Michael T. White

Office-based ultrasound-guided cryoablation of breast fibroadenomas

BACKGROUND Fibroadenomas commonly found by palpation and routine mammography account for approximately 20% of open surgical breast biopsies. Alternatives to open surgery include tumor removal using an automated coring device and tumor ablation using heating or cooling elements. We report our initial experience with cryoablation of biopsy-proven benign fibroadenomas. METHODS A table-top cryoablation system employing a 2.4-mm cryoprobe was used to treat biopsy-proven benign fibroadenomas up to 4 cm in maximum diameter in a prospective nonrandomized fashion. The cryoprobe was placed under ultrasound guidance. Using a treatment algorithm based on fibroadenoma size, all tumors were subjected to two freeze cycles with an interposing thaw. Skin appearance and temperature, probe temperature, iceball size, and patient comfort were closely monitored during the procedure. Follow-up examinations including ultrasonography and photographs were scheduled for up to 12 months postablation. RESULTS Fifty patients with 57 core biopsy-proven benign fibroadenomas were treated. Seven early cases were treated in an ambulatory surgery center setting. The remaining procedures were completely office-based using only local anesthetic. Tumor diameter varied from 7 mm to 42 mm (mean 21 mm). The iceball engulfed the target lesion in each case. Transient postoperative side effects were local swelling and ecchymosis. Postoperative discomfort rarely required medication beyond acetaminophen or ibuprofen. Lesions showed progressive shrinkage and disappearance over 3 to 12 months. No skin injury was noted and appearance remained excellent. Patient satisfaction was excellent. CONCLUSIONS With office-based use of ultrasound-guided cryoablation for fibroadenomas there was little or no pain, target lesions were reduced in size or eliminated, scarring was minimal, cosmesis outstanding, and patient satisfaction was excellent. Cryoablation offers a useful office-based alternative to surgical excision of benign fibroadenomas.

Ethnicity related differences in the survival of young breast carcinoma patients

African‐American women face an increased risk of early‐onset breast carcinoma compared to white American women, and breast carcinoma has been reported to be particularly aggressive in premenopausal women.

Pneumonia after inhalation injury

We sought to evaluate the incidence, morbidity, and mortality of pneumonia among inhalation injury patients requiring admission to our burn unit. We undertook a retrospective study of 228 consecutive patients with inhalation injury who were admitted to the burn unit of a level one trauma center between 2001 and 2004. Of the remaining 117 patients with inhalation injury and requiring hospitalization for at least 48 hours, 32 (27%) developed pneumonia. The average patient with inhalation injury and pneumonia developed their infiltrate on day 6 ± 5 days and required 3 ± 4 burn operations. There was no difference seen in age, sex, or carboxyhemoglobin level between inhalation injury patients with and without pneumonia (P > .05). The inhalation injury patients that had an associated TBSA burn of at least 20% had a 60% (12/20) pneumonia rate, which was significantly higher then the 21% (20/97) pneumonia rate observed in patients with an association burn less then 20%. The overall mortality of patients with inhalation injury and pneumonia was 19% (6/32), double the mortality rate of 9% (8/85) found in patients with inhalation injury and no pneumonia. The average length of stay of inhalation injury patients with pneumonia was significantly longer (47 ± 44 days) then inhalation injury patients without pneumonia (26 ± 54 days; P < .05). The presence of pneumonia among inhalation injury patients significantly increased length of stay and doubled mortality rates. Admission carboxyhemoglobin levels, age, and sex had no relationship to the development of pneumonia. An increase in TBSA burn was associated with a higher pneumonia rate.

Factors affecting prognosis of inhalation injury

As care for burn injuries continue to improve, inhalation injuries have become a more significant cause of death. The purpose of this study was to evaluate factors affecting prognosis in patients with inhalation injuries. We undertook a retrospective chart review of all 829 consecutive patients admitted to our burn unit from January 2000 to September 2004. The 600 patients with thermal injury and no inhalation injury had a mortality of 3% (20/600). The 229 (28%) patients with an inhalation injury had an overall mortality of 16% (36/229; P < .001). Of these patients, 22 (10%) died in the first 48 hours, 90 (39%) were discharged in the first 48 hours, and 117 (51%) required hospitalization of at least 48 hours. Of the remaining 117 patients with inhalation injury the mortality was 12%. No difference in mortality (5% vs 3%) or length of stay (18 days vs 14 days) was seen between patients with an isolated inhalation injury and those with an inhalation injury plus an associated burn of less than 10% (P > .05). A significant difference was noted after the associated burn was larger then 10% (P < .05). The mortality rate and length of stay appear to be increased primarily by the severity of the associated burn in patients with inhalation injury andburns.

