Baha Zengel

Sentinel lymph node biopsy in breast cancer: review on various methodological approaches.

AIMS AND BACKGROUND Sentinel lymph node biopsy has been accepted as a standard procedure for early stage breast cancer. In this retrospective analysis, the results obtained with different methodological approaches using radiocolloid with or without blue dye were examined. METHODS A total of 158 sentinel lymph node biopsies were performed in 152 patients. Group A (85 patients) underwent lymphatic mapping using a combination of periareolar intradermal radiocolloid and subareolar blue dye injections. Group B (73 patients) underwent only periareolar intradermal radiocolloid injection. One large tin colloid and two small radiocolloids (nanocolloid of serum albumin -NC- and colloidal rhenium sulphide -CS-) were used. RESULTS Successful lymphatic mapping was attained in 157 of 158 procedures (99.4%). Radiocolloids localized sentinel lymph nodes in 99.4% and blue dye in 75.3% of the cases. The number of sentinel lymph nodes removed was greater in nanocolloid and colloidal rhenium sulphide groups (P ≤0.05). Among 60 metastatic sentinel lymph nodes, frozen section analysis using hematoxylin and eosin staining failed to detect 1 macro- and 10 micrometastasis. Radiocolloid uptake was higher in sentinel lymph nodes accumulating blue dye (1643 ± 3216 counts/10 sec vs 526 ± 1284 counts/10 sec, P <0.001). Higher count rates were obtained by using larger sized colloids (median and interquartile range: tin colloid, 2050 and 4548; nanocolloid, 835 and 1799; colloidal rhenium sulphide, 996 and 2079; P = 0.01). Only 2 extra-axillary sentinel lymph nodes were visualized using periareolar intradermal injection modality. CONCLUSIONS Radiocolloids were more successful than blue dye in sentinel lymph node detection. More sentinel lymph nodes were harvested with small colloids, but different sized radiocolloids were similarly successful. Sentinel lymph nodes having higher radiocolloid uptake tended to accumulate blue dye more frequently. Sentinel lymph nodes manifested higher count rates when a larger colloid was used. Frozen section was very successful in detecting macrometastatic disease in sentinel lymph nodes, but the technique failed in most of the micrometastates.

Sentinel lymph node biopsy in breast cancer: predictors of axillary and non-sentinel lymph node involvement.

BACKGROUND Sentinel lymph node biopsy is a standard method for the evaluation of axillary status in patients with T1-2N0M0 breast cancers. AIMS To determine the prognostic significance of primary tumour-related clinico-histopathological factors on axillary and non-sentinel lymph node involvement of patients who underwent sentinel lymph node biopsy. STUDY DESIGN Retrospective clinical study. METHODS In the present study, 157 sentinel lymph node biopsies were performed in 151 consecutive patients with early stage breast cancer between June 2008 and December 2011. RESULTS Successful lymphatic mapping was obtained in 157 of 158 procedures (99.4%). The incidence of larger tumour size (2.543±1.21 vs. 1.974±1.04), lymphatic vessel invasion (70.6% vs. 29.4%), blood vessel invasion (84.2% vs. 15.8%), and invasive lobular carcinoma subtype (72.7% vs. 27.3%) were statistically significantly higher in patients with positive SLNs. Logistic stepwise regression analysis disclosed tumour size (odds ratio: 1.51, p=0.0021) and lymphatic vessel invasion (odds ratio: 4.68, p=0.001) as significant primary tumour-related prognostic determinants of SLN metastasis. CONCLUSION A close relationship was identified between tumour size and lymphatic vessel invasion of the primary tumour and axillary lymph node involvement. However, the positive predictive value of these two independent variables is low and there is no compelling evidence to recommend their use in routine clinical practice.

