J S Mitnick

Complications of Level I and II Axillary Dissection in the Treatment of Carcinoma of the Breast

OBJECTIVE To assess the complications of level I and II axillary lymph node dissection in the treatment of stage I and II breast cancer, with breast-conservation surgery and mastectomy. SUMMARY BACKGROUND DATA The role of axillary dissection for staging, and as an effective means of controlling regional nodal disease, has long been recognized. As small and low-grade lesions have been detected more frequently, and as its therapeutic impact has been questioned, axillary dissection has increasingly been perceived as associated with significant complications. METHODS Two hundred patients, 112 of whom had breast-conservation surgery with axillary dissection and 88 of whom had total mastectomy with axillary dissection, were evaluated 1 year or more after surgery for arm swelling as well as nonedema complications. All patients had arm circumference measurements at the same four sites on both the operated and nonoperated sides. RESULTS No patient had an axillary recurrence. The mean difference in circumference on the nonoperated versus operated side was 0.425 cm +/- 1.39 at the midbiceps (p < 0.001), 0.315 cm +/- 1.27 at the antecubital fossa (p < 0.001), 0.355 cm +/- 1.53 at the midforearm (p < 0.005), and 0.055 cm +/- 0.75 at the wrist (n.s.). Seven patients (3.5%) had mild swelling of the hand. Heavy and obese body habitus were the only significant predictors of edema on multivariate analysis. One hundred fifty-three (76.5%) patients had numbness or paresthesias of the medial arm and/or axilla after surgery; in 125 (82%) of these, the problem had lessened or had resolved on follow-up assessment. CONCLUSIONS The characterization of a level I and II axillary dissection as a procedure with significant complications does not appear justified based on this experience.

Metastatic neoplasm to the kidney studied by computed tomography and sonography.

Surgicalue to the widespread use of CT for tumor staging and diagnostic workup, the discovery of metastatic neoplasm to the kidney has become a more frequent occurrence. Nine patients with metastatic carcinoma to the kidney have been studied by CT, including six by sonography. Carcinoma of the lung was the primary tumor in eight. Bilateral renal involvement was seen in all cases. The presentation of the clinical and radiologic findings in these cases with differential diagnosis is included.

Stereotactic fine-needle aspiration biopsy for the evaluation of nonpalpable breast lesions: Report of an experience based on 2,988 cases

AbstractBackground: The increasing use of mammography has led to a significant increase in the detection of clinically occult lesions, the majority of which prove to be benign. SFNB has been suggested as a means of expediting a diagnosis for lesions that are malignant while limiting surgical biopsies for those that are benign. Methods: Clinically occult mammographic lesions were assessed by SFNB in 2,988 patients. Definitive histologic diagnoses were made on surgical specimens in all instances in which the cytologic diagnosis was malignant, suspicious, or atypical. Patients with benign cytology were either followed with interval mammograms or underwent surgical biopsy. Results: Two hundred ninety-one of the 295 lesions (99%) diagnosed as cancer via SFNB were confirmed by histopathology. Twenty-two of the 22 lesions (100%) that were diagnosed as suspicious were diagnosed on histopathology as malignant. Forty-three of the 70 lesions (61%) with cytologic atypia were diagnosed on histopathology to be malignant. Conclusions: SFNB is an accurate means of diagnosing carcinoma, but must be followed by surgical biopsy when the cytology shows atypia. For lesions diagnosed as benign by SFNB, close interval mammography is essential.

The contribution of computed tomography to the evaluation of the obstructed ureter

Computed tomography (CT) has been found to make a valuable contribution to the diagnosis of the etiology of ureteral obstruction when routine urography and pyelography have not been diagnostic. We believe CT can replace more invasive techniques such as antegrade pyelography and even retrograde pyelography in the evaluation of many of these cases. This presentation will summarize our experience with the use of CT to evaluate the etiology of ureteral obstruction, indicate those disease processes likely to be encountered, emphasize the limitations of the technique, and indicate the place CT has in the study of these patients.

