Marko Buta

Intraductal papilloma of ectopic breast tissue in axillary lymph node of a patient with a previous intraductal papilloma of ipsilateral breast: a case report and review of the literature

The presence of ectopic breast tissue in axillary lymph nodes (ALN) is a benign condition that must be differentiated from primary or metastatic carcinoma. Here we report a patient who underwent excision of enlarged ALN 10 years after she had received surgical treatment of ipsilateral breast for an intracystic intraductal papilloma (IDP). Histological examination of the removed ALN revealed that the proliferative lesion consisted of papillary and tubular structures lined by luminal cuboidal cells and a distinct outer layer of myoepithelial cells resembling IDP of the breast. Immunostaining with a set of immunohistochemical markers including AE/AE3, alpha-smooth muscle actin and p63 in combination with estrogen and progesterone receptors confirmed the diagnosis of ectopic IDP.This case shows that even though benign proliferative change in ectopic breast tissue is an extremely rare phenomenon, this possibility should be taken into account for correct diagnosis.

Overexpression of Calreticulin in Malignant and Benign Breast Tumors: Relationship with Humoral Immunity

Objective: Calreticulin is a multicompartmental protein which regulates many important cellular responses. The aim of this study was to elucidate whether the intensity and location of calreticulin overexpression in tumor cells are related to the elevated humoral immunity to calreticulin in patients with benign or malignant breast disease. Methods: This study involved 27 patients with benign and 58 patients with malignant breast tumors before surgical resection and 38 healthy volunteers. Cytoplasmatic or membranous calreticulin overexpression in malignant or benign cells in paraffin-embedded tissues was determined using immunohistochemistry. Levels of the serum anti-calreticulin autoantibodies were detected by ELISA. Results: Statistically significant differences between serum levels of IgA of anti-calreticulin antibodies in controls and patients with breast tumors, and between controls and patients with nonmalignant breast diseases were found, but no statistically significant differences were found between levels of serum IgG anti-calreticulin antibodies. Humoral immunity to calreticulin developed against cytoplasmatic and co-localized membranous calreticulin was not correlated to the intensity of its overexpression and was present even in the absence of its membranous localization. Conclusions: The degree of calreticulin overexpression in lobular breast carcinoma is lower than in ductal breast carcinoma. Elevated concentrations of anti-calreticulin IgA antibodies were present more frequently in patients with metastasis in locoregional lymph nodes in comparison to anti-calreticulin IgG antibodies.

Trefoil factor 1 in early breast carcinoma: a potential indicator of clinical outcome during the first 3 years of follow-up.

Background. A role of an estrogen-regulated, autocrine motogenic factor was assumed to be a major biological role of trefoil factor 1 (TFF1) in breast cancer. TFF1 is regarded as a predictive factor for positive response to endocrine therapy in breast cancer patients. The aim of our study was to examine TFF1 level distribution in breast carcinomas in order to distinguish estrogen-independent from estrogen-dependent TFF1 expression and to evaluate clinical usefulness of TFF1 status in early breast cancer during the first 3 years of follow-up. Methods. The study included 226 patients with primary operable invasive early breast carcinomas for whom an equal, a 3-year follow-up was conducted. TFF1 levels as well as estrogen receptor (ER) and progesterone receptor (PR) levels were measured in cytosolic extracts of tumor samples by immunoradiometric assay or by use of classical biochemical method, respectively. Non-parametric statistical tests were applied for data analyses. Results. Statistical analysis revealed that TFF1 levels were significantly higher in premenopausal patients (p=0.02), or in tumors with: lower histological grade (p<0.001), positive ER or PR status (p<0.001, in both cases). On the basis of TFF1 level distribution between ER-negative and ER-positive postmenopausal patients with tumors of different histological grade, 14 ng/mg was set as the cut-off value to distinguish estrogen-independent from estrogen-dependent TFF1 expression in breast cancer. Depending on menopausal and PR status, positive TFF1 status identified patients at opposite risk for relapse among ER-positive patients with grade II tumors. Among ER- and PR-positive premenopausal patients with grade II tumors, TFF1 status alone identified patients at opposite risk for relapse. Conclusions. Determination of TFF1 status might identify patients at different risk for relapse and help in making decision on administering adjuvant therapy for early breast cancer patients during the first 3 years of follow-up.