The effect of radiocolloid preference on major parameters in sentinel lymph node biopsy practice in breast cancer

INTRODUCTION The possible effects of radiocolloid preference on sentinel lymph node biopsy (SLNB) were investigated. METHODS A total of 200 patients with T1-2N0M0 breast cancer were evaluated. The first 100 patients underwent SLNB using (99m)Tc tin colloid (TC) and the next 100 using (99m)Tc nanocolloid (NC). Radiocolloid was injected intradermally at four quadrants of the periareolar region the day before surgery. All patients underwent lymphoscintigraphy 1 h after injection. All nodes having fourfold activity of the background were harvested using gamma probe. RESULTS Sentinel lymph node (SLN) identification rate by gamma probe was 98% in each group. The number of SLNs identified by lymphoscintigraphy, gamma probe and pathological evaluation was 1.39 ± 0.7, 1.70 ± 1.0 and 2.23 ± 1.70 in the TC and 2.03 ± 0.94, 2.60 ± 1.36 and 3.05 ± 1.90 in the NC group, respectively (P<.05). Metastatic SLN was found in 24 (24.4%) of 98 patients in the TC group and 41 (41.8%) of 98 patients in the NC group (P=.04). None of the patients showed dispersion to internal mammarian lymph nodes. Lymphatic vessel visualization was observed in eight (8.1%) of 98 TC patients and in 47 (47.9%) of 98 NC patients (P=.000). SLNs were the only metastatic node(s) in 54.1% of TC and 73.1% of NC patients. CONCLUSION The periareolar intradermal injection technique gives a high detection rate in the localization of SLNs independently from the choice of the tracer. Mean SLN numbers and lymphatic vessel visualization frequency were significantly higher using a smaller albumin Tc-99m nanocolloid as compared to a stannous fluoride Tc-99m tin colloid. The results of our study support the idea that the influence of increased number of SLNs on positive SLN frequency is critical.

Properties of Synchronous Versus Metachronous Bilateral Breast Carcinoma with Long Time Follow Up.

BACKGROUND Breast cancer is the most common cancer type among women with increasing incidence rates, improved prognosis and survival. According to the localization of the tumor, breast cancer is designated as unilateral (UBC) or bilateral (BBC). BBC can be classified as synchronous (SBBC) or metachronous (MBBC) based on the time interval between the diagnosis of the first and the secondary tumors. According to the guideline of WHO 2012, BBC is generally defined as SBBC when contralateral breast carcinoma is diagnosed within 3 months. The aim of this study was to compare the characteristics and patterns of metastasis of BBC patients with UBC. MATERIALS AND METHODS A cohort of 768 patients with breast cancer treated at the Turkish Ministry of Health-Izmir Bozyaka Research and Training Hospital between 1976 and 2012 were studied. Survival analysis was performed comparing UBC and BBC patients. In addition, evaluations were performed in patients with SBBC and MBBC sub-groups. We used a 3-months interval to distinguish metachronous from synchronous. RESULTS When clinical and histopathological parameters were statistically evaluated, ER status, event-free and overall survival were found to be significant between UBC and BBC patients. In comparison of SBBC and MBBC patients, age, histological type of tumor, event-free and overall survival were found to be significant. CONCLUSIONS BBC cases were found to show worse prognosis than UBC cases. Among BBC, SBBC had the worst prognosis based on overall survival rates.

Immune profile of asplenic patients following single or double vaccine administration: A longitudinal cross-sectional study.

OBJECTIVE Splenectomy poses a lifelong threat for the development of uncontrolled sepsis despite vaccination. As it is impractical to measure the levels of each antibody against 23 most frequent bacterial serotypes, different surrogate markers of immune response should be identified. MATERIAL AND METHODS Forty-eight patients with benign disorders were vaccinated with Pneumo-23 and Act-HIB before or at the day of surgery. The immunological response and opsonization capacity of the patients after splenectomy was analyzed through the quantitative measurement of IgG, IgM, C3, and C4 titers; flow-cytometric analysis of (CD3+) T-lymphocytes and (CD19+) B-lymphocytes; and isolation of CD27+ B cells by immunomagnetic positive selection. Blood samples were drawn at the sixth month and 5 and 7 years after surgery. RESULTS The mean follow-up period was 98.4 months. All the patients in this series had normal IgG, C3, C4 levels and a normal distribution of CD19+ B-cells and CD8+ T-cells in three follow-up periods. Moreover, C3 levels markedly improved to 133.5±37.3 mg/dL at 5 years and remained stable thereafter. CD19+ B-lymphocyte values have progressively improved to the normal range in 98% patients at 7 years. Further, low levels of CD27+ B-cell population (memory cells) was observed in only 12.5% patients at the last follow-up. Adequate seroconversion of IgG, IgM with normal C3, C4, and CD19+ B-cell levels were accomplished in almost all patients. Early postoperative death and late overwhelming infections did not occur. CONCLUSION Our results are indicative of the resumption of the immune function following Pneumo-23 and Act-HIB administrations, instigated by the probable activation of B cells and adequate production of C3, C4, IgG, and IgM antibodies in remote lymphoid tissues.