Tubular Carcinoma of the Breast: Immunohistochemical and DNA Flow Cytometric Profile

▪ Abstract: Molecular markers of ordinary invasive ductal carcinoma of the breast have been extensively studied and their prognostic significance has been assessed. A common variant of breast cancer, tubular carcinoma, has an excellent prognosis as judged from several clinicopathologic studies. One would assume that tubular carcinomas have “favorable” molecular markers, however, published series of tubular carcinomas do not include molecular markers. We describe the molecular markers of 39 consecutive tubular carcinomas collected between January 1995 and July 1997. DNA ploidy, S‐phase, estrogen and progesterone receptor (ER and PR, respectively) expression, and immunoreactivity for MIB‐1, p53, and erbB2 were evaluated. Seventy‐two percent of tubular carcinomas were DNA diploid, 49% had an S‐phase less than 5%, 95% were ER positive, 69% were PR positive, 88% had less than 10% MIB‐1‐positive cells, 97% were p53 negative, and 97% did not overexpress erbB2 protein. Thus tubular carcinomas exhibit favorable molecular characteristics, which may play a role in their good prognosis. ▪

Numerical abnormalities of chromosomes 7, 18, and X in precancerous breast disease defined by fluorescent in situ hybridization

Abstract: Nonrandom numerical chromosomal abnormalities (NCA) are frequent in invasive breast cancer, but little is known about such changes in microscopic precursor lesions. Mammographically detected “suspicious” breast lesions were localized by specimen radiology of sliced breast tissue. The slices containing the lesion were imprinted onto coated slides by gentle scraping. The corresponding hematoxylin and eosin stained histologic sections and Diff‐Quik stained imprints were used for classification as ductal hyperplasia (DH), atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS). Additional slide imprints were evaluated for copy number of chromosomes 7, 18, and X by using fluorescent in situ hybridization with alpha satellite probes. NCA were detected in 1 of 9 (11%) cases of DH, in 2 of 8 (25%) cases of ADH, and in 14 of 16 (87%) cases of DCIS. There was selective loss (chromosome 18) in one case of DCIS; all other cases with NCA had a gain of at least one chromosome. There is a progressive increase in incidence of NCA in DH, ADH and DCIS. The majority of NCA are chromosomal gains.

Stereotactic localization for fine needle aspiration biopsy in patients with augmentation prostheses.

Fifteen patients with augmentation mammoplasties had mammography demonstrating nonpalpable breast lesions. Of the 15 patients, three (20%) had adenocarcinoma confirmed by open biopsy and histopathology. All patients underwent stereotactic localization for fine needle aspiration biopsy. Four of the 15 patients had benign cysts (26%). None of the cysts could be diagnosed by ultrasound. The remaining eight patients had mammary dysplasia of a proliferative or nonproliferative type of fibroadenoma. These benign entities were followed with interval mammography demonstrating no change. The data suggest that fine needle aspiration biopsy is an effective technique to assess nonpalpable breast lesions in patients who have had augmentation mammoplasties.Mitnick JS, Vazquez MF, Roses DF, Harris MN, Colen SR, Colen HS: Stereotactic localization for fine needle aspiration biopsy in patients with augmentation prostheses. Ann Plast Surg 1992;29:31–35

Fine needle aspiration biopsy in patients with augmentation prostheses and a palpable mass.

Six patients with augmentation prostheses presented with a firm, painless, breast mass that could not be visualized by mammography. One lesion was demonstrated to be solid by ultrasound, and the remaining sonograms were nondiagnostic. The lesions were indistinguishable from carcinoma, by physical examination. All of the patients had fine needle aspiration biopsy despite close proximity to the implant. The patients all had silicone granulomas related to silicone leakage. Our experience suggests that fine needle aspiration biopsy is a useful technique to evaluate palpable breast masses that are not visualized by mammography in patients with augmentation prostheses.

Two cases of spontaneous ureteral rupture secondary to outlet obstruction.

Two patients with outlet obstruction and spontaneous extravasation of contrast material from their ureters during an intravenous urogram (IVU) are reported. Both cases are unusual in that spontaneous ureteral extravasation is rare and usually occurs with calculus disease. These patients had no evidence of calculi; therefore, the increased intraluminal pressure alone appears to have caused ureteral rupture.

Hydrometrocolpos and polydactyly

Two cases of hydrometrocolpos and polydactyly in female infants with persistent urogenital sinus are reported. The importance of considering hydrometrocolpos as the cause of an abdominal mass in female infants with polydactyly is stressed. Cytologic examination of the vaginal fluid may help in early diagnosis.