Unilateral follicular variant of papillary thyroid carcinoma with unique KRAS mutation in struma ovarii in bilateral ovarian teratoma: a rare case report

BackgroundStruma ovarii (SO) is a rare form of ovarian mature teratoma in which thyroid tissue is the predominant element. Because of its rarity, the differential diagnosis between benign and malignant SO has not been clearly defined. It is believed that malignant transformation of SO has similar molecular features with and its prognosis corresponds to that of malignant tumors originating in the thyroid.Case presentationWe report 35-year-old woman with bilateral ovarian cysts incidentally detected by ultrasound during the first trimester of pregnancy. Four months after delivery of a healthy child without complication she was admitted to the hospital for acute abdominal pain. Laparoscopic left adnexectomy was performed initially in a regional hospital; right cystectomy was done later in a specialized clinic. Intraoperative frozen section and a final pathology revealed that the cyst from the left ovary was composed of mature teratomatous elements, normal thyroid tissue (>50%) and a non-encapsulated focus of follicular variant of papillary thyroid carcinoma (PTC).Normal and cancerous thyroid tissues were tested for BRAF and RAS mutations by direct sequencing, and for RET/PTC rearrangements by RT-PCR/Southern blotting. A KRAS codon 12 mutation, the GGT → GTT transversion, corresponding to the Gly → Val amino acid change was identified in the absence of other genetic alterations commonly found in PTC.ConclusionTo the best of our knowledge, this is the first time this mutation is described in a papillary thyroid carcinoma arising in struma in the ovarii. This finding provides further evidence that even rare mutations specific for PTC may occur in such tumors. Molecular testing may be a useful adjunct to common differential diagnostic methods of thyroid malignancy in SO.

Right thyroid hemiagenesis with adenoma and hyperplasia of parathyroid glands -case report.

BackgroundThyroid hemiagenesis is a rare anomaly, more commonly seen on the left side (ratio 4:1) and in females (ratio 3:1). The first to describe this anomaly was Handfield Jones in 1852.Case presentationWe present a 66 year old female patient with right thyroid hemiagenesis, parathyroid adenoma on the side of hemiagenesis and parathyroid hyperplasia on the contralateral side. The patient had neck pain and was diagnosed as Hashimto thyroiditis with hyperparathyroidism. Parathyroid hormone, thyroglobulin antibodies (Tg-Ab) and thyroid peroxidase antibodies (TPO-Ab) were elevated. Neck ultrasound and technetium 99mTc-methoxyisobutyl isonitrile (MIBI) scintigraphy confirmed the right thyroid hemiagenesis, but not adenoma of parathyroid glands. Intraoperatively, right thyroid hemiagenesis was confirmed and left loboistmectomy was performed with removal of left inferior hyperplastic parathyroid gland. Postoperative PTH (parathyroid hormone) levels were within normal range. Five months after the operation PTH level was elevated again with calcium values at the upper limit. MIBI scintigraphy was performed again which showed increased accumulation of MIBI in the projection of the right parathyroid gland. Surgical reexploration of the neck and excision of the right upper parathyroid adenoma was performed which was located behind cricoid laryngeal cartilage. After surgery a normalization of calcium and PTH occured.ConclusionFrom available literature we have not found the case that described parathyroid adenoma on the side of thyroid hemiagenesis,with parathyroid hyperplasia on the contralateral side.

Cathepsin D as an indicator of clinical outcome in early breast carcinoma during the first 3 years of follow-up.

