Julie A. Miller

Risk Factors for Invasive Breast Cancer When Core Needle Biopsy Shows Ductal Carcinoma In Situ

HYPOTHESIS A core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) may be associated with a final diagnosis of invasive cancer. Preoperative radiologic, clinical, and pathological features may identify patients at high risk of diagnostic upstaging, who may be appropriate candidates for sentinel node biopsy at initial surgery. DESIGN Review of prospectively collected database. SETTING Tertiary teaching referral hospital and a population-based breast screening center. PATIENTS Consecutive patients from January 1, 1994, to December 31, 2006, whose CNB findings showed DCIS or DCIS with microinvasion. MAIN OUTCOME MEASURES Upstaging to invasive cancer. RESULTS Eleven of 15 cases of DCIS with microinvasion (73.3%) and 65 of 375 cases of DCIS (17.3%) were upstaged to invasive cancer. Ten of 21 palpable lesions (47.6%) were found to have microinvasion. For impalpable DCIS, multivariate analysis showed that noncalcific mammographic features (mass, architectural distortion, or nonspecific density) (odds ratio [95% confidence interval], 2.00 [1.02-3.94]), mammographic size of 20 mm or greater (2.80 [1.46-5.38]), and prolonged screening interval of 3 years or longer (4.41 [1.60-12.13]) were associated with upstaging. The DCIS grade on CNB was significant on univariate analysis (P = .04). The rate of upstaging increased with the number of significant factors present in a patient: 8.3% in patients with no risk factors, 20.8% in those with 1 risk factor, 39.6% in those with 2 risk factors, and 57.1% in those with 3 risk factors. CONCLUSIONS The risk of upstaging can be estimated by using preoperative features in patients with DCIS on CNB. We propose a management algorithm that includes sentinel node biopsy for patients with DCIS who have microinvasion on CNB, palpable DCIS, 2 or more predictive factors, and planned total mastectomy.

Use of breast cancer screening and treatment services by Australian women aged 25–44 years following Kylie Minogue's breast cancer diagnosis

OBJECTIVE To examine the effects of the publicity surrounding Kylie Minogues diagnosis with breast cancer on doctor-referred breast imaging, image-guided biopsy, and cancer excisions among a low-risk population of women in Australia. Method We examine changes in unilateral and bilateral breast imaging, image-guided breast biopsies, and surgical excisions of breast cancer before and after the announcement of Kylie Minogues diagnosis with breast cancer in May 2005. The study included procedures provided through the Australian public health system to women aged 25-44 years from October 2004 and June 2006. RESULTS The odds of women aged 25-44 years undergoing imaging procedures increased by 20% in the first and second quarters after the Minogue publicity, compared to the preceding two quarters. The volume of biopsies als increased but the biopsy rate, measured as a proportion of imaging procedures, did not change among women aged 25-34 years and decreased among women aged 35-44 years. The volume of operations to excise breast cancers did not change for either age group. Compared to the 6 month period before the publicity, there was a large and significant decrease in the odds that an excision would follow biopsy (25-34 years: OR 95% CI=0.69, 0.48-0.98; 35-44 years: OR 95% CI=0.83, 0.72-0.95). CONCLUSIONS High-publicised illnesses may affect both consumer and provider behaviour. Although they present opportunities to improve public health, they also have the potential to adversely impact the appropriateness and cost-effectiveness of service delivery.

Secondary Causes of Low Bone Mass in Patients With Breast Cancer: A Need for Greater Vigilance

