Eric R. Frykberg

Lobular Carcinoma In Situ of the Breast

▪ Abstract: LCIS was first described in 1941 as a distinct pathologic entity by Foote and Stewart who called it a “rare form of mammary carcinoma.” It is thought to represent a transitional intra‐epithelial, or in situ, stage in the evolution of breast cancer from hyperplastic breast epithelium. With the wide application of mammography, its detection has increased in recent years, being found in approximately 1% of all breast biopsy specimens and 5% of all breast malignancies. Its true incidence is unknown, because the absence of any clinical or radiographic manifestations makes its detection completely arbitrary and random. LCIS has distinct pathologic features characterized by proliferation of bland, homogeneous malignant cells within the terminal duct–lobular apparatus. The lobular architecture and investing basement membrane remain intact with no evidence of invasion into the surrounding stoma. It is assumed to be widely disseminated throughout all breast tissue whenever it is found, having close to 100% incidence of multicentricity and bilaterality. The cells are typically of low histologic and nuclear grade, highly estrogen receptor positive, and have tumor marker characteristics of indolent growth and good prognosis. This is very different from its noninvasive ductal counterpart, DCIS, which is typified by more aggressive cytologic and biologic characteristics. Although LCIS imparts as much as a 12‐fold increased risk of subsequent invasive breast carcinoma, its natural history suggests it is more of a marker of risk rather than a true premalignant lesion. Most subsequent malignancies occur more than 15 years after diagnosis, and are ductal rather than lobular. This risk is also equally applied to both breasts, regardless of which breast contains the diagnosed focus. Subsequent invasive breast cancers are typically early with very low mortality, most likely due to the strict mammographic surveillance provided to these women. Although originally treated by mastectomy, most now manage LCIS by careful non‐operative observation, in the same way that other risk factors such as family history or atypical hyperplasia are managed. In fact, it has been questioned whether there should be any real distinction between lobular hyperplasia and LCIS. There is no role for excision of biopsy sites of LCIS to obtain clear margins, nor for cytotoxic chemotherapy. However, the NSABP P‐1 Prevention Trial strongly suggests that subsequent risk can be significantly reduced by tamoxifen. The only rational surgical treatment, if ablation is judged necessary, would be bilateral mastectomy, which appears far too aggressive in view of its low overall risks. Further investigation should clarify the optimal management of LCIS. ▪

Prospective evaluation of radiologically directed fine‐needle aspiration biopsy of nonpalpable breast lesions

The application of fine‐needle aspiration biopsy (FNAB) to the diagnosis of nonpalpable breast lesions was evaluated with a new method which uses standard needle localization under mammographic guidance to assure accurate sampling by FNAB. This method was prospectively applied to 100 mammographically detected breast lesions in 100 women (mean age, 53 years). All 100 patients underwent surgical excision of these nonpalpable lesions after cytologic aspiration. Sufficient aspirated material was obtained for cytologic diagnosis from 91 patients (91%). The histologic and cytologic interpretations were then compared. Twenty malignancies were ultimately diagnosed by histology (12 invasive ductal carcinoma, six ductal carcinoma in situ, and two lobular carcinoma in situ), of which 17 had been cytologically diagnosed. There were no false‐positive diagnoses of malignancy by FNAB. False‐negative readings (3.3%) included two cases of lobular carcinoma in situ and one case of ductal carcinoma in situ. This technique thus demonstrated a sensitivity of 85%, specificity of 100%, and overall diagnostic accuracy of 96.7% for the nonsurgical detection of malignancy in nonpalpable breast lesions. These results suggest that the established safety, reliability, and cost‐effectiveness of FNAB can be maintained in this clinical setting. This procedure may obviate the need for open surgical biopsy in those patients with an unequivocal diagnosis of malignancy. It can also be done using standard techniques and equipment available in many community hospitals.

COLOR: A Randomized Clinical Trial Comparing Laparoscopic and Open Resection for Colon Cancer

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within <2 years, more than 540 patients have been randomized for right hemicolectomy (45%), left hemicolectomy (10%) and sigmoidectomy (45%). 33 patients (6%) were excluded after randomization. The accrual rate is approximately 25 patients/month. Current survival rates for the whole study group are: stage I: 95%, stage II: 98%, stage III: 93%, stage IV: 64%. For all patients with stage I disease, the mortality was not cancer related. Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

New perspectives on the management of penetrating trauma in proximity to major limb arteries

Current management of penetrating injuries in the proximity of major extremity arteries with no evidence of vascular trauma remains controversial. A total of 318 such injuries in 254 patients were evaluated prospectively to clarify the appropriate timing and role of arteriography, as well as the natural history of these injuries. The arteries at risk were: axillary, 47; brachial, 57; superficial femoral, 176; and popliteal, 38. No deaths occurred, and no morbidity resulted from arteriographic delay of 6 to 24 hours after injury. Of the 48 arteriographic abnormalities detected, 16 involved noncritical branch vessels. There were 32 injuries to major arteries (10.0%), including localized narrowing (n = 13), intimal flap (n = 12), false aneurysm (n = 6), and arteriovenous fistula (n = 1). Shotgun wounds led to a greater arterial injury rate (3/17; 17.6%) than did gunshot wounds (24/247; 9.7%) or stab wounds (5/54; 9.3%). At the surgeons discretion, three injuries underwent immediate exploration (one negative), whereas the remaining 29 vessel injuries were followed up nonoperatively by repeat arteriography (n = 22) or clinical examination (n = 7), for a mean interval of 2.8 months. Fifteen abnormalities resolved, 10 improved or remained unchanged, and 4 worsened. The four lesions (13.7%) that worsened (two shotgun and two axillary artery injuries) were identified within 3 months of injury and repaired surgically with no morbidity. In conclusion, only 6 operations were required out of 3218 potential injuries (1.8%), suggesting that routine arteriography is not a cost-effective means of evaluating these injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Advances in the Diagnosis and Treatment of Extremity Vascular Trauma

Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The still evolving trend in management of these injuries is toward more rapid, less costly, and less invasive diagnostic modalities, an improved understanding of the therapeutic implications of the clinical presentation, prompt repair of significant vascular injuries, and a liberal use of adjunctive techniques such as fasciotomy. Many issues remain to be resolved by further experience and investigation, in order to achieve optimal limb salvage in this setting.

Redefining the Role of Arterial Imaging in the Management of Penetrating Zone 3 Neck Injuries

The purpose of this study was to assess the role of arteriography (AG) in the diagnosis and treatment of vascular trauma in patients with zone 3 penetrating neck injuries. The records of all cases of penetrating neck trauma for the past 14 years at a level 1 trauma center were reviewed retrospectively. Eight hundred forty-four penetrating neck injuries were documented, of which 72 (8.5%) traversed zone 3 of the neck (gunshot, 35; stab, 32; shotgun, 5). Twenty patients (27%) had hard signs of vascular injury (hemorrhage, expanding hematoma, bruit, thrill, neurologic deficit). Twelve of these (60%) underwent immediate exploration, 1 had no significant injury, and 11 had successful surgical repair or ligation of the vascular injury. AG in the other eight patients with hard signs revealed injuries requiring embolization (three patients), urokinase infusion (one patient), and observation (three patients) and one normal examination. Fifty-two patients had no hard signs of vascular injury. Twenty-four of these underwent AG, of which 18 were negative. Positive findings included internal carotid artery narrowings (two patients), external compression of the internal carotid artery (one patient), vertebral artery intimal flap (one patient), and nonbleeding injuries to small, noncritical arteries (two patients), none of which required treatment. Twenty-four of the remaining 28 patients were observed clinically, and 4 patients had negative explorations. Nine patients had ultrasonography performed, but these examinations did not yield any useful information. The absence of hard signs reliably excludes surgically significant vascular injuries in penetrating zone 3 neck trauma, suggesting that AG is not necessary. Hard signs in stable patients should mandate AG because these vascular injuries may be amenable to endovascular therapy.

The impact of selective laboratory evaluation on utilization of laboratory resources and patient care in a level-i trauma center

BACKGROUND Routine laboratory evaluation of preoperative patients has not been shown to be cost effective when a detailed history and physical examination are performed. However, since such a detailed history is not possible in trauma patients, the time-honored approach has been for laboratory evaluation to be protocol driven. The cost-benefit ratio of this practice has never been evaluated. METHODS Trauma patients who underwent routine laboratory evaluation (n = 552; group I) were compared with patients who had laboratory evaluation based on clinical need (n = 603; group II). A concurrent review of each case in group II was conducted every day while a retrospective review of charts was conducted for patients in group I to determine patient care issues and identify abnormal trauma center test results. RESULTS The number of patients with laboratory tests decreased from 97% in group I to 27% in group II (P < 0.0001). Positive chemistry profiles increased (55% versus 92%; P < 0.0001) as did coagulation profiles (8% versus 33%; P < 0.0001). There were no differences in the percentage of patients receiving intervention based on laboratory data (7% in group I versus 8% in group II). No adverse effect on patient care was identified as a result of absent laboratory information in group II. Mortality, length of stay, and intensive care unit days were statistically unchanged. There was an annualized savings of

Owen H. Wangensteen, MD, PhD

1.5 million in billed trauma center laboratory charges in group II. CONCLUSION Selective laboratory evaluation of trauma patients can greatly reduce medical cost and does not adversely affect care.

Contents Vol. 17, 2000

The legacy of Owen Harding Wangensteen in the field of surgery has been unsurpassed. Called, ‘The Chief’ by his colleagues, he was the Professor and Chairman of the Department of Surgery at the University of Minnesota for 37 years. His vision, dedication as a surgeon, imagination and instillation of interest in the students of surgery as well as the originality and abundance of his scientific research, have placed him high in the ranks of the great surgeons of the 20th century.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases.

421 Postgraduate Course: Common Laparoscopic Procedures from Revolution to Standard of Care Chairpersons: Hunter, J. (USA); Lacy, A. (Spain) Ongoing Clinical Trials Section Editor: S. Galandiuk, MD, Louisville 427 Oncology 431 Inflammatory Bowel Disease 431 Surgical Infection/Sepsis 433 Miscellaneous 435 Questionnaire for Trial Submission 437 EDS News 438 Announcement Review 439 Human Islet Autotransplantation to Prevent Diabetes after Pancreas Resection White, S.A.; Robertson, G.S.M.; London, N.J.M.; Dennison, A.R. (Leicester)