Bernard Ho

Surgical excision of intraductal breast papilloma diagnosed on core biopsy.

Background:  The need for surgical excision of benign papillary lesions diagnosed on core biopsy remains debatable. This lack of consensus arises because although there is a possibility of histological underestimation, there are as yet no reliable predictors of malignancy. We therefore aimed to evaluate the incidence of histological underestimation in our practice, and to identify factors that predict for this, in order to reduce unnecessary surgery without missing out on possible malignancy.

Predictors of Nonsentinel Nodal Involvement to Aid Intraoperative Decision Making in Breast Cancer Patients with Positive Sentinel Lymph Nodes

Background. Up to 60% of patients with a positive sentinel lymph node (SLN) have no additional nodal involvement and do not benefit from completion axillary lymph node dissection (ALND). We aim to identify factors predicting for non-SLN involvement and to validate the MSKCC nomogram and Tenon score in our population. Methods. Retrospective review was performed of 110 consecutive patients with positive SLNs who underwent ALND over an 8-year period. Results. Fifty patients (45%) had non-SLN involvement. Non-SLN involvement correlated positively with the number of positive SLNs (P = 0.04), macrometastasis (P = 0.01), and inversely with the total number of SLNs harvested (P = 0.03). The MSKCC nomogram and Tenon score both failed to perform as previously reported. Conclusions. The MSKCC nomogram and Tenon score have limited value in our practice. Instead, we identified three independent predictors, which are more relevant in guiding the intraoperative decision for ALND.

Extent of Margin Involvement, Lymphovascular Invasion, and Extensive Intraductal Component Predict for Residual Disease After Wide Local Excision for Breast Cancer

UNLABELLED In the present study, we identified predictors of residual disease after an inadequate wide local excision. Residual tumor was more likely when tumor was present at the inked margin, when more than a single radial margin was affected, and in tumors associated with lymphovascular invasion and an extensive intraductal component. BACKGROUND Positive margins after wide local excision (WLE) increase the probability of residual disease, and additional surgery is often recommended. However, residual tumor will be found in only two thirds of cases, suggesting that additional surgery can be avoided in many instances. In the present study, we sought to establish the frequency of residual tumor when the surgical margins are inadequate and to identify factors that predict for residual tumor. MATERIALS AND METHODS A retrospective review was performed of 720 consecutive patients who had undergone WLE for ductal carcinoma in situ and nonmetastatic breast cancer at a single unit from January 1, 2004 to December 31, 2010. RESULTS At least a single radial margin was affected (either involved or close, defined as tumor < 1 mm from the margin) in 244 patients who had undergone WLE, and either the anterior or posterior margin was affected in another 103 patients. Reoperation was performed in 215 patients with affected radial margins and 9 others with affected anterior or posterior margins. Residual disease was found in 98 of 224 patients (43.8%) and was more likely when tumor was present at the inked margin, when > 1 radial margin was affected, and when lymphovascular invasion (LVI) or an extensive intraductal component (EIC) was present. The association with tumor size was of borderline significance. No association was found with tumor histologic type or patient age. CONCLUSION Additional evaluation is needed to determine whether additional surgery can be safely omitted in women with tumors without LVI or EIC when a single radial margin has been deemed to be close.

Achieving Breast Cancer Surgery in a Single Setting With Intraoperative Frozen Section Analysis of the Sentinel Lymph Node

BACKGROUND Current guidelines recommend full axillary lymph node dissection (ALND) whenever the SLN is positive for metastases. In our institute, we aim to complete surgery in a single setting and base the decision for ALND on the intraoperative FS analysis of the SLN. In this study, we evaluate the efficacy this practice in terms of the accuracy of FS analysis, patient recall rate, and additional time required for FS analysis. MATERIALS AND METHODS Retrospective review was performed of 586 patients who underwent SLN biopsy at our institution from January 1, 2006 to December 31, 2010. Intraoperative FS analysis was routinely performed in all cases with a preoperative diagnosis of invasive breast cancer and in selected cases of ductal carcinoma in situ according to surgeon preference. RESULTS The SLN was positive for metastases in 123 (22.7%) patients; this was identified on FS analysis in 107 patients. FS analysis had a sensitivity of 87.0% and specificity of 100% and resulted in a patient recall rate of 3%. Micrometastasis accounted for most of the false negative FS results. These deposits were mostly detected only on deeper sectioning of the permanent sections of the SLN. An invasive lobular histology and lymphovascular invasion were found to be independent predictors of a false negative FS on multivariate analysis (P < .01). Intraoperative FS did not significantly prolong operating times. CONCLUSION Intraoperative FS analysis is an accurate and efficient means of rapid SLN assessment and allows ALND to be completed in a single setting.