AIM The aim of this study was to evaluate clinical usefulness of cathepsin D status in early breast cancer during the first 3 years of follow-up. PATIENTS & METHODS The study included 226 patients with histologically verified, primary operable invasive early breast carcinomas. Concentrations of estrogen receptor (ER) and progesterone receptor (PR) in breast tumor cytosols were measured by use of the classical biochemical method. The concentration of three cathepsin D forms (52-, 48- and 34-kDa proteins) was determined by a radioimmunoassay RESULTS On the basis of differences in cathepsin D levels either within an ER(-)/PR(-) phenotype or between this and either ER(+)/PR(+) or ER(+)/PR(-) phenotypes, a concentration of 39 pmol/mg was determined as the cutoff value for distinguishing estrogen-regulated cathepsin D expression. Estrogen-regulated cathepsin D expression was recognized as a high-risk biomarker for low-risk (histological grade I) breast cancer patients and as a low-risk biomarker for high-risk patients (pN(+) pT2,3). CONCLUSION Determination of cathepsin D status in breast cancer might identify patients at different risk for relapse and might facilitate the selection of more or less aggressive adjuvant therapy for early breast cancer patients during the first 3 years of follow-up.

Complications in Thyroid Surgery

Thyroid surgery is the surgery of parathyroid glands and recurrent laryngeal nerves. Surgeon is the most important prognostic factor for the complication rate. Possible complications of thyroid surgery are numerous, including bleeding, infection, hypoparathyroidism, recurrent and superior laryngeal nerve injury, thoracic duct injury, as well as injury of the lateral neck nerves, arteries, and veins. Some complications are considered minor, but can reduce quality of life significantly. These include pain, paresthesia, seroma, poor scaring, granuloma, sinus (fistula), and wound dehiscence. Excellent knowledge of anatomic landmarks and meticulous surgical technique is a prerequisite for prevention of surgical complications. However, if complications occur, timely diagnosis and adequate treatment are mandatory, since some of them can be life threatening if not recognized on time.

Breast cancer metastasis to the conjunctiva.

INTRODUCTION Conjunctival metastasis is exceedingly rare, and it is, as a rule, a sign of advanced malignant disease with poor prognosis. We presented a female patient with breast cancer metastasis to the conjunctiva. CASE REPORT A 45-year-old premenopausal female patient was presented with a solitary, yellowish, thin, demarcated lesion in the superior nasal quadrant of the bulbar conjunctiva of the left eye noted by chance a week earlier. There was no sign of irritation, and no pain, and no other functional or morphological problem in either eye or orbit. Five years before the appearance of conjunctival metastasis, breast carcinoma was diagnosed and the patient underwent chemotherapy, preoperative radiotherapy and radical mastectomy. Three years later, computed tomography scan showed metastasis in the left hepatic lobe with ascites and the patient underwent chemotherapy again. But, four months prior to the appearance of conjunctival lesion body scintigraphy showed multifocal sceletal lesions and nuclear magnetic resonance revealed diffuse hepatic metastases and bilateral ovarial tumors. Paliative radiotherapy and hormonal therapy (megestrol, 160 mg) were carried out. An excisional biopsy of the observed conjunctival lesion was performed under topical anesthesia and the material was subjected to histopathological (HP) examination. HP and immunohistochemical examinations established the presence of breast infiltrating lobular carcinoma metastatic to the conjunctiva. The patient showed rapid deterioration after intervention, and died after three weeks. CONCLUSION A survival period less than one month after the appearance of conjunctival metastasis deserves attention because it is unexpected and has never been reported previously. It is not a rule that HP presentation of a metastatic lesion is so characteristic that it is possible to determine a primary tumor.

Surgical treatment of colorectal liver metastasis after neoadjuvant chemotherapy.

