Robert G. Somers

The use of closed suction drainage after lumpectomy and axillary node dissection for breast cancer. A prospective randomized trial.

Closed suction drainage has been used to prevent seroma formation after lumpectomy and axillary node dissection for breast cancer. To study the efficacy of closed suction drains, the authors conducted a prospective randomized study from 1987 to 1990 of 227 axillary dissections. One hundred eight were randomized to a drain group (DG) and 119 to a no drain group (NDG). Drains were removed on the first postoperative day just before patient discharge. Postoperatively, all palpable axillary collections were aspirated on each follow-up visit. The volume aspirated, the number of aspirations, the time to seroma resolution, and all complications were recorded. The mean number of aspirations in the DG was significantly lower than the NDG (2.2 ± 2.2 versus 3.3 ± 2.1; p ≤ 0.002). Mean volume aspirated in the DG (146.3 ± 181.1 mL) was less than the NDG (266.1 ± 247.6 mL; p ≤ 0.003), and the time to seroma resolution was decreased in the DG as compared with the NDG (11.5 ± 10 days versus 18 ± 10.1 days; p ≤ 0.0002). Closed suction drainage after lumpectomy and axillary node dissection is advantageous in decreasing the incidence and degree of seroma formation and need not delay early hospital discharge.

Cells producing cathepsins D, B, and L in human breast carcinoma and their association with prognosis

Lysosomal proteinases, cathepsins D, B, and L have been associated with malignant tumor progression and with prognosis in various human carcinomas. In the current study, the immunohistochemical localization of cathepsins in tumor cells was correlated with cathepsin protein concentration in breast carcinoma cytosols from 77 patients. Significant correlation was found for cathepsin D (P < .041) and borderline correlation for cathepsin B (P < .055) but not for cathepsin L. We hypothesize that the poor correlation of cysteine cathepsins was attributable to the fact that they were present not only in malignant epithelial cells, but also in infiltrating macrophages and stromal fibroblasts. In addition, tumor-surrounding myoepithelial cells (42% of tumors) and myofibroblasts (26% of tumors) as well as endothelial cells of neovasculature (10% of tumors) all stained specifically for cathepsin B. Two thirds of tumors co-expressed cathepsins B and L in tumor cells, whereas only 17% of tumors co-expressed all 3 cathepsins. Intense immunostaining for cathepsin D of tumor cells was observed in tumors at high TNM stage and tumors having positive lymph nodes. The expression of cathepsin B was independent of established prognostic factors, whereas intense cathepsin L staining in tumor cells was associated with high histological grade. With respect to prognosis of patient survival, only tumor cell-associated cathepsin D (P = .042) and myoepithelial cell-associated cathepsin B (P = .061) showed borderline significance. Cathepsins B and L immunostaining in tumor cells was not prognostic. In contrast, cytosolic levels of cathepsin B correlated with higher rate of relapse. Taken together, these results show the diversity in the cellular distribution of cathepsins in human breast carcinoma, presumably reflecting specific regulation and function of each of the cathepsins during tumor progression.

Photodynamic therapy in the management of metastatic cutaneous adenocarcinomas: case reports from phase 1/2 studies using tin ethyl etiopurpurin (SnET2).

Background and Objectives: Photodynamic therapy (PDT) using a photoreactive purpurin, tin ethyl etiopurpurin (SnET2, Purlytin⌖, Miravant Medical Technologies, Santa Barbara, CA), was investigated as a treatment for cutaneous metastatic disease that had failed other treatment options.

Carcinoid tumor of the breast: Treatment with breast conservation in three patients

AbstractBackground: Carcinoid tumors of the breast have been described in the literature. The diagnosis is made by identification of typical histologic features and confirmed by a positive argyrophilic reaction or the presence of neurosecretory granules. There are several theories of the pathogenesis of carcinoid tumors in the breast and controversy as to whether these tumors actually originate in the breast ducts or are tumors that arise from neuroectodermal cells that have migrated to the breast ducts. Historically, treatment of carcinoid of the breast has been by mastectomy. Methods: We report three cases of primary carcinoid tumor of the breast treated with lumpectomy and axillary node dissection. No adjuvant radiation or systemic treatment was administered. Results: In all three cases, no metastases were identified in lymph nodes sampled and all patients have remained clinically free of recurrent disease. Conclusions: Decisions about the need for radiation or systemic treatment of breast carcinoid tumors depend on ones interpretation of the pathogenesis of this disease. Breast conservation is a surgical option that has not been previously reported. Larger series of carcinoid tumors of the breast, their treatment, and their follow-up are needed.

