Cameron D. Adkisson

Predictors of accuracy in preoperative parathyroid adenoma localization using ultrasound and Tc-99 m-Sestamibi: A 4-quadrant analysis☆☆☆★

PURPOSE To compare the accuracy of preoperative parathyroid adenoma localization in patients with primary hyperparathyroidism (pHPT) due to a single adenoma using a detailed 4-quadrant analysis and to identify patient and tumor characteristics associated with accurate preoperative localization. MATERIALS AND METHODS Retrospective review of 203 patients who underwent parathyroidectomy for pHPT due to a single adenoma between 2008 and 2011. Results from preoperative ultrasound and Tc-99m-sestamibi were compared to operative findings to determine accuracy of localization studies. Associations between clinicopathologic features and accurate preoperative adenoma localization were evaluated. RESULTS Ultrasound was performed on 198 patients, sestamibi on 177 patients, and both on 172 patients. Accurate localization occurred significantly more often for ultrasound than sestamibi (63% vs. 41%, P<0.001). For ultrasound, accurate localization was found in patients with larger or heavier adenomas, those with adenomas located inferiorly, patients not having a reoperative procedure, and patients with higher post-operative serum calcium levels. For sestamibi, greater adenoma size or weight, adenomas located inferiorly, and patients with associated thyroid cancer on pathology were most predictive of accurate preoperative localization. CONCLUSIONS Our results provide evidence that ultrasound is more accurate in localizing parathyroid adenomas in patients with pHPT due to a single adenoma when compared to sestamibi scan using 4-quadrant location analysis and may be the preferred preoperative imaging modality in these patients. No significant preoperative patient factors were associated with accurate localization by ultrasound or sestamibi, but adenoma size, weight, and location in an inferior position were predictive of accurate preoperative localization.

The role of preoperative bilateral breast magnetic resonance imaging in patient selection for partial breast irradiation in ductal carcinoma in situ.

Purpose. Women with ductal carcinoma in situ (DCIS) are often candidates for breast-conserving therapy, and one option for radiation treatment is partial breast irradiation (PBI). This study evaluates the use of preoperative breast magnetic resonance imaging (MRI) for PBI selection in DCIS patients. Methods. Between 2002 and 2009, 136 women with newly diagnosed DCIS underwent a preoperative bilateral breast MRI at Mayo Clinic in Florida. One hundred seventeen women were deemed eligible for PBI by the NSABP B-39 (National Surgical Adjuvant Breast and Bowel Project, Protocol B-39) inclusion criteria using physical examination, mammogram, and/or ultrasound. MRIs were reviewed for their impact on patient eligibility, and findings were pathologically confirmed. Results. Of the 117 patients, 23 (20%) were found ineligible because of pathologically proven MRI findings. MRI detected additional ipsilateral breast cancer in 21 (18%) patients. Of these women, 15 (13%) had more extensive disease than originally noted before MRI, and 6 (5%) had multicentric disease in the ipsilateral breast. In addition, contralateral breast cancer was detected in 4 (4%). Conclusions. Preoperative breast MRI altered the PBI recommendations for 20% of women. Bilateral breast MRI should be an integral part of the preoperative evaluation of all patients with DCIS being considered for PBI.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac

Purpose: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. Case report: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. Conclusion: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Classification System for Identifying Women at Risk for Altered Partial Breast Irradiation Recommendations After Breast Magnetic Resonance Imaging

PURPOSE To study the utility of preoperative breast MRI for partial breast irradiation (PBI) patient selection, using multivariable analysis of significant risk factors to create a classification rule. METHODS AND MATERIALS Between 2002 and 2009, 712 women with newly diagnosed breast cancer underwent preoperative bilateral breast MRI at Mayo Clinic Florida. Of this cohort, 566 were retrospectively deemed eligible for PBI according to the National Surgical Adjuvant Breast and Bowel Project Protocol B-39 inclusion criteria using physical examination, mammogram, and/or ultrasound. Magnetic resonance images were then reviewed to determine their impact on patient eligibility. The patient and tumor characteristics were evaluated to determine risk factors for altered PBI eligibility after MRI and to create a classification rule. RESULTS Of the 566 patients initially eligible for PBI, 141 (25%) were found ineligible because of pathologically proven MRI findings. Magnetic resonance imaging detected additional ipsilateral breast cancer in 118 (21%). Of these, 62 (11%) had more extensive disease than originally noted before MRI, and 64 (11%) had multicentric disease. Contralateral breast cancer was detected in 28 (5%). Four characteristics were found to be significantly associated with PBI ineligibility after MRI on multivariable analysis: premenopausal status (P=.021), detection by palpation (P<.001), first-degree relative with a history of breast cancer (P=.033), and lobular histology (P=.002). Risk factors were assigned a score of 0-2. The risk of altered PBI eligibility from MRI based on number of risk factors was 0:18%; 1:22%; 2:42%; 3:65%. CONCLUSIONS Preoperative bilateral breast MRI altered the PBI recommendations for 25% of women. Women who may undergo PBI should be considered for breast MRI, especially those with lobular histology or with 2 or more of the following risk factors: premenopausal, detection by palpation, and first-degree relative with a history of breast cancer.

What Extent of Pancreatic Resection Do Patients with MEN-1 Require?

