George M. Filippakis

Electrothermal bipolar vessel sealing system is a safe and time-saving alternative to classic suture ligation in total thyroidectomy.

Total thyroidectomy is associated with minimal morbidity. The electrothermal bipolar vessel sealing system is an adjunct to the surgical technique, recently made available to thyroid surgery.

Modified Radical Mastectomy With Axillary Dissection Using the Electrothermal Bipolar Vessel Sealing System

HYPOTHESIS The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN Prospective study. SETTING University surgical department. PATIENTS Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Breast ductal endoscopy: how many procedures qualify?

BackgroundBreast ductal endoscopy is a relatively new diagnostic method with ever growing importance in the work-up of patients with bloody nipple discharge. The ability to perform ductal endoscopy is very important and useful for breast fellows. Learning curve in breast ductal endoscopy remains a terra incognita, since no systematic studies have addressed this topic. The purpose of this study is to determine the point (number of procedures during training) beyond which ductal endoscopy is successfully performed.FindingsTen breast fellows received training in our Breast Unit. For the training process, an ex vivo model was adopted. Fellows were trained on 20 surgical specimens derived from modified radical mastectomy for breast cancer. The target of the education program was to acquire proficiency in performing ductoscopy. The achievement of four consecutively successful ductal endoscopies was determined as the point beyond which proficiency had been achieved. The number of procedures needed for the achievement of proficiency as defined above ranged between 9 and 17 procedures. The median value was 13 procedures; i.e. 50% of trainees had achieved proficiency at the 13th procedure or earlier.ConclusionThese pilot findings point to approximately 13 procedures as a point beyond which ductal endoscopy is successfully performed; studies on a larger number of fellows are nevertheless needed. Further research, focusing on the learning curves of different training models of ductal endoscopy, seems desirable.

Complete Endoscopic Axillary Lymph Node Dissection Without Liposuction for Breast Cancer: Initial Experience and Mid-term Outcome

Aim To present our initial experience with complete endoscopic axillary lymph node dissection (EALND) in 4 breast cancer patients with respect to feasibility, safety, and clinical outcome. Patients and Methods Between January 2003 and March 2004, 4 women consented to be treated with lumpectomy followed by complete (level I, II, and III) EALND without liposuction, at the Laparoendoscopic Unit of Athens Medical School. All 4 patients presented with a solitary breast cancer lesion smaller than 2 cm in diameter and a negative clinical and sonographic lymph node status (<1 cm). Results All the operations were completed endoscopically in less than 70 minutes (44 to 69 min). The axillary lymph node harvest ranged between 12 and 21 nodes. No lymphedema, motor nerve damage, seroma formation, or wound complications were observed. Prolonged hospitalization, owing to persistent lymphorrhoea was required for 1 patient. During a mean follow-up of 21.3 months, 2 patients reported mild hypoesthesia-paresthesia along the upper medial part of the respective arm, whereas no tumor recurrences were documented. Conclusions Although partial EALND has not been established as the treatment of choice for axillary management, complete EALND seems to be a feasible and effective minimally invasive treatment modality, which could be safely applied in patients with positive sentinel node biopsy, treated in specialized centers.

Breast conserving surgery with preservation of the nipple-areola complex as a feasible and safe approach in male breast cancer: a case report

IntroductionBreast cancer in men is rare. The evidence about treatment has been derived from data on the management of the disease in women. The usual treatment is for male patients to undergo modified radical mastectomy. There is insufficient experience of breast conserving surgery with preservation of the nipple. The management of patients who demand such an approach for personal reasons remains a challenge for both the surgeon and oncologist.Case presentationA 50-year-old man with a breast cancer was successfully managed with breast conserving surgery with nipple preservation combined with axillary clearance and postoperative radiotherapy, chemotherapy and hormone treatment. Since there are no similar cases in the literature, we discuss the feasibility, safety and possible indications of such an approach.ConclusionDespite the limited indications and evidence about the safety and efficacy of breast conserving surgery with nipple preservation in men with breast cancer, it is a feasible approach if other options are declined by the patient. More studies are necessary to reach firm conclusions about the safety of such an approach.

Downgrading BIRADS 3 to BIRADS 2 category using a computer-aided microcalcification analysis and risk assessment system for early breast cancer

This paper explores the potential of a computer-aided diagnosis system to discriminate the real benign microcalcifications among a specific subset of 109 patients with BIRADS 3 mammograms who had undergone biopsy, thus making it possible to downgrade them to BIRADS 2 category. The system detected and quantified critical features of microcalcifications and classified them on a risk percentage scale for malignancy. The system successfully detected all cancers. Nevertheless, it suggested biopsy for 11/15 atypical lesions. Finally, the system characterized as definitely benign (BIRADS 2) 29/88 benign lesions, previously assigned to BIRADS 3, and thus achieved a reduction of 33% in unnecessary biopsies.