688 Background: Liver is typical place for metastasis for patients with colorectal carcinoma. During the period of disease, 50% of patients with colorectal carcinoma will get liver metastases, 20% of the will have synchronous and 30% metachronous. Surgical resection is modality of choice in treatment for liver metastases in colorectal carcinoma. Applying neoadjuvant chemotherapy in patients with colorectal cancer liver metastases, which are primarily nonresectable or potentially resectable, it is possible to transform in resectable state. The goal of treatment is R0 liver resection and putting the patient in the NED stage of disease. METHODS All patients received protocol for potentially resectable metastase- FOLFOX-bevacizumab. The assessment was conducted on the basis of angioCT and NMR. With all patients liver resection procedures and RFA were applied. RESULTS During the period from June 2007 to December 2009 in 40 patients with nonresectable or potentially resectable metastases the neoadjuvant HT FOLFOX-bevacizumab was applied on average for three months. The patients were operated 6 weeks after the last application of bevacizumab, because of the possibility of intraoperative bleeding. The number of metastases ranged from 1 to 6. With 17 patients lobar resection was performed, and with 10 patients segmental resection was performed. With another 11 patients metastasectomy was performed, while RFA was performed with 2 patients. 3 years survival is 57.5%. CONCLUSIONS By applying neoadjuvant HT and bevacizumab with patients suffering from colorectal cancer liver metastases as the only existing metastases, it is possible to significantly reduce metastases, and thereby resection as well. With this approach time without disease and survival are increased.