CONTEXT The surgical management of pancreatic endocrine tumors in patients with multiple endocrine neoplasia type 1 (MEN-1) is controversial and complicated by the fact that these tumors are frequently multifocal. The degree of tumor resection is determined by weighing the risk of malignancy or tumor recurrence against the risks of endocrine/exocrine insufficiency with complete gland removal. METHODS A retrospective review was performed identifying 4 patients with MEN-1 and pancreatic endocrine tumors treated with pancreatic resection over a 2-year period at our institution. RESULTS Mean age at operation was 35 years. Surgical approach was determined by size of tumor(s) and presence of multifocality. MRI and EUS were performed in all patients. While EUS identified a greater number of tumors when compared to MRI (median 5 versus 1), both studies grossly underestimated the total number of tumors found on final pathology. Three patients underwent laparoscopic total pancreatectomy for multifocal disease with diffuse pancreatic involvement, finding a median of 12 tumors. One patient underwent laparoscopic subtotal pancreatectomy for a presumed single pancreatic tail mass, but was found to have multifocal disease on final pathology consisting of 7 tumors. The average number of tumors found on final pathology was 13.5 with an average size of 2.6 cm. The median number of lymph nodes analyzed was 14. Diffuse, multifocal disease was present in all 4 patients. No major postoperative complications were observed. CONCLUSION In patients with MEN-1 and pancreatic endocrine tumors, preoperative workup underestimates extent of disease and total pancreatectomy should be considered for complete tumor removal.

Aneurysmectomy and Revascularization of a Large Hepatic Artery Aneurysm

Aneurysms of the hepatic artery are rare, but are associated with significant mortality because of their lack of symptoms at presentation and risk of rupture. We report a case of an enlarging 4-cm hepatic artery aneurysm involving the proximal common hepatic artery to the bifurcation of the right and left hepatic arteries which was found incidentally on ultrasound examination. Endovascular treatment with a stent was considered, but because of the location of the aneurysm as well as the presence of significant thrombosis involving the right and left hepatic arteries, aneurysmectomy and revascularization using saphenous vein was performed. Doppler ultrasound measurements demonstrated good flow through the graft postoperatively and at 1-month follow-up. Although a variety of endovascular techniques exist to treat hepatic artery aneurysms, our results indicate that open excision and revascularization may be required and can have a good outcome.

A hemorrhoid by any other name.

A 92-year-old man with dementia presented with perianal discomfort and fecal incontinence of 1 week duration. He denied pain, pruritus, bleeding, or sensation of a mass. Physical examination was notable for a raised verrucous mass (0.75 cm) extending from the dentate line distally for 7 cm, circumferentially covering 75% of the anal margin. Punch biopsy specimens were obtained for diagnosis. Histology revealed intraepithelial cells with prominent nucleoli and abundant clear cytoplasm. Surgical options were explained to the patient, but given his decline in function and overall poor life expectancy, radiation therapy was offered. He successfully completed a regimen of 44 Gy in 11 fractions. On follow-up examination, no appreciable perianal mass was observed; the patient denied anal discomfort, pain, bleeding, or symptoms of obstruction. Perianal Paget disease is uncommon, with fewer than 300 cases reported in the literature.1,2 Classically described as involving the breast, Paget disease has been shown to affect areas containing apocrine glands, including the perianal region, vulva, penis, scrotum, thighs, buttocks, and axilla.2 Perianal Paget disease typically presents in the sixth decade of life with pruritus ani, bleeding, excoriation, pain with defecation, anal pain, or mass sensation.2 Lesions are characterized as slightly raised, erythematous, and well-demarcated.3 Treatment is predominantly surgical, consisting of local excision, wide local excision with skin grafting or flap reconstruction, or in severe cases abdominoperineal resection.4,5 Radiation therapy can be offered in select patients with good outcome.

Breast cancer treatment and recurrence in octogenarians.

94 Background: Octogenarian breast cancer (BrCa) patients accept less aggressive BrCa treatment due to decreased life expectancy, increased comorbidities, and high likelihood of death from other causes. Unfortunately little data exist stratifying octogenarian outcomes by disease risk. We sought to characterize treatment and recurrence patterns in patients >80yo. METHODS Retrospective review identified 432 women >80yo treated surgically for stage 0-3 BrCa between 11/99-8/11. We gathered clinicopathologic data and classified patients by disease risk as DCIS only, low risk (<2cm and ER positive and node negative), or high risk (>2cm or ER negative or node positive). We compared recurrence rates and estimated survival by Kaplan-Meier curves. RESULTS Among the 432 women, disease was found by mammogram in 86%, treated with BCT in 64%, and predominantly ER-positive (87%). We classified patients as having DCIS only (N=61), low risk (N=205), or high risk (N=166) disease. We identified the following deviations from standard treatment guidelines: 68% DCIS BCT and 38% high risk BCT patients did not have radiation therapy, 25% low risk BCT patients had surgery only, 51% low risk patients did not take adjuvant hormonal therapy, and 40% high risk patients had no adjuvant chemo/hormonal therapy. At 5 and 10 years the overall estimated survival was 63% and 31%, respectively. Overall, 19/432 (5%) patients developed recurrence (table 1). Patients needing mastectomy for high risk disease had significantly higher risk of recurrence than high or low risk BCT patients (p=0.02). Of the 19 recurrence patients, 7/19 (37%; 1 DCIS, 1 low risk, 5 high risk) occurred despite standard multimodality treatment, while12 (63%; 3 low risk, 9 high risk) had the initial tumor treated less aggressively due to patient choice (n=9) or medical co-morbidities (n=3). CONCLUSIONS Significant deviations from treatment guidelines occur in women >80yo. Those with high risk disease should be counseled accordingly and encouraged to receive adjuvant treatment as two thirds of women >80yo will live at least 5 years. [Table: see text].