Molecular Classification of Breast Carcinoma: From Traditional, Old-Fashioned Way to A New Age, and A New Way

Breast carcinoma comprises a group of diseases with specific clinical, histopathologic and molecular properties. Traditional classification use morphology to divide tumors into separate categories with differing behavior and prognosis. However, there are limitations of traditional classification systems, and new molecular methods are expected to improve classification systems. Molecular subtypes of breast carcinomas have been characterized in the last 11 years, and have been studied extensively. Much of the information accumulated in recent years, and molecular taxonomy seems to be still developing and undergoing change. The main question is whether new molecular techniques such as gene expression profiling will be accepted as gold standard in determining breast cancer subtypes, and whether molecular classification is useful in specific subtypes of breast cancer as it is in ductal carcinoma (nonspecific type). In addition, critical review of the literature reveals major problems such as poor definition, lack of reproducibility and lack of quality control in current molecular techniques and classifications. Therefore, current molecular approaches are not yet used in routine clinical practice and treatment guidance since they are immature and can even lead to incorrect assessment.

Lymphoepithelioma-like Carcinoma of the Breast: A Case Report

Lymphoepithelioma-like carcinoma carries similar histopathological features with lymphoepithelioma typically located in the nasopharynx. Lymphoepithelioma-like carcinoma of the breast can be mistaken for breast lymphoma or medullary carcinoma due to the undifferentiated appearance of tumor cells and presence of prominent lymphoid component. Lymphoepithelioma-like carcinoma is rare, and the similarity between medullary carcinoma of the breast makes it difficult to distinguish these two tumors. In the presented case, neither lymph node nor distant metastases were detected. Breast lymphoepithelioma-like carcinoma is extremely rare with only 21 reported cases in the literature. Herein we present a 59-year-old woman with lymphoepithelioma-like carcinoma of the breast along with the cases previously published in the literature.

Sigmoid kolon ve lenf düğümünde ekstragenital endometriozis

Brucellosis, is an endemic disease in our country, may lead to bacteremia and cause different clinic manifestations. A 44-year-old male patient admitted to our policlinic with high fever, shivering, chilling, pollacuria, and left costovertebral pain, and interned with diagnosis of acute pyelonephritis. Subsequently, acute pyelonephritis due to acute brucellosis was detected in the clinical and laboratory examination. Antibiotic treatment for brucellosis was given to patient for eight week and after treatment full recovery was seen. Patients with brucellosis may refer with symptoms of acute pyelonephritis in endemic areas for brucellosis. By using brucellos serologies to patients who have the symptoms of acute pyelonephritis may available in the diagnosis of this rare complication in areas where brucellosis is endemic.Objectives: Internal splinting is defined as early tendon transfer performed during or just after nerve repair followsing nerve injury and is a controversial issue. The objecstives of internal splinting are avoiding the use of long term external splinting, avoiding permanent hand deformities until the injured nerve is reinnervated and supporting sensorial recovery. In this paper we present our clinical cases of internal splinting and discuss the results in terms of indications, timing, advantages, and disadvantages of internal splinting. Materials and Methods: We applied internal splinting in 11 patients, 3 patients with radial nerve injury and 8 patients with ulnar nerve injury. Internal splinting was performed contemporarily with the nerve repair in 5 pastients, in 2 weeks following nerve repair in 1 patient and in 4 weeks following nerve repair in 5 patients. Pronator teres was transferred to extensor carpi radialis brevis and flexor carpi radialis was transferred to extensor digitorum communis in radial nerve injuries. Omer\s superficial Y technique and its modification were used for ulnar nerve injuries. Results: Patients were followed up for at least 1 year with physical examination and electroneuromyelography and recovery of sensorial and motor functions were achieved in all of them. Conclusion: We concluded that internal splinting is usesful for avoiding external splint usage and preventing the establishment of hand deformity until recovery of the nerve. The contribution of internal splinting to sensorial recovery was noteworthy as stated in the literature but the lack of control group and the small number of our cases was limited to come to a definite conclusion. We did not experience any disadvantage of internal splinting.

