Christina Cellini

Factors Associated With Residual Breast Cancer After Re-excision for Close or Positive Margins

Background: Successful breast conservation surgery (BCS) requires complete tumor excision. Margin status of the initial specimen determines the need for additional surgery. We explored factors associated with residual cancer (RC) upon follow-up surgery in patients with close, positive, or undetermined margins following BCS.Methods: A retrospective analysis of 276 patients with initial close, positive, or undetermined margins who underwent re-excision (RE) or mastectomy was conducted. All initial excisions were intended as definitive procedures. Chi-square analysis was used to identify factors that may predict RC.Results: Of 276 patients, 87 had close, 168 had positive, and 21 had undetermined margins on initial excision. Of this group, 63% (175/276) had RC upon RE or mastectomy. Of positive-margin patients, 68% had RC, compared with 53% of close-margin and 67% of undetermined-margin patients (P = .006). Tumors ≥2 cm were more often associated with RC than smaller tumors (70.8% vs. 56.5%; P = .07). This association was strongest in positive-margin patients (P = .04). High tumor grade was associated with RC in all groups. RC linearly increased with the number of involved margins (P = .02). Specimen inking with multiple colors was associated with decreased risk of RC (P = .004).Conclusions: Over half of patients with involved or undetermined margins had RC upon RE or mastectomy. Positive and undetermined margins were more often associated with RC than close margins. Larger tumor size was associated with RC in patients with positive. Increasing tumor grade suggests a greater chance of detecting RC in all groups. Multiple involved margins led to a greater risk of RC.

Varying Features of Early Age-of-Onset "Sporadic" and Hereditary Nonpolyposis Colorectal Cancer Patients

PURPOSE: Although the criteria for clinical diagnosis of hereditary nonpolyposis colorectal cancer are not fully agreed on, young age seems to be a common trait. The purpose of this study is to identify clinicopathologic features of hereditary nonpolyposis colorectal cancer in early age-of-onset colorectal cancer patients stratified as a function of family cancer history. METHODS: Two hundred thirty consecutive colorectal cancer patients 40 years or older at time of diagnosis were registered into an ongoing database during a ten-year period. Accurate family history was obtainedvia medical records, telephone calls, and questionnaires on 146 patients. According to extent of family history of cancer, patients were stratified into seven groups: 1) fulfilling Amsterdam criteria, 2) fulfilling less strict criteria, 3) having at least one first-degree relative with colorectal cancer, 4) having at least one distant relative with colorectal cancer, 5) having at least one first-degree relative with any cancer, 6) having at least one distant relative with any cancer, 7) having no family history of cancer. RESULTS: Twenty-two of 146 patients fulfilled Amsterdam and less strict hereditary nonpolyposis colorectal cancer criteria (15 percent). These hereditary nonpolyposis colorectal cancer patients were significantly younger (31vs. 35 years;P=0.0003) and had more metachronous colorectal cancer (27 percentvs. 2 percent;P=0.007) and less colorectal cancer with nodal or metastatic spread than the non-hereditary nonpolyposis colorectal cancer patients (35 percentvs. 65 percent;P=0.01). CONCLUSION: Precise familial cancer assessment in early age-of-onset colorectal cancer increases the yield of hereditary nonpolyposis colorectal cancer diagnosis. Because of the frequent development of metachronous colorectal cancer and favorable prognosis, extensive rather than segmental surgery should be considered in early age-of-onset colorectal cancer patients belonging to hereditary nonpolyposis colorectal cancer families.

Limitations of family cancer history assessment at initial surgical consultation.

PURPOSE: Although important for the diagnosis of familial clustering of colorectal cancer and hereditary nonpolyposis colorectal cancer, the accuracy of familial cancer history assessment in the office setting has been questioned. Furthermore, there are few publications describing the optimal method for accurately capturing a family cancer history. The purpose of this study was to determine how well family cancer history is assessed in patients with early age-of-onset colorectal cancer at initial surgical consultation compared with a telephone interview and mailed questionnaire. METHODS: Medical records of patients 40 years old or younger at the time of colorectal cancer surgery were reviewed for documentation of family cancer history at initial surgical consultation. In addition, family cancer history was solicited from surviving patients or their next of kin by telephone and a mailed questionnaire. The kappa coefficient was used to measure degree of correlation between family cancer history obtained at initial surgical consultation and subsequent telephone interview and questionnaire. RESULTS: One hundred twenty-five patients were available for analysis. Family cancer history was documented on the initial surgical consultation report in 78 percent of cases. Although 31.2 percent were identified as having no family cancer history at initial surgical consultation, this proportion decreased to 13.5 percent after telephone interviews and questionnaires. Family history assessment at initial surgical consultation also failed to identify 7 of 11 individuals meeting Amsterdam criteria for hereditary nonpolyposis colorectal cancer and 10 of 16 individuals meeting modified clinical criteria for hereditary nonpolyposis colorectal cancer. CONCLUSIONS: Although family cancer history was commonly obtained during the initial surgical consultation of patients with colorectal cancer, there was a tendency to underestimate the extent of familial cancer. A telephone interview and questionnaire conducted at a later date may reveal a more comprehensive family cancer history. This is an important observation, because individuals identified as high-risk for hereditary nonpolyposis colorectal cancer or familial clustering of colorectal cancer require special consideration with respect to screening, surveillance, and surgical management.

Surgical management of pyogenic complications of Crohn's disease

&NA; Patients with Crohns disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohns disease. (Inflamm Bowel Dis 2010)

Effect of esophageal ligation on small intestinal development in normal and growth-retarded fetal rabbits.