PURPOSE An observational study to assess the prevalence of secondary causes of low bone density in patients with breast cancer. PATIENTS AND METHODS Female patients within 5 years of breast cancer diagnosis and age older than 50 years at diagnosis were recruited. Consenting patients completed a questionnaire and had blood taken for serum calcium, vitamin D, parathyroid hormone (PTH), and thyroid function testing. Bone mineral density (BMD) was assessed. Abnormalities were additionally investigated and treated. RESULTS Two hundred patients were recruited. The median age at diagnosis was 62 years. One hundred sixty-nine patients had hormone receptor (HR) -positive cancer. Vitamin D and thyroid function were assessed in 200 patients; PTH was assessed in 197 patients; and BMD was assessed in 187 patients. Eighty-seven patients (46.5%) had osteopenia, and 24 patients (12.8%) had osteoporosis. Vitamin D levels were insufficient (ie, 50 to 75 nmol/L) in 74 patients (37%) and were deficient (ie, < 50 nmol/L) in 54 patients (27%). Only 24 of 65 patients taking vitamin D supplements were replete (ie, > 75 nmol/L). Thirty-nine (21%) of 197 patients had PTH concentrations greater than the normal range. Six had primary hyperparathyroidism (PHPT), and two more had recent surgery for PHPT. Twenty-seven had secondary hyperparathyroidism (HPT) from vitamin D deficiency and six had normocalcemic HPT. Of 90 patients with low BMD and HR-positive cancer, 8% (seven of 90 patients) had new or recent PHPT, and 63% (57 of 90 patients) had insufficient or deficient vitamin D. More patients with HR-positive cancer than with HR-negative cancer had elevated PTH (38 of 167 v three of 30 patients, respectively; P = .10). CONCLUSION Secondary causes of low BMD are common in postmenopausal women. Identification and management of secondary causes should be included in bone health management algorithms.

Safe introduction of a new surgical technique: remote telementoring for posterior retroperitoneoscopic adrenalectomy

Posterior retroperitoneoscopic adrenalectomy (PRA) is a safe and effective approach to adrenalectomy, offering less pain and faster recovery than open or laparoscopic surgery. Although the popularity of PRA is increasing, few surgical centres have extensive experience with the procedure. The ideal approach to achieve proficiency with any new technique involves on‐site observation of an experienced surgeon‐mentor, followed by mentored hands‐on experience of the surgeon‐learner. However, it is not always feasible for a surgeon‐mentor to offer on‐site supervision to the surgeon‐learner in his or her home institution. Advances in Internet applications have made remote telementoring a viable alternative to on‐site mentoring in selected situations.

Small ruptured abdominal aneurysm diagnosed by emergency physician ultrasound.

Ruptured abdominal aortic aneurysms currently have a high rate of both mortality and misdiagnosis. Aneurysms smaller than 4 cm are not commonly considered for surgical repair. This report describes the case of a ruptured abdominal aneurysm measuring less than 4 cm diagnosed by the emergency physician utilizing bedside ultrasound. Within 30 minutes of arrival at the emergency department the patients abdominal pain resolved spontaneously after defecation. If the bedside ultrasound had not been performed it is possible the patient would have been discharged from the hospital without surgical intervention. Bedside ultrasound by emergency physicians may improve the diagnosis of ruptured aortic aneurysms, particularly if the presentation is atypical.

Comparison of outcomes after laparoscopic versus posterior retroperitoneoscopic adrenalectomy: a pilot study.

Background:Posterior retroperitoneoscopic adrenalectomy (PRA) was popularized by Walz and colleagues as an alternative approach to minimally invasive adrenalectomy, offering less postoperative pain and faster return to normal activity compared with laparoscopic transperitoneal adrenalectomy (LA). The authors have recently changed from LA to PRA in suitable patients and audited their outcomes. Methods:Data were prospectively collected for 10 patients who underwent PRA, and a chart review and telephone interviews were conducted with 13 consecutive patients who underwent LA by the same surgeon. Patient demographics, tumor characteristics, analgesia use, operative and anesthetic time, length of stay, and complications were recorded. Results:Data were collected for 13 LAs and 10 PRAs. Patients’ baseline characteristics, including age, BMI, and tumor size, were similar between the 2 groups. There were no conversions to open surgery, transfusions, or deaths. Operative time was similar between the 2 groups. PRA patients required less, inpatient postoperative opioid analgesia compared with LA patients (median 1.25 vs. 23 mg of intravenous morphine equivalent, P=0.003), and had a shorter length of stay (median 1 vs. 2 d, P<0.001). The median total days on opioids were lower for PRA patients compared with LA patients (0.5 vs. 9 d, P<0.001). Conclusion:Our initial results supports previously published findings that PRA is a safe procedure, with a relatively short learning curve, resulting in reduced postoperative analgesia use, and reduced length of hospital stay when compared with the laparoscopic transperitoneal approach.