Taxane-based adjuvant chemotherapy in node positive, early stage Turkish breast cancer patients

Adjuvant chemotherapy decreases the risk of breast cancer recurrence in patients with breast cancer. In addition, it increases the rate of survival. Therefore, various chemotherapy regimens are administered in the treatment of breast cancer. The efficacy of taxane-based adjuvant chemotherapies has been demonstrated in various trials. This trial was designed to retrospectively evaluate the efficacy of taxane-based chemotherapies in lymph node-positive, early-stage Turkish breast cancer patients. 29 patients receiving TAC regimen and 29 patients receiving AC+P regimen were evaluated. 6 courses of TAC regimen were administered every 3 weeks (docetaxel 75 mg/m2, doxorubicine 50 mg/m2, cyclophosphamide 500 mg/m2). The other patient group was administered AC+P regimen (4 courses of doxorubicin 60mg/m2, cyclophosphamide 600 mg/m2 combination every 2 weeks, followed by paclitaxel 175 mg/m2 for 4 courses every 2 weeks). The 1-year, 2-year and 3-year disease-free survival (DFS) rates were 96.3%, 81.1% and 72.8% respectively. No significant difference was detected in DFS between premenopausal and postmenopausal patients on the taxane regimen (p=0.82). There was no significant difference in DFS between estrogen or progesterone receptor positive and negative patients (p=0.46). Disease-free survival of patients receiving TAC and AC+P adjuvant chemotherapy regimen was compared. The follow-up period of patients on AC+P chemotherapy was longer than those receiving TAC (AC+P mean 38.6±12.8 months, TAC mean 17.1±5.4 months). No significant difference was observed upon evaluation of both treatment arms with respect to DFS (p=0.92). In conclusion, this trial once more demonstrated that taxane-based adjuvant chemotherapy was effective and safe in lymph node-positive, early-stage Turkish breast cancer patients.

Role of diffusion-weighted MR Imaging in solid breast masses and complicated cysts

Objective: The purpose of this study is to evaluate the characteristics of malign/benign lesions and complicated cysts/abscesses in diffusion weighted magnetic resonance imaging and to investigate the contribution of apparent diffusion coefficient (ADC) to differential diagnosis. Methods: In this retrospective study; histopathologically proven 177 lesions (21 complicated cysts, 91 malign and 65 bening lesions) were evaluated in 116 women using conventional MRI and diffusion weighted imaging (DWI). Results: Mean ADC values obtained in our study were 0.88±0.3x10-3 cm2/sec for 91 malignant, and 1.52±0.3x10-3 cm2/sec for 65 benign lesions, 0.55±0.3x10-3 cm2/sec for 21 complicated cysts/abscesses and and a statistically significant difference was detected among mean lesion ADC values (P<0.001). We calculated threshold ADC values to discriminate between malignant and benign lesions, and between these lesions and complicated cysts/abscesses as 1.1x10-3 cm2/sec (P<0.001), and 0.6x10-3 cm2/sec (P<0.001), respectively. The ADC values identified for complicated cysts/abscesses are significantly lower than the ADC values of benign and malign values reported in the literature. Conclusion: As a result, the specificity, positive predictive value and negative predictive value of DWI when it is used alone are higher than conventional MRI, while sensitivity of DWI is nearly the same. DWI is effective in detecting breast lesions and also ADC value is useful in distinguishing among complicated cysts/abscesses, malignant and benign breast lesions.