Histopathologic Evidence of Tumor Regression in the Axillary Lymph Nodes of Patients Treated With Preoperative Chemotherapy Correlates With Breast Cancer Outcome

Background: The benefits of primary tumor downstaging and assessment of chemoresponsiveness have resulted in expanded applications for induction chemotherapy. However, the pathologic evaluation and prognostic significance of response in preoperatively treated lymph nodes have not been defined.Methods: The axillary lymph nodes of 71 patients with locally advanced breast cancer treated with induction chemotherapy were evaluated for histological evidence of tumor regression as defined by the presence of nodal fibrosis, mucin pools, or aggregates of foamy histiocytes.Results: Complete pathologic response in the breast and axilla occurred in 10 patients (14%); 19 (26.8%) had evidence of tumor regression in 1 or more lymph nodes. Patients without nodal metastases and no evidence of tumor regression had the best outcome (median disease-free survival, 31.5 months; relapse rate, 27%). Patients with residual nodal metastases and no evidence of treatment effect had the worst outcome (median disease-free survival, 19.8 months; relapse rate, 55%). The median disease-free survival was 22.1 months, and the relapse rate was 32% for patients with histopathologic evidence of tumor regression in the axillary lymph nodes.Conclusions: Detection of treatment effect in axillary lymph nodes after induction chemotherapy identifies a subset of patients with an outcome intermediate between that of completely node-negative and node-positive patients. The axillary lymph nodes of patients receiving preoperative chemotherapy should be routinely analyzed for the presence of these features.

Does gender predict performance of novices undergoing Fundamentals of Laparoscopic Surgery (FLS) training

BACKGROUND This study was performed to assess the hypothesis that performance levels for Fundamentals of Laparoscopic Surgery (FLS) tasks were not dependent on trainee gender. METHODS Initial and final task completion times for 4 FLS tasks performed by 132 novices (4th-year medical students and 1st-year residents) were collated by task type and compared by gender. RESULTS All novices improved significantly with training (P > .001) on all tasks. Initial performance by men was better than by women but only reached significance for peg transfer and intracorporeal knot tying (P > .05). With training, womens performance became equivalent to that of men but showed a comparable or greater response to training. CONCLUSIONS The gender-related differences noted in initial FLS task performance disappeared after training. Gender displayed no effect on FLS training outcomes. The use of initial FLS task performance levels, seemingly objective selection criteria, would introduce gender bias into the ranking process.

Bedside assessment of swallowing is predictive of an abnormal barium swallow examination.

Adequate nutritional support after thermal burn injury is essential for achieving successful patient outcomes. Dysphagia is common in burn patients. Our objective was to analyze hospitalized burn patients referred to speech pathology for swallowing evaluation. A retrospective study of burn patients admitted to our center and evaluated by speech pathology from December 2001 through July 2006 was performed. Of the 16 patients, 5 (31%) had a normal bedside swallow examination, did not undergo a modified barium swallow study (MBSS), and were excluded. Six (55%) of the 11 included patients were men. The average age was 44 ± 18 years. All 11 patients had a thermal burn with an average total body surface area burn of 36% ± 16%. Facial burns were present in 91% (10 of 11) of the patients, and inhalation injury was confirmed by bronchoscopy in 55% (6 of 11) of the patients. The average length of stay was 84 ± 45 days. Of the 11 abnormal bedside assessments performed, 10 (91%) were associated with an abnormal MBSS. One patient had evidence of oral dysphagia only and one patient had evidence of pharyngeal dysphagia only. Six patients had oral and pharyngeal dysphagia, and two patients had pharyngeal and esophageal dysphagia. One tracheal-esophageal fistula was identified. A bedside assessment of swallowing performed by a speech pathologist is predictive of an abnormal modified barium swallow in burn patients. Burn patients with facial burns, inhalation injury, pneumonia, and a prolonged ICU stay are at increased risk for dysphagia. Prospective studies are necessary to determine in which patients an MBSS adds additional relevant clinical information.

Carbon monoxide-induced status epilepticus in an adult.

There have been numerous reports documenting the occurrence of self-limiting seizures after carbon monoxide poisoning in the pediatric population. However, the literature has been less informative concerning the adult population. This report documents a 70-year-old female who was found to be in nonconvulsive status epilepticus after acute carbon monoxide poisoning with a carboxyhemoglobin level of 35%. To our knowledge, this is the first report of acute carbon monoxide poisoning inducing nonconvulsive status epilepticus in an adult. This report adds to the growing body of knowledge concerning acute carbon monoxide poisoning by further exploring the very complex symptomatology that presents in the adult population.

Extensive toxic epidermal necrolysis versus acute graft versus host disease after allogenic hematopoietic stem-cell transplantation: challenges in diagnosis and management.

Toxic epidermal necrolysis (TEN) is a rare complication after allogeneic hematopoietic stem-cell transplantation and carries high mortality rates. Graft-vs-host disease (GVHD) is also a life-threatening complication, and potentially indistinguishable from TEN because of similar clinical symptoms. However, current therapeutic recommendations differ between these two conditions, thereby posing a diagnostic dilemma. The authors, herein, present a complicated postoperative course after bone marrow transplantation with concurrent gastrointestinal and hepatic GVHD, and extensive epidermolytic disease compatible with both severe cutaneous GVHD and TEN. An early consult to a specialized burn service, and prompt transfer to a burn intensive care unit with extensive supportive care and nursing are of paramount importance in the management of immunosuppressed patients with TEN. Better understanding of the pathogenesis of TEN and GVHD after hematopoietic stem-cell transplantation, further treatment strategies, and more advanced diagnostic techniques are still needed to achieve acceptable mortality rates.

Smoking and home oxygen therapy--a preventable public health hazard

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were