Carla Cedolini

Role of Mammography, Ultrasound and Large Core Biopsy in the Diagnostic Evaluation of Papillary Breast Lesions

Background: It is well recognized that distinguishing benign from malignant papillary lesions of the breast may pose challenging diagnostic problems. To prospectively evaluate the potential role of mammography, ultrasound and image-guided core biopsy in the diagnosis of papillary lesions of the breast. Methods: 1,442 women consecutively underwent 14-gauge core biopsy and in 51 cases (3.5%) a diagnosis of papillary lesion was formulated. Both radiologists and pathologists independently expressed their degree of suspicion of malignancy (not suspicious, low, moderate, high) on the basis of radiological and core biopsy findings, respectively. Surgical excision of the lesion was used as gold standard and diagnostic agreement was assessed by the kappa statistic. Results: At surgery, 19 of the 49 (38.7%) resected cases had a diagnosis of malignancy. A poor agreement was found between mammography and core biopsy results in the categorization of suspicion of malignancy (k = 0.03). Similar data were obtained between ultrasound and core biopsy (k = 0.07). A poor agreement was also observed between radiological and surgical results (k < 0.20). In contrast, a good agreement was found between core biopsy and surgical samples (k > 0.70). However, 5 (26%) out of the 19 malignant cases at surgery were judged as benign or probably benign on core biopsy. Depending on how the categories of suspicion on core biopsy were set up, the range of sensitivity was 74–89%, whereas specificity ranged from 91 to 97%. Conclusions: Image-guided large core biopsy allows for a correct diagnosis in the majority of papillary lesions. However, its sensitivity is not good enough for surgical excision to be avoided.

Laparoscopic treatment of symptomatic lymphoceles after kidney transplantation.

AbstractBackground: The incidence of lymphocele after kidney transplantation ranges from 0.6% to 18%. This study examines the use of laparoscopic ultrasound for the location of lymphoceles during laparoscopic drainage. Methods: Between July 1993 and October 1998, we performed 147 kidney transplants. A symptomatic lymphocele was observed in 19 patients (12.9%). All of these patients underwent peritoneal laparoscopic fenestration of the lymphocele. The graft, kidney hilum, ureter, iliac vessels, and lymphoceles were identified by laparoscopic ultrasound. Results: All but one patient were discharged within 24 h. One recurrence (5.2%), which was successfully treated by laparoscopy, was observed at a mean follow-up of 15.5 months. We had one complication (5.2 %)—a left hydrocele that occurred 2 days after drainage of a lymphocele located in the left iliac fossa. Conclusions: Laparoscopic peritoneal drainage of posttransplant lymphoceles shares the well known advantages of laparoscopy. Furthermore, laparoscopic ultrasound is a useful tool that allows the recognition of anatomical structures and decreases the risk of iatrogenic lesions.

Type of Breast Cancer Diagnosis, Screening, and Survival

INTRODUCTION Breast cancer screening is known to reduce mortality. In the present study, we analyzed the prevalence of breast cancers detected through screening, before and after introduction of an organized screening, and we evaluated the overall survival of these patients in comparison with women with an extrascreening imaging-detected breast cancer or those with palpable breast cancers. MATERIALS AND METHODS We collected data about all women who underwent a breast operation for cancer in our department between 2001 and 2008, focusing on type of tumor diagnosis, tumor characteristics, therapies administered, and patient outcome in terms of overall survival, and recurrences. Data was analyzed by R (version 2.15.2), and P < .05 was considered significant. RESULTS Among the 2070 cases of invasive breast cancer we considered, 157 were detected by regional mammographic screening (group A), 843 by extrascreening breast imaging (group B: 507 by mammography and 336 by ultrasound), and 1070 by extrascreening breast objective examination (group C). The 5-year overall survival in groups A, B, and C were, respectively, 99% (95% CI, 98%-100%), 98% (95% CI, 97%-99%), and 91% (95% CI, 90%-93%), with a significant difference between the first 2 groups and the third (P < .05) and a trend between groups A and B (P = .081). CONCLUSION The diagnosis of invasive breast cancer with screening in our population resulted in a survival gain at 5 years from the diagnosis, but a longer follow-up is necessary to confirm this data.

Magnetic resonance imaging of radial sclerosing lesions (radial scars) of the breast.