Histopathologically proven siderotic cataract with disintegrated intralenticular foreign body

Cataract formation may be an indicator of early siderosis and has been associated with intralenticular foreign bodies. We report a unique case of histopathologically proven lens siderosis in a young man with a preceding history of trauma but no signs of retained intraocular foreign body. He presented with a total white cataract with brownish deposits on anterior capsule and underwent cataract surgery for same followed by histopathological staining of anterior capsule for iron deposits. This case illustrates the importance of close monitoring of patients with history of trauma or previous penetrating injury to the eye, albeit no intraocular foreign body, as they might develop ocular siderosis at a later stage.

A 62‐Year‐Old Man With Progressive Weakness, Multiple Neurologic Deficits, and Hypernatremia

History of the presenting symptom The patient had a 6-month history of unsteady gait and generalized weakness with constitutional symptoms of loss of weight and appetite. He consulted his general practitioner 2 months later. Laboratory investigations then showed normal complete blood count and liver and thyroid function tests. Magnetic resonance imaging (MRI) of the brain with contrast fluid-attenuated inversion recovery (FLAIR) sequences and diffusion-weighted imaging showed multiple nonspecific foci of an abnormal signal seen in the white matter of both cerebral hemispheres. VDRL serology was nonreactive. The only abnormal investigation was an elevated serum sodium level at 148 mmoles/liter (reference interval 135–145). He was referred to a neurologist, who made a diagnosis of multiple system atrophy based on features of cerebellar dysfunction and dysautonomia, which included orthostatic hypotension and erectile dysfunction. His serum vitamin E level was 11.3 mg/liter (reference interval 5.5–18.0). He was commenced on highdose oral vitamin E therapy as an antioxidant for multiple system atrophy. He subsequently presented to the general medicine department and was admitted for progression of symptoms. Medical history He had been attending long-term followup visits with his general practitioner for hyperlipidemia and type 2 diabetes mellitus for 10 years. Glycosylated hemoglobin (HbA1c) 2 months prior to admission was 11.8%. His regular medications included lovastatin, glipizide, and vitamin E tablets. He had no recent exposure to anyone with tuberculosis or history of pulmonary tuberculosis.

Axillary lymphangioma in an asymptomatic adult female

carcinoma. While breast cancer can present in the lower axilla at the Tail of Spence, it is rare for a primary breast tumor to present in the hair-bearing region of the axilla. The embryologic development of the breast begins along the ventral milk line from the anterior axilla to the groin. The majority of this tissue involutes, leaving mammary tissue only in the pectoral region. Incomplete involution can result in accessory breast tissue along the milk line, commonly within the axilla. Incidence of accessory breast tissue is thought to be 2%-6%. It is believed that malignancies within ectopic tissue account for 0.3%-0.6% of breast cancers. Other etiologies of palpable axillary masses should be considered, including apocrine adenocarcinoma, occult primary breast cancer with axillary metastases, lymphoma, and reactive lymphadenopathy. Of the carcinomas, it can be difficult to differentiate between breast and apocrine tumors. Apocrine tumors are quite rare; therefore primary breast malignancy should be excluded first. Immunohistochemistry is crucial in determining primary breast origin. While no stain guarantees breast origin, GATA3 is highly sensitive and fairly specific for breast carcinoma. As with analysis of metastases of unknown primary, CK7 positivity and CK20 negativity are helpful in identifying ectopic breast tissue. Once identified, breast cancer within ectopic axillary breast tissue can be treated with standard breast conservation therapy, meaning local excision to adequate margins followed by radiation therapy. Adjuvant systemic therapy may also be indicated in cases of primary ectopic breast cancer, mirroring orthotopic breast cancer treatment. In these cases, multidisciplinary work-up including imaging and pathologic staining are required for diagnosis. Clinicians need to be aware of these infrequent entities as treatment modalities differ widely.