539. Recurrent Laryngeal Nerve Reconstruction After Resection During the Operation of Locally Advanced Thyroid Cancer

S 887 MNGs,31 adenomas and 9 cysts.Out of 165 cancer cases 109 were papillary,20 follicular,46 mixed type and 5 medullary.18 had intrathorasic extensions.Using single ipsilateral incision 40 hemithyroidectomies,70 total thyroidectomies of benign and 55 early cancers were done.Central compartment clearance done in cancers. Bilateral approach used in 110 cases of carcinomas requiring bilateral node dissection and for 8 cases of bilateral intrathorasic extensions. Parathyroids were dissected pulvurised and injected into Sternocleidomastoid muscle before dissection. Results: Blood loss was 10-15 ml and hospital stay 24 hrs.There were no nerve injuries.Parathyroid deficiency was reported in 10/283. 165 thyroidectomies (115 total) were performed with single lateral incision. Within 6 months scar disappeared, sensory stimuli returned to normal giving excellent cosmesis and quality of life. Conclusions: ’Minimally invasive open Thyroidectomy’*’Thomas technique’, is a novel method applicable for all thyroid neoplasms . Avoidance of ’handling’ of the gland upfront,better accessibility and direct vision of nerves, ligation of vascular pedicles upfront, makes this approach unique and ’bloodless’.New technique facilitate better lymph adenectomy than anterior approach, is safest for intrathorasic extensions and even forTotal thyroidectomy with single lateral incision. Complications described in the literature are minimised with superior cosmetic results compared to Kocher~ Os technique. 539. Recurrent Laryngeal Nerve Reconstruction After Resection During the Operation of Locally Advanced Thyroid Cancer I. Markovic, R. Dzodic, I. Djurisic, M. Buta, M. Oruci, S. Nikolic, S. Petrovic, M. Mitrovic, M. Jevric, G. Pupic 1 Institute of Radiology and Oncology, Surgery, Belgrade, Serbia Background: Recurrent laryngeal nerve (RLN) palsy is a major obstacle in thyroid and parathyroid surgery. Permanent RLN paralysis was reported in 0.5 to 10% of cases. RLN injuries are more frequent during the operation and reoperations of cancer and recurrent goiter. In locally advanced thyroid cancer RLN could be infiltrated by tumor or lymph node metastases in paratracheal region. Primary objective is to achieve complete resection of tumor and lymph nodes. Resection of RLN in length of infiltration is sometimes necessary. Secondary goal during the operations is to improve phonation. A method of RLN reconstruction depends on type of injury. If end-to-end suture is not possible, anastomosis of proximal end of RLN with ansa cervicalis (ARA) using Miyauchi technique could be performed. Patient and Methods: A female patient in middle forties who was admitted to our Institute due to locally advanced multifocal papillary thyroid cancer with bulk lymph node metastases in both central and lateral neck compartments. Total thyroidectomy, central and bilateral modified radical neck dissections were performed using classic neck and modified McFee incisions. Right RLN was infiltrated about 3 cm in length up to its entrance into the larynx. Block resection of right lobe and paratracheal LNM was performed. Immediate ARA reconstruction with 6-0 resorbable sutures followed the operation. Results: The rate of RLN recovery was verified by postoperative direct laryngoscopy. It is important to underline that if the nerves were reconstructed by sutures vocal cords don‘t regain normal movement and are usually fixed in the median position. The patient‘s voice improves because reinervated cords recover from atrophy and restore tension during phonation which is shown on audio recording. Conclusion: Nerve reconstruction is strongly suggested in cases of planed or accidental resection. The ultimate method to evaluate quantitatively the voice recovery is the maximum phonation time. 541. Incidental Parathyroidectomy During Total Thyroidectomy G. Katsouli, O. Ignatova, G. Chinari, N. Perrakis, G. Tassopoulos, N. Petridis, P. Sarof, J. Nomikos, P. Arapantoni, K. Ntatsis Metaxa Cancer Hospital, Surgery, Piraeus, Greece Metaxa Cancer Hospital, Pathology, Piraeus, Greece Metaxa Cancer Hospital, Head and Neck Surgery, Piraeus, Greece Objectives: A retrospective study of the Second Department of Surgery and ENT Department of METAXA Cancer Hospital, in order to identify the degree of correlation of the presence parathyroid tissue in the thyroid specimens after elective total thyroidectomy. Patients-Methods: 183 cases of total thyroidectomy have been evaluated between 10/2009 and 10/2011.Preoperative calcium, phosphorus, PTH, FT3, FT4, TSH levels, Ultrasound, CT, R* Chest and FNA were reviewed in this patients. 36 of the 183 were males between 22 to 85 years old and 147 were females between 20 to 82 years old. This study evaluated the histopathological findings of total thyroidectomy. The presence or absence of parathyroid gland in the surgical thyroid specimen is reviewed. Results: 78 cases out of 183 patients confirmed thyroid malignancy. Among these 78 cases of thyroid malignancy, parathyroid tissue was found in 25 thyroid specimens. Among the 105 patients with benign disease, 14 with parathyroid tissue have been detected. Statistical evaluation with the X test proves a statistically significant relationship between malignancy and inadverted parathyroidectomy in total thyroid resection (0,001<P<0,01). Conclusion: The inadverted parathyroidectomy is noted frequently after total thyroidectomy with underlying malignancy. The suspicion of malignancy probably influences the surgeon to more radical resection.In literature is confirmed the findings of this study. There are also opposite results. 543. Evaluation of Effective Clinicopathologic Factors on Patients Outcome with Well Differentiated Thyroid Carcinoma A. Fanipakdel, H. Saidisaedi, S. Shahidsales, S.S. Roodbari 1 Omid Hospital, Radiotherapy-Oncology, Mashad, Iran 2 Razi Hospital, Radiotherapy-Oncology, Rasht, Iran Kowsar Hospital, Surgery, Astaneh Ashrafieh, Iran Introduction: Thyroid cancer is the most common cancer of endocrine system. Clinical, pathological and therapeutic factors affect patients’ outcome with differentiated thyroid carcinoma. The aim of this study was evaluation of the effective clinicopathologic factors on patients’ outcome with well differentiated thyroid carcinoma. Materials and Methods: In this retrospective analytic-descriptive study, patients’ files with thyroid carcinoma who referred to radiology-oncology departments in Omid and Ghaem hospital of Mashhad,Iran, were assessed from 1996-2006. Cases with pathologic report of papillary and follicular carcinoma were considered and a specific questionnaire including age, sex,time of admission, pathologic subtype, tumor size and metastases, adjuvant treatment, recurrence time, patient’s condition in the last visit and death time were recorded. Results: The patients’ mean age was 50.14 and median age was 52 years. Sixty patients (85.7%) had papillary and 11 cases (14.3%) had follicular carcinoma. End condition in 43 cases (55.8%) was good and in 34 cases (44.2%) was bad. Mean survival time was 44.1 and median survival time was 36 months. There was a significant association between T stage with end condition (P1⁄40.037) but there was no significant association between N stage with end condition (P1⁄40.665). Metastases at the time of the first visit had a significant correlation with patients outcome. 41patients (59.4%) from 69 cases with M0 disease had a good end condition versus only one patient (16.7%) from 6 cases with M1 disease with a good outcome