PURPOSE To identify magnetic resonance (MR) imaging (MRI) features of radial sclerosing lesions (RSLs) of the breast. METHODS AND MATERIALS The radiologic and pathologic records for 4629 consecutive patients undergoing MR examinations of the breast were retrospectively reviewed. Patients who received a pathologic diagnosis of RSL without atypia or carcinoma at surgical excision were identified. The MR images were evaluated according to the BI-RADS-MRI lexicon by two experienced breast radiologists. The frequency of morphologic and kinetic patterns and of BI-RADS-MRI assessment categories was calculated. RESULTS Twenty-nine patients with 29 surgically excised RSL were identified. Nine (31%) RSL were MR-occult; the remaining 20 (69%) RSL presented as masses (10/20, 50%), architectural distortions (5/20, 25%), non-mass lesions (4/20, 20%), and focus (1/20, 5%). Kinetic analysis was performed in 18 RSL: enhancement features were benign in 9 (50%) cases, suspicious in 7 (39%) cases and indeterminate in 2 (11%) cases. Twelve (41%) MR examinations were assessed as suspicious (BI-RADS-MRI 4 and 5), and 17 (59%) as negative (BI-RADS-MRI 1) or benign (BI-RADS-MRI 2 and 3). CONCLUSION RSLs are often visualized on MR imaging. Just as in mammography and sonography, RSL can have variable morphologic and kinetic features, and not infrequently they can mimic invasive carcinoma of the breast.

Impact of intraoperative radiotherapy on cosmetic outcome and complications after oncoplastic breast surgery.

Breast cancer is one of the most common tumors in the population worldwide. Conservative breast surgery (CBS) is one of the preferred surgical options, because both the oncologic and esthetic needs of the patient can be addressed. CBS surgical outcomes tend to be more effective with reduced chances of disease recurrence when radiotherapy (RT) treatment is considered as an adjunct treatment, either applied during surgery (IORT) and/or after (EBRT). The purpose of our study was to compare surgical outcomes between IORT and EBRT after CBS. In the past 5 years, we performed CBS in 489 patients in our clinic. Of these patients, 83 underwent adjunct treatment with IORT and 109 were treated with EBRT in accordance with our university approved clinical protocol. Surgical outcomes, early complication rates, and esthetic results were compared between these two groups of CBS patients, with a mean follow‐up time of 17 months. IORT allowed breast irradiation treatment to be performed without effecting overlying skin, thus cosmetic outcomes tended to be favorable. Esthetic postoperative results assessed with the Breast Cancer Conservation Treatment (BCCTcore) software showed that the differences between IORT and EBRT were not statistically significant (including those patients that underwent further oncoplastic techniques after EBRT). The disease recurrence rates between the two groups were not significantly different. IORT is a safe, fast, and feasible technique that provides effective and comparable CBS outcomes for patients with breast cancer.

Minimally invasive esophagectomy: a comparative study of transhiatal laparoscopic approach versus laparoscopic right transthoracic esophagectomy.

Background The development of minimally invasive surgery gave birth to an interest in a mini-invasive approach to esophageal cancer; however, it is still considered to be one of the most complex gastrointestinal surgical operations, and many questions still remain unanswered, regarding the oncologic results of a mini-invasive approach in long-term follow-ups. Here, the authors report on the short-term and long-term results of a series of laparoscopic esophagectomies. Patients and Methods From January 2002 to March 2006, 22 nonrandomized patients were recruited to undergo an esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were carried out using the laparoscopic transhiatal technique in 9 patients; whereas, a combined laparoscopic and right-transthoracic incision was performed in the other 13 patients. Results The mean follow-up was 21±3.23 months (mean±SD); range, 2 to 46 months. The overall survival rate resulted 84.0% at 12 months, 61.3% at 24 months, and 51.0% at 36 months. The proportions of cumulative survival showed significant differences when the following variables were considered: site of neoplasm (lower esophagus), American Society of Anesthesiologists 2, chronic obstructive pulmonary disease, type of surgical procedure, and inclusion in neoadjuvant protocol and staging. Recurrence rates were 3 (25%) in the radio-chemotherapy–treated group, and 5 (50%) in the primary surgery group (P=n.s.). Conclusions The two-year survival rates (61.3%) recorded in our series are comparable with those reported in other series of both laparoscopic and open surgeries. The logical conclusion was that a less invasive procedure did not imply a less curative one.

Feasibility of concervative breast surgery and intraoperative radiation therapy for early breast cancer: A single-center, open, non-randomized, prospective pilot study

Intraoperative radiotherapy (IORT) consists of an accelerated, single-dose, partial breast irradiation, performed immediately after breast conservative surgery. In the present study, we report the results of our feasibility protocol study using IORT between 2005 and 2009. We analyzed the data from a single-center, open, non-randomized, prospective pilot study including patients who underwent breast conservative surgery for invasive breast cancer between January 2005 and December 2009 at our Clinic of Surgery. Patients were divided based on IORT performance and stratified by age (≥48 or <48 years). Data were analyzed using R (version 2.15.2), considering a level of significance at P<0.05. Among the 247 eligible patients, 81 accepted the IORT protocol. Intraoperative IORT feasibility was 95.1% (77/81). In 71.4% (55/77) of the cases no postoperative complication was registered. Concerning local recurrence and overall survival, no significant difference was observed between women who underwent the IORT protocol or standard treatment. Among the patients aged <48 years, no local recurrence was noted after IORT protocol, and among women aged ≥48, local recurrences developed later in patients treated with IORT than with standard treatment. IORT represents a feasible and promising technique for the treatment of early breast cancer, with low morbidity, and beneficial aesthetic and oncologic results. Further studies are required in order to extend the inclusion criteria and offer IORT to a larger number of breast cancer patients.

