisional biopsy for benign breast disease; 22 healthy volunteers represented the control group. No cytokeratin RT-PCR positivity was found in the control or preoperative samples. Cytokeratin RT-PCR positivity was found in 21 postoperative samples (39%). CONCLUSIONS: This finding shows that benign epithelial cells can be mobilized during breast surgery; this effect of surgical manipulation warrants caution in the interpretation of RT-PCR positivity for cytokeratin mRNA in the peripheral blood of patients undergoing surgery for breast cancer.

Radical, modified, and selective neck dissection for cutaneous malignant melanoma.

BACKGROUND: The roles of modified and selective neck dissections in treating patients with clinical metastatic melanoma and the place of adjuvant radiotherapy are unclear. In the elective setting, the efficacy of various selective dissections also requires clarification. METHODS: The prospectively documented experience of the senior author (COB) was analyzed. A total of 175 patients had 183 neck dissections and 92 parotidectomies in 6 years. There were 75 therapeutic and 108 elective operations. Modified or selective neck dissections were performed in 58% of patients with clinical neck metastases. Ali but two elective operations were modified or selective dissections. Postoperative radiotherapy was given to 27 dissected necks. Minimum follow-up was 12 months, and 86% of patients were followed up for 2 years or to neck recurrence. RESULTS: Nodes were histologically positive in 80 dissections. The cumulative rate of control of metastatic melanoma in the neck was 86% at 5 years. Neck recurrence developed in 14% of radical dissections, 0% of modified, and 23% of selective dissections performed for clinical disease. Neck recurrence occurred after 5% of elective dissections. Recurrence was 7% among irradiated necks compared to 23% in nonirradiated (p-value not significant). The 5-year survival rate was 50%, and this was significantly worsened by increasing node involvement. CONCLUSIONS: Modified radical neck dissection is highly effective in controlling metastatic melanoma in selected patients. Selective dissections are less effective and need further study. Adjuvant radiotherapy appears to decrease the risk of neck recurrence. In the elective setting, recurrence is uncommon following the selective neck dissections described.

Enucleation of parotid lymphoepithelial cyst in patients who are human immunodeficiency virus positive.

The incidence of benign lymphoepithelial lesions of the parotid gland in patients afflicted with HIV has increased. Enucleation is a safe and effective procedure that provides the patient with complete removal of the cyst and a low recurrence rate. Enucleation of these parotid cysts should be considered in treating these patients.

Head and neck reconstruction using the platysma myocutaneous flap.

A retrospective analysis of our experience with 41 patients who received a platysma myocutaneous flap for reconstruction of intraoral and pharyngeal defects is presented. All patients had epidermoid carcinoma of the head and neck region, with tumor size ranging from T1 to T4. The primary sites of malignancy were the oral cavity (61%), the oropharynx (32%), and the hypopharynx (7%). Either radical or modified radical neck dissection requiring routine ligation of the facial artery was performed in all 41 patients. Adjuvant therapy included preoperative or postoperative radiotherapy (39%) and preoperative chemotherapy (73%). The mean hospital stay was 13 days. Flap-related complications occurred in eight patients (19%) only. These included partial flap necrosis involving the epithelium alone, skin necrosis of the neck suture line, and fistula formation. Most complications resolved with local care only. Minor surgical intervention was required in three patients. There were no perioperative deaths. These results indicate that the platysma myocutaneous flap is a viable alternative in head and neck reconstruction.

Chondrosarcomas of the head and neck.

Chondrosarcomas of the head and neck are uncommon. Over a 35-year period (1950-1985) at our institution, 557 patients had an established diagnosis of chondrosarcoma. In 28 (5%) of these patients, the tumor was located in the head and neck region. A retrospective analysis was performed in an attempt to accurately define clinical characteristics, management, and outcome in these 28 patients. The patient population consisted of 15 males and 13 females whose ages ranged from 10 to 72 years, with a median of 38 years. Ten (36%) patients were untreated and 18 (64%) previously treated patients were referred for further management. The primary sites were maxilla (11), cervical vertebrae (7), mandible (3), skull (2), sphenoid and ethmoid sinuses (2), frontal sinus (1), nasal septum (1), and orbit (1). Lesions arising in the larynx were excluded from this study. The most common presenting symptom was a painless mass. Surgery was the definitive treatment in all patients. However, adjuvant radiation therapy or chemotherapy was utilized for residual disease in almost half of the cases (13 patients). Follow-up ranged from 5 to 35 years. Twelve (43%) of the 28 patients were known to be alive and free of disease more than 5 years after surgery. The most common cause of death was uncontrollable local disease (88%). However, only 3 of the 10 previously untreated patients developed local recurrence. For all patients, the median interval from time of first recurrence until death was 25 months (range 6 to 70 months). Positive margins in 8 of 12 patients resulted in local recurrence and eventual death.(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid and parathyroid surgery without drains.

The question of routine wound drainage after thyroid and parathyroid surgery remains controversial among experienced surgeons. Review of the literature failed to reveal any study that established the benefit of drainage after thyroidectomy and parathyroidectomy. A retrospective review of 139 thyroid or parathyroid procedures performed without drainage was conducted. One hundred ten thyroid operations were performed, including unilateral lobectomy with isthmusectomy [82 (74.5%)], total or bilateral subtotal thyroidectomy [26 (23.6%)], and isthmusectomy [2 (1.8%)]. Histologic examination yielded a benign diagnosis in 94 specimens (85.4%); 16 specimens (14.5%) contained thyroid carcinoma. Parathyroid explorations were performed in 29 patients (20.8%) all of whom had adenomas. Postoperatively, there were no instances of wound hematomas, infections, or rebleeding necessitating reoperation. Minor complications included asymptomatic wound seromas (4-30 mL) in five (3.6%) patients, which were aspirated 2 weeks after discharge without further recurrence. This minimal complication rate of 3.6% with undrained neck incisions suggests that routine prophylactic drainage of thyroid and parathyroid wounds is unnecessary.