Posterior retroperitoneoscopic adrenalectomy: outcomes and lessons learned from initial 50 cases

Posterior retroperitoneoscopic adrenalectomy (PRA) is an alternative approach to minimally invasive adrenalectomy, potentially offering less pain and faster recovery compared with laparoscopic transperitoneal adrenalectomy (LA). The authors have recently changed from LA to PRA in suitable patients and audited their first 50 cases.

Penetrating liver injury managed with a combination of balloon tamponade and venous stenting. A case report and literature review.

AAST-OIS grade V complex hepatic injuries are often fatal as a result of exsanguination. We report a patient presenting in extremis with a penetrating injury to the right kidney, liver, middle hepatic vein, diaphragm, and lung. A combination of intrahepatic balloon tamponade and hepatic venous stenting was used to control exsanguinating haemorrhage, the first time this combination has been reported. Rapid assessment and treatment and a team approach, together with the innovative application of haemostatic techniques, allowed a multidisciplinary team to salvage this patient.

Cousins not twins: Intratumoural and intertumoural heterogeneity in syndromic neuroendocrine tumours

Hereditary endocrine neoplasias, including phaeochromocytoma/paraganglioma and medullary thyroid cancer, are caused by autosomal dominant mutations in several familial cancer genes. A common feature of these diseases is the presentation of multiple primary tumours, or multifocal disease representing independent tumour clones that have arisen from the same initiating genetic lesion, but have undergone independent clonal evolution. Such tumours provide an opportunity to discover common cooperative changes required for tumourigenesis, while controlling for the genetic background of the individual. We performed genomic analysis of synchronous and metachronous tumours from five patients bearing germline mutations in the genes SDHB, RET, and MAX. Using whole exome sequencing and high‐density single‐nucleotide polymorphism arrays, we analysed two to four primary tumours from each patient. We also applied multi‐region sampling, to assess intratumoural heterogeneity and clonal evolution, in two cases involving paraganglioma and medullary thyroid cancer, respectively. Heterogeneous patterns of genomic change existed between synchronous or metachronous tumours, with evidence of branching evolution. We observed striking examples of evolutionary convergence involving the same rare somatic copy‐number events in synchronous primary phaeochromocytoma/paraganglioma. Convergent events also occurred during clonal evolution of metastatic medullary thyroid cancer. These observations suggest that genetic or epigenetic changes acquired early within precursor cells, or pre‐existing within the genetic background of the individual, create contingencies that determine the evolutionary trajectory of the tumour. Copyright

Cousins not twins: intra and inter-tumoral heterogeneity in syndromic neuroendocrine tumours

Hereditary endocrine neoplasias, including phaeochromocytoma/paraganglioma and medullary thyroid cancer, are caused by autosomal dominant mutations in several familial cancer genes. A common feature of these diseases is the presentation of multiple primary tumours, or multifocal disease representing independent tumour clones that have arisen from the same initiating genetic lesion, but have undergone independent clonal evolution. Such tumours provide an opportunity to discover common cooperative changes required for tumourigenesis, while controlling for the genetic background of the individual. We performed genomic analysis of synchronous and metachronous tumours from five patients bearing germline mutations in the genes SDHB, RET, and MAX. Using whole exome sequencing and high‐density single‐nucleotide polymorphism arrays, we analysed two to four primary tumours from each patient. We also applied multi‐region sampling, to assess intratumoural heterogeneity and clonal evolution, in two cases involving paraganglioma and medullary thyroid cancer, respectively. Heterogeneous patterns of genomic change existed between synchronous or metachronous tumours, with evidence of branching evolution. We observed striking examples of evolutionary convergence involving the same rare somatic copy‐number events in synchronous primary phaeochromocytoma/paraganglioma. Convergent events also occurred during clonal evolution of metastatic medullary thyroid cancer. These observations suggest that genetic or epigenetic changes acquired early within precursor cells, or pre‐existing within the genetic background of the individual, create contingencies that determine the evolutionary trajectory of the tumour. Copyright