Chee Chee H Stucky

Is there concordance of invasive breast cancer pathologic tumor size with magnetic resonance imaging

BACKGROUND In the era of breast conservation therapy, preoperative imaging is imperative in planning a single definitive surgical treatment. METHODS We performed a retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer over 5 years. Clinical and pathologic variables were analyzed with respect to magnetic resonance imaging (MRI) and pathologic tumor size using analysis of variance F tests and chi-square tests. RESULTS Of 190 patients, 53% had concordance of MRI and pathologic cancer size within .5 cm. MRI overestimated 33% and underestimated 15% of tumors. Neoadjuvant chemotherapy and lymph node status were associated with discordance. Among tumors overestimated by MRI, 65% had additional significant findings in the breast tissue around the main lesion: satellite lesions, ductal carcinoma in situ, and/or lymphovascular invasion. CONCLUSIONS Breast MRI is concordant with pathologic tumor size within .5 cm among 53% of patients. Most patients with tumors overestimated by MRI have significant findings in the surrounding breast tissue, the excision of which would be expected to benefit the patient.

Risk factors associated with local and in-transit recurrence of cutaneous melanoma

BACKGROUND Understanding the risk factors for local and in-transit recurrences (LR/ITR) may help facilitate methods of prevention, early detection, and treatment. METHODS A retrospective review of a prospectively collected database was performed on patients diagnosed with single-lesion cutaneous melanoma. Clinical and pathologic characteristics of the tumors were evaluated. RESULTS Of 225 patients, 10% had LR/ITR. Patients with LR/ITR were older (P = .0002), had thicker tumors (P = .018), and positive angiolymphatic invasion more frequently (P < .0001). An increased tumor mitotic rate (TMR) was more common in LR/ITRs (P = .051). On univariate logistic regression, age, thickness, TMR of 11/mm(2) or greater, and angiolymphatic invasion were all significant risk factors for LR/ITR. Multivariate logistic regression showed age, thickness, and angiolymphatic invasion were the only significant risk factors. CONCLUSIONS Older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for LR/ITR. Such patients warrant consideration of preventative strategies and should receive close clinical follow-up evaluation for early recurrence.

Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer

BACKGROUND The purpose of this study was to examine the relationship between magnetic resonance imaging (MRI) and surgical treatment of invasive breast cancer (IBC). METHOD The IBC patients treated from January 2003-June 2008 were reviewed by a single institution. RESULTS A total of 814 patients were treated, out of which 562 (69%) underwent breast conservation therapy (BCT), 151 (19%) chose mastectomy alone (M), and 101 (12%) chose mastectomy with reconstruction (M+ R). The mean age was comparatively low in M + R patients (P <or= 0.001). The mean tumor size was the lowest in BCT patients (P <or= 0.001). MRI use increased with no significant difference in type of surgery as noted by year. In multivariate analysis, type of surgery was significantly associated with tumor size, multifocality, age, and MRI use. The factors associated with MRI performance were: multifocality, younger age, tumor size, lobular histology, body mass index, and genetic testing. CONCLUSIONS The use of MRI in IBC patients has increased over the past 5 years, without any observable impact on surgical treatment. Similar factors are associated with mastectomy and MRI performance.

A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year

BACKGROUND Although mammography is the gold standard for breast cancer screening, clinical breast examination (CBE) and self breast examination (SBE) are important adjuncts whose utility has been questioned. METHODS A retrospective review of invasive breast cancer patients from 2000 to 2008 was performed. We compared 3 groups: breast cancer detected by (1) imaging only (nonpalpable) or palpable mass with a normal mammogram (2) ≥ 1 year (mammogram ≥ 1 year) or (3) <1 year (mammogram <1 year). RESULTS Of 1,222 women, presentation included 67% nonpalpable, 21% mammogram ≥ 1 year, and 13% mammogram <1 year. Patients presenting with palpable masses on SBE or CBE even with a normal mammogram within 1 year tended to have more aggressive tumors (larger size, lymph node positive, and triple-negative disease) resulting in more aggressive therapy (a higher mastectomy rate and a greater likelihood of chemotherapy). CONCLUSION A significant number of women present with palpable breast cancer within 1 year of a normal mammogram, many with an aggressive cancer. Therefore, we continue to advocate SBE and CBE for breast cancer screening.