Psychophysical Stress and Individual Susceptibility to Breast Cancer

Environmental risk factors for cancer have been widely investigated, with the conviction that people’s sickness derives from factors attacking them from the outside. At the same time, little attention was directed to what determines the resistance or the susceptibility to cancer and only few authors have wondered why certain individuals, similarly exposed to the same agent, remain healthy or become ill.

The Breast Cancer: a Comparison among Different Diagnostic and Therapeutic Protocols

To the Editor: Experience gained in years of breast cancer research has given rise to the definition of complex and articulated treatment plans. It is safe to say that nowadays, no modern breast surgery unit can fail to involve more than one specialist in its activities [1]. On the other hand, there is still no single protocol, nor even any consensus among the scientific community on the most appropriate timing of the treatments needed to deal with breast cancer [2]. Every different patient care strategy has its pros and cons. In times when economic resources need to be managed more rationally, there is not just an ethical requirement to fulfill, but also a second important one: the chosen protocol must be as cost-effective as possible. The breast surgery protocol adopted at the Udine Surgery Department is the result of an effort to extend this same concept, offering patients a treatment plan that limits the number of treatments they receive to a minimum. All breast cancer patients registered at the clinic are studied by performing breast ultrasound, bilateral mammography, and needle biopsy, followed by magnetic resonance imaging (MRI) of the breast. These tests, including the MRI, are conducted for all patients (not just for dubious cases) to enable an accurate diagnosis of the disease and obtain a precise picture of the lesion’s extent, so that the most suitable, definitive surgery can be planned (aiming for oncological radicality), thus avoiding any need for any further resurgery. When sentinel lymph node biopsy (SLNB) during surgery is required, we have recently adopted the one-step nucleic acid amplification (OSNA) method. Finding a positive lymph node leads to a full axillary lymphadenectomy, completed during the same surgical procedure. Here again, this avoids any need to reoperate after obtaining a definitive histology report [3]. OSNA has drastically reduced the time the pathologist needs to examine the sample, indirectly reducing our operating times too [4]. The breast surgery protocol adopted at our Surgery Department differs in two aspects from what is the standard model, because all patients routinely undergo breast MRI, and any SLNB entails an intraoperative histologic examination. The treatment protocol for breast cancer adopted at our clinic closely resembles the approach taken by such an internationally acknowledged organization as the European Institute of Oncology (IEO) in Milan. The only difference between the IEO’s protocol and the one adopted in Udine lies in that the IEO also does not conduct an MRI routinely in all cases. The aim of this study was to compare the three above-described breast surgery protocols from the economic standpoint, calculating their costs when applied to the case series of surgical procedures performed at our Surgery Department in Udine over a 5-year period. The study considered 767 consecutive patients at the Udine Surgery Department from November 2005 to December 2010. For each patient, we analyzed the available first-level test results and established whether the MRI findings had prompted any changes in the treatment strategy. We considered the type of surgery performed, and particularly any recourse to SLNB. Lymph node positivity would require an axillary lymphadenectomy during the same surgical procedure and we recorded all the cases in which axillary lymphadenectomy was performed. For the data set thus obtained, each parameter of the breast cancer pathway was associated with the corresponding cost to the health care organization. The various costs were combined for each patient, based on the type of surgery performed and the protocol applied. For each patient, we thus obtained three different costs, i.e., the actual cost and those that would have been incurred for the same patient with the same disease had they been treated according to Address correspondence and reprint requests to: Federico Cattin, General Surgery Department, University of Udine, P.le Santa Maria della Misericordia 3, Udine 33100, Italy, or e-mail: doctorfef@gmail.com

Post-Traumatic Right Lumbar Abscess as First Manifestation of Perforated Right Colon Cancer - A Case Report.

Besides most common signs and symptoms suggesting a colic cancer, sometimes the clinical presentation can be difficult. Extra-abdominal abscess as a first sign of perforated colon carcinoma is a very unusual finding. We report a case of an old male patient, in bad general condition, with a post-traumatic finding of right lumbar abscess. After the percutaneous drainage with discharge of fecal material and a postponed explorative laparotomy, we discovered a perforated right colon carcinoma with a covered perforation affecting the duodenum wall and spreading to the hepatic bedand over to the back lumbar muscular wall. Because of the diffusion of the tumor, the patient was treated with palliative surgery with duodenum suture, right colon segment resection and subsequent ileocolic anastomosis with an uneventful postoperative course. The patient died 2 months later because of neoplastic cachexia.