Objective: The uninterrupted passage of amniotic fluid through the gastrointestinal tract is hypothesized to influence both intestinal and overall fetal somatic development. The effect of in utero esophageal ligation (EL) and therefore the exclusion of AF on somatic growth, small intestinal (SI) morphology and proliferation, and the expression of the glucose transporter sodium-glucose cotransporter 1 (SGLT-1) in both normal and intrauterine growth-retarded (IUGR) fetal rabbits were evaluated. Methods: Thirteen pregnant New Zealand white rabbits underwent surgery on day 24 of their normal 31-day gestation. Ipsilateral normal and IUGR fetuses underwent EL; the contralateral normal and IUGR fetuses underwent cervical exploration only forming 4 study groups (control-normal, control-IUGR, EL-normal and EL-IUGR). Rabbits were killed on day 31. Small intestinal villus height was measured, and epithelial cell proliferation was deter mined by proliferating cell nuclear antigen staining. Sodium-glucose cotransporter 1 messenger RNA (mRNA) and protein expressions were analyzed. Statistical analysis was performed using 2-way analysis of variance. Results: Esophageal ligation reduced fetal weight in IUGR by 15% and in normal by 10%. Villus height was significantly reduced in IUGR versus normal in both control and EL (control, P = 0.01; EL, P = 0.05). Intrauterine growth-retarded fetuses had reduced SI proliferation versus normal in both control and EL. Sodium-glucose cotransporter 1 mRNA production in EL fetuses was equal to control fetuses. Esophageal ligation-normal and EL-IUGR fetuses exhibited reduced protein levels and decreased staining for SGLT-1 in villus enterocytes. Conclusions: Amniotic fluid exclusion by in utero EL reduced fetal weight. Small intestinal proliferation was not affected by EL. Although SGLT-1 mRNA and protein were produced in all 4 groups, exposure of the fetal gastrointestinal tract to amniotic fluid appears necessary for proper brush border expression of nutrient transporter proteins.

Surgical Management of Colon Cancer

Surgery remains the primary treatment modality for colon cancer. Prior to surgery, all patients should be clinically staged with a total colon exam; computed tomography scanning of the chest, abdomen, and pelvis; and measurement of serum CEA level. The principles of surgical resection for colon cancer include four components. First, the colon and its mesentery should be resected along the planes to keep its fascia intact. Second, the primary vessel to the resected segment of the colon should be ligated at its origin. Third, a wide mesenteric resection should be performed to ensure a harvest of at least 12 lymph nodes. Finally, the tumor should be resected with at least a 5 cm distal or proximal margin. Resection of the primary tumor can be approached either open or laparoscopically. The Clinical Outcomes of Surgical Therapy Study Group (COST), Conventional versus Laparscopic-Assisted Surgery in Colorectal Cancer (CLASICC), and COlorectal cancer Laparoscopic or Open Resection (COLOR) trials demonstrated that the laparoscopic approach was not inferior to open resection of colon cancers. There are several technical approaches to resecting right- and left-sided cancers, which include medial to lateral, lateral to medial, posterior, or superior and medial to lateral and lateral to medial, respectively. The management of obstructing and perforated cancers presents unique challenges. Resection of obstructing cancers provides the most effective treatment of the primary tumor and the obstruction. Endoscopic stenting as a bridge to surgery is an effective option in selected patients. Perforated cancers can present as acutely with free spillage of feculent material or subacutely with contained contamination. In either case, the best cancer-related outcome is associated with an oncologic resection. Improvements in the chemotherapy regimens for metastatic colon cancer have greatly changed the management of these patients. Patients with metastatic disease and an asymptomatic primary tumor should receive chemotherapy as the first line of therapy. The rate of the primary tumor developing symptoms in this setting is quite low. For patients who present with bleeding or obstructive symptoms, surgical resection should be the first line of therapy. The long-term cancer-related outcomes for colon cancer are dependent upon the Tumor, Node, Metastatisis (TNM) stage of the tumor, the quality of the surgical resection, and when indicated the timely administration of adjuvant chemotherapy.

Lupus-associated vasculitis manifesting as acute appendicitis in a 16 year old girl

A 16 year old female with systemic lupus erythematosus presents with acute appendicitis. Final pathologic analysis of the appendix describes a lupus-associated vasculitis.

Breast cancer in patients with residual invasive carcinoma is more accurately staged with additive tumor size assessment

BackgroundAccurate assessment of tumor size for patients with breast cancer undergoing re-excision following breast-conserving therapy is important for appropriate staging and adjuvant treatment. We investigated the accuracy of additive vs. nonadditive size assessment in determining final tumor stage.MethodsPatients with infiltrating carcinoma in the initial excision and in at least one additional re-excision (re-excision positive; n=89) had tumor size assessed with additive and nonadditive techniques. This group was compared with patients undergoing re-excision but without identifiable residual carcinoma (re-excision negative; n=105) regarding rates of lymph node (LN) metastasis.ResultsThe re-excision positive patients had a different median final tumor size depending on the size assessment technique used (nonadditive: 1.8 cm; additive:3.0 cm;P<.0001). Both groups of patients had a median tumor size consistent with T1c staging in nonadditive size assessment. However, re-excision positive patients had a significantly higher incidence of LN metastasis (P<.05) than did re-excision negative patients. Both groups were then separated into T1 and T2 stages and the LN metastasis rates were assessed. Compared with nonadditive size assessment, additive size assessment distributed re-excision positive patients into T stages whereby the LN metastasis rates more closely approximated those of re-excision negative patients (T1, 3% vs. 6% difference; T2, 4% vs. 13% difference).ConclusionsWith regard to LN metastasis, staging for patients with residual invasive carcinoma in re-excision specimens is more accurate with additive tumor size assessment.