Excellent local control with preoperative radiation therapy, surgical resection, and intra-operative electron radiation therapy for retroperitoneal sarcoma

To examine the value of surgical resection combined with preoperative external beam radiation therapy and intraoperative radiation therapy (Surg‐RT) for retroperitoneal sarcoma (RPS).

Does magnetic resonance imaging accurately predict residual disease in breast cancer

BACKGROUND The accuracy of magnetic resonance imaging (MRI) in identifying residual disease after breast conservation therapy (BCT) is unclear. METHOD Review of an institutional database identified patients with positive or close (<or=2 mm) margins undergoing MRI before re-excision. Histopathologic correlation was performed. RESULTS Forty-three women underwent MRI after BCT. MRI suggested residual disease in 29 patients, of whom 20 (69%) had residual carcinoma pathologically. Nine patients had false-positive MRI as seen by benign pathology findings. Fourteen MRIs indicated no residual disease, of which 6 had residual disease pathologically. The sensitivity and positive predictive value of MRI was 77% and 69%, respectively. MRI conducted within 28 days of the original surgery was 85% sensitive. MRI performed after 28 days was 69% sensitive. CONCLUSIONS MRI is able to detect residual disease among most patients undergoing re-excision. False-positive results may be caused by inflammatory processes that resemble residual disease.

How does a concurrent diagnosis of cancer influence outcomes in emergency general surgery patients

BACKGROUND A significant proportion of hospital admissions in the US are secondary to emergency general surgery (EGS). The aim of this study is to quantify outcomes for EGS patients with cancer. METHODS The Nationwide Inpatient Sample (2007 to 2011) was queried for patients with a diagnosis of an EGS condition as determined by the American Association for the Surgery of Trauma. Of these, patients with a diagnosis of malignant cancers (ICD-9-CM diagnosis codes; 140-208.9, 238.4, 289.8) were identified. Patients with and without cancer were matched across baseline characteristics using propensity-scores. Outcome measures included all-cause mortality, complications, failure-to-rescue, length of stay, and cost. Multivariable logistic regression analyses further adjusted for hospital characteristics and volume. RESULTS Analysis of 3,625,906 EGS patients revealed an 8.9% prevalence of concurrent malignancies. The most common EGS conditions in cancer patients included gastro-intestinal bleeding (24.8%), intestinal obstruction (13.5%), and peritonitis (10.7%). EGS patients with cancer universally had higher odds of complications (odds ratio [OR] 95% confidence interval [CI]: 1.20 [1.19 to 1.21]), mortality (OR [95% CI]: 2.00 [1.96 to 2.04]), failure-to-rescue (OR [95% CI]: 1.52 [1.48 to 1.56]), and prolonged hospital stay (OR [95% CI]: 1.69 [1.67 to 1.70]). CONCLUSIONS EGS patients with concurrent cancer have worse outcomes compared with patients without cancer after risk-adjustment.

A Technique to Address Peritoneal Dialysis Catheter Malfunction

Malpositioned peritoneal dialysis catheters may be repositioned laparoscopically with a testicular prosthesis used as an anchoring weight.

The diagnostic value of splenectomy in patients without a definitive preoperative diagnosis

BACKGROUND The purpose of this study was to describe the diagnostic value and therapeutic benefit of diagnostic splenectomy. METHODS Retrospective review was performed of patients undergoing splenectomy with an unknown diagnosis (UD), a hematologic malignancy (HM) or idiopathic thrombocytopenic purpura. Surgical indications and postoperative outcomes were evaluated. RESULTS 113 splenectomy patients were identified. Of the UD patients undergoing splenectomy, 46% (n = 16) received a definitive diagnosis postoperatively. A change in diagnosis occurred in 12% (n = 4) of HM patients. Complete symptom relief was observed more often in UD patients who received a definitive diagnosis after splenectomy 69% (n = 11), compared to the 47% (n = 9) who did not receive definitive diagnosis postoperatively. CONCLUSIONS The diagnostic ability of splenectomy was 46% when the diagnosis was unknown preoperatively. Additionally, a majority of patients experienced relief of symptoms postoperatively. Splenectomy may be a useful diagnostic and therapeutic tool in select UD and HM patients.