Cathepsins D, B, and L in transformed human breast epithelial cells

To investigate the regulation of lysosomal enzymes during carcinogenesis, we measured cathepsins (Cats) D, B, and L in MCF-10F, which is a human breast epithelial cell line, and cells evolved after treatment with carcinogen and transfected with c-Ha-ras oncogene. The clones used in this study, MCF-10FTras, D3, D3-1, and D3-1Tras, expressed no estrogen receptors and gradually increased invasive potential, while oncogenetransfected lines were also tumorigenic in SCID mice [16,19]. Cats D, B, and L were determined in the cells and in cell media using enzyme-linked immunosorbent assay (ELISA), specific enzyme activity measurements, and immunocytochemistry. The major intra- and extracellular lysosomal proteinase in these cells was Cat D (30–180 pm/mg), followed by Cat B (2–10 pm/mg) and Cat L (1–5 pm/mg). An inverse relationship between intracellular Cat D levels and invasive potential of carcinogen-treated and c-Ha-ras oncogene-transfected cell lines was observed. No significant changes in extracellular concentration of Cat D precursor in this series of cell lines was observed. Intracellular levels of Cats B and L were unchanged or slightly lower in carcinogentreated D3 and D3-1 cells, as well as in MCF-10FTras. On the other hand, in D3-1Tras cell line, evolving from c-Ha-ras transfected D3-1 line, 3.5 fold and 4.4 fold increases in Cat B and Cat L, respectively, but a 2 fold decrease in Cat D, were observed compared to the parental cell line. Immunocytochemical staining showed a granular, polarized perinuclear and cytoplasmic staining of cathepsins in all cell lines. Cysteine proteinases stained more frequently and more intensely in D3-1Tras compared to other lines, confirming the immunochemical assays. We hypothesize that several molecular events, caused by a carcinogen and an oncogene such as c-Ha-ras, are needed to increase Cat B and Cat L, but not Cat D, expression. Therefore, the cysteine and aspartic lysosomal proteinases are differentially expressed in the breast cell lines with more invasive phenotype.

Use of pectoralis minor muscle in immediate reconstruction of the breast.

A technique is described in which the pectoralis minor muscle is rotated as a muscle pedicle flap to be used in immediate reconstruction of the breast. The advantages of this procedure are that it provides additional muscle coverage over the prosthesis as well as preventing lateral displacement. Seven patients have undergone this technique with excellent results.

Selective digital venous hypertension: A rare complication of hemodialysis arteriovenous fistula

We report and document angiographically a case of selective venous hypertension, masquerading as an infection, which involved the three middle digits of the right hand in a patient with an access arteriovenous (AV) fistula. This complication arose following hemodialysis and was resolved after resection of the right radial artery at the site of AV fistula and re-anastomosis.

Influence of Initial Biopsy Technique on the Ability to Identify Sentinel Nodes in Breast Cancer Patients

To the Editor: Screening mammograms are able to detect many breast cancers at early stages. As the ability to find small lesions has improved, there has been a trend away from surgical biopsies as the primary approach to cancer diagnosis toward core biopsies via ultrasound guidance or stereotactic procedures. One postulated advantage to these techniques is the avoidance of the disruption of lymphatic channels, potentially allowing for a more successful sentinel node biopsy (1). Early studies of sentinel node biopsies showed less success when patients had undergone prior excisional biopsies (2). Others have reported no impact of the type of biopsy on the success of lymphatic mapping (3). A retrospective study of all patients undergoing sentinel node biopsy by isosulfan blue dye alone by two surgeons from May 1997 through August 2003 was performed at the Albert Einstein Medical Center, Philadelphia, PA. Data were collected prospectively, including patient and tumor characteristics and the type of initial biopsy performed, in order to establish the relationship between these parameters. Of the 547 consecutive sentinel node biopsies, diagnosis was by excisional biopsy in 392 cases and by nonexcisional technique (core or fine-needle aspiration biopsy) in 155 cases. The results showed that sentinel node biopsy was successful in 91.3% of those cases with prior excision and was successful in 91.6% of cases with nonexcisional biopsies (p = 0.91). Even when controlling for patient age, tumor size, tumor location, and surgical experience, the successful identification of a sentinel node was not associated with the original biopsy technique (p > 0.4). In the evaluation of a potential breast cancer patient, the type of biopsy performed can be quite important to the overall care of the individual. The advantage of the core biopsy is in its ability to provide the correct diagnosis with minimal morbidity. One potential disadvantage for small mammographically detected lesions is the fragmented removal of the bulk of the tumor, which may impede the accuracy of the reported size and stage. The choice of initial biopsy technique should be made with consideration of patient tolerance and specific mammographic or physical parameters. Whether prior excisional or nonexcisional techniques are employed, there is no difference in the ability to successfully perform a sentinel node biopsy.