Cyclin D1, p16INK4A and p27Kip1 in pancreatic adenocarcinoma: assessing prognostic implications through quantitative image analysis

The prognostic significance of cyclin D1, p16INK4A and p27Kip1 expression has been documented in several human malignancies; however, their prognostic potential in pancreatic adenocarcinoma is still unclear. This study aimed to assess the correlation of the aforementioned molecules with clinicopathological parameters and prognosis. Sixty patients with pancreatic ductal adenocarcinoma underwent surgical resection at a single institution; immunohistochemical staining of the studied markers was quantified by Ιmage analysis system. Cyclin D1 overexpression was positively associated with grade, neural infiltration and vascular invasion, whereas p27 positively correlated with age. Higher cyclin D1 expression indicated poorer survival (adjusted HR = 9.75, 95%CI: 1.48–64.31, p = 0.018, increment: one unit in H‐score), whereas a marginal trend toward an association between p16 positivity and improved survival was observed (adjusted HR = 0.58, 95%CI: 0.32–1.05, p = 0.072 regarding positive vs negative cases). No significant association with overall survival was noted regarding p27. In conclusion, cyclin D1 overexpression and possibly p16 loss of expression in pancreatic adenocarcinoma seem to be adverse prognostic factors, whereas p27 expression did not seem to possess such prognostic properties. Further validation of the present findings in studies encompassing larger samples seems to be needed.

Synchronous Bilateral Breast Cancer with Different Biological Profile and Estrogen-Progesterone Receptor Status

To the Editor: Bilateral breast cancer (biBC) is not an uncommon clinical problem, but still today many biological and treatment issues are yet to be clarified. Numerous papers in the international literature have described the many controversial issues concerning the disease, such as the true incidence, the risk factors, the dissimilarity in histological and immunohistological characteristics, the differences in biologic profile and estrogen-progesterone receptor status, the means of diagnosis, the various treatment modalities, and the prognosis of the disease. However, because of the differences in the approach, methodology and results of these reports, biBC still remains a controversial disease. Risk factors for biBC include personal history of breast cancer, age at diagnosis, family history, multicentricity of the first tumor, histological type, and whether or not the patient received adjuvant treatment. Patients with breast cancer have an increased risk of developing a synchronous or metachronous second breast cancer. The incidence of synchronous biBC is relatively low and ranges in most reports between 1 and 2.6%, whereas that of metachronous is somewhat higher ranging from 1 to 23%. Certain authors report that the incidence of bilateral cancer among the patients already treated for breast cancer is about 1% for every year of follow-up. Women already diagnosed with primary breast cancer have a twoto sixfold possibility of developing cancer in the contra lateral breast in relation to the general population. Age is also an important risk factor and younger breast cancer patients (with diagnosis of breast cancer before the age of 50) have a 10to 14-fold incidence rate of biBC. Recent studies have demonstrated that women with diagnosed breast cancer between the ages of 30 and 39 have a 15to 25-fold risk of developing contra lateral breast carcinoma, women between 40 and 49 have a 5-fold risk and those between 50 and 59 have a 2.5-fold risk. The relative risk for biBC in women above 60 years of age is almost similar with the general population. There are studies that demonstrate an increase relative risk (up to 3-fold) for biBC among breast cancer patients with significant family history of the disease. Other factors include multicentricity of the first tumor (threeto fourfold relative risk), the histological type of the first tumor (increased relative risk in lobular carcinoma in situ, invasive lobular carcinomas, and in low grade invasive ductal carcinomas), the stage of the tumor and adjuvant treatment for the initial breast carcinoma. A 54-year-old perimenopausal Caucasian woman was admitted in our hospital with diagnosis of right lower lobe pneumonia. Extensive clinical examination revealed bilateral suspicious (S4) palpable lumps. Soon after initial recovery from the respiratory infection, the patient was referred to our Breast Unit and had mammographic evaluation of the lesions that showed suspicious lumps with micro calcifications (grade BiRad 5) on the lower outer quadrant of both breasts (mirror image). Fine needle aspiration cytology and core biopsy were performed and the pathology report was positive for invasive ductal carcinoma for both tumors, establishing the diagnosis of synchronous biBC. Bilateral modified radical mastectomy with axillary dissection was undertaken 4 weeks later. In the left breast, the tumor measured 3.5 · 4.5 · 1.5 cm and there were two, among 22, axillary lymph nodes positive for metastases. In the right breast, the tumor measured 3.5 · 2.5 · 2 cm and the 19 lymph nodes dissected from the axilla were free of metastases. Hormonal receptor status and molecular markers were assessed for both tumors. The left breast tumor was negative (0%) for estrogen receptors but strongly positive for progesterone receptors (90–100%), whereas the right breast tumor was strongly positive Address correspondence and reprint requests to: George M. Filippakis, MD, PhD, Hippocration General Hospital, A’ Propaedeutic Surgical Department, 115 Vass.Sofias Ave., Abelokoipoi, P.C.:11526, Athens, Greece, or e-mail: gfilipp@hotmail.com.