Rose Venegas

Focused microwave phased array thermotherapy for ablation of early-stage breast cancer: results of thermal dose escalation

Background: Tumor ablation as a means of treating breast cancer is being investigated. Microwave energy is promising because it can preferentially heat high-water-content breast carcinomas, compared to adipose and glandular tissues.Methods: This is a prospective, multicenter, nonrandomized dose-escalation study of microwave treatment. Thermal dose was measured as (1) thermal equivalent minutes (cumulative equivalent minutes; CEM) of treatment relative to a temperature of 43°C and (2) peak tumor temperature. Microwaves were guided by an antenna-temperature sensor placed percutaneously into the tumor. Outcomes measured were pathologic response (tumor necrosis) side effects.Results: Twenty-five patients (mean age, 57 years) were enrolled. The mean tumor diameter was 1.8 cm. Tumoricidal temperatures (>43°C) were reached in 23 patients (92%). Tumor size was unchanged after thermotherapy (P = not significant). Pathologic necrosis was achieved in 17 (68%) patients. Complete necrosis of the invasive component was achieved in two patients. One hundred forty CEM is predictive of a 50% tumor response, and 210 CEM is predictive of a 100% tumor response (P = .003). Univariate linear regression predicts that peak tumor temperatures of 47.4°C and 49.7°C cause a 50% tumor response and a 100% tumor response, respectively.Conclusions: Thermotherapy causes tumor necrosis and can be performed safely with minimal morbidity. The degree of tumor necrosis is a function of the thermal dose. Future studies will evaluate the impact of high doses of thermotherapy on margin status and complete tumor ablation.

Choledochal fungal ball

SummaryA 31-year-old patient with sickle-cell disease who had previous cholecystectomy developed acute onset of jaundice and abdominal pain. An endoscopic retrograde cholangiography demonstrated multiple filling defects within the bile ducts. Microscopic examination of “calculi” removed at surgery revealed that a fungal ball composed ofCandida was the cause of biliary obstruction in this case. The patient eventually recovered after removal of the fungal masses and intrabiliary instillation of amphotericin.

A new era of neoadjuvant treatment with Pertuzumab: Should the 10-lymph node guideline for axillary lymph node dissection in breast cancer be revised?

Pertuzumab has improved pathologic complete response rates when compared with other chemotherapeutics in the treatment of HER‐2 positive breast cancer patients.

The importance of recognizing parasitic organisms in cytologic specimens.

We would like to report a case of disseminated strongyloidiasis diagnosed by microscopic examination of bronchioalveolar wash/lavage and stress the importance of recognizing parasitic organisms in cytology specimens. A 39-year-old man was referred to Harbor-UCLA medical center after 10 days of unrelenting abdominal pain with distention and shortness of breath. He had previously presented to other medical centers with intermittent rashes at different sites on the trunk and limbs, chronic fatigue and proximal muscle weakness. He had a history of traveling to Guatemala and to Kentucky before presenting with these symptoms. He was diagnosed to have dermatomyositis and had been treated with steroids for ~ 1 year before presentation at Harbor-UCLA. Whether he was initially misdiagnosed or he developed strongyloidiasis as a result of steroid therapy was not clear. During the hospital course, the abdominal distention progressed and the patient developed hemoptysis (pulmonary hemorrhage). Plasmapheresis was planned for the presumed dermatomyositis before the Papanicolaou-stained smears of bronchioalveolar lavage fluid revealed filariform larvae and embryonated eggs of Strongyloides (Figure 1). Subsequent skin biopsy showed the larva in reticular dermis and confirmed the above diagnosis. Strongyloidiasis is caused by Strongyloides stercoralis parasitic infection. It is estimated to infect 30 million people in 70 different countries.1 The initial infection usually enters the human body through the skin. As the life cycle of the nematode progresses, various organ systems are involved and symptoms can be both protean and nonspecific. Definitive diagnosis of strongyloidiasis is usually made on the basis of microscopic detection of larvae in the stool, but a single stool examination is reported to have a detection failure rate of up to 70%.2 Other testing modalities such as serologic testing may be available, but sensitivity is often low because of immunodeficiency in many of these patients. Diagnosis of strongyloidiasis is often delayed because of nonspecific symptoms, clinically inapparent course, lack of a reliable specific and sensitive diagnostic test, low parasite load and irregular larval output. As in this case, recognition of the parasitic organism in a cytologic specimen may be the first step to diagnose this infection. As the number of patients likely to be infected with parasites increases (increasing worldwide travel, increase in chemotherapy patients, transplant recipients, steroid therapy and human immune deficiency virus [HIV]-positive patients3), vigilance for this diagnosis needs to increase. Aside from bronchial specimens, Strongyloides organisms have been observed in cervicovaginal smears,4-6 urinary sediment,6 cerebrospinal fluid7,8,9 and ascitic and pleural fluids.7,10-12 In conclusion, it behooves all of us, colleagues in cytology, to be alert for the possible presence of parasitic organisms in some cytology specimens. Although this is uncommon, we could play a crucial role in the initial diagnosis and proper treatment of Strongyloides stercoralis infection and potentially other parasitic infections.