Sarkis Meterissian

Accuracy of axillary ultrasound in the diagnosis of nodal metastasis in invasive breast cancer: a review.

Axillary lymph node status is the most important prognostic factor in early-stage breast cancer. Sentinel lymph node biopsy is used to determine the need for axillary node dissection. This technique incurs cost associated with radio-isotope administration and use of the operating room. Accordingly, there is a need to preoperatively identify patients with nodal metastases who can proceed directly to axillary dissection. Axillary ultrasound has increasingly been used to determine nodal status prior to surgery. It has been shown to be a sensitive and specific modality in the detection of nodal metastases. When combined with fine-needle aspiration, the specificity of this modality significantly increases. Here we present a current review of the usefulness of preoperative axillary ultrasound in early and locally advanced breast cancer patients with and without fine-needle aspiration biopsy. Based on this review, we estimate the proportion of patients that can be spared a sentinel lymph node biopsy and the concomitant benefit of axillary ultrasound in terms of cost.

Preoperative Axillary Ultrasound and Fine-needle Aspiration Biopsy in the Diagnosis of Axillary Metastases in Patients with Breast Cancer: Predictors of Accuracy and Future Implications

BackgroundThe utility of axillary lymph node dissection after sentinel lymph node biopsy has been called into question. We sought to determine the sensitivity, specificity, and accuracy of axillary ultrasound and fine-needle aspiration biopsy (FNAB) in the identification of axillary nodal metastasis in early breast cancer patients.MethodsData of patients with stage I and II breast cancer who underwent surgery and staging were reviewed. Axillary ultrasound findings were assessed and lymph node status recorded after axillary dissection. The data were cross-tabulated, and test characteristics were calculated.ResultsOf 235 patients, none demonstrated more than 2 positive sentinel lymph nodes. Ductal carcinoma was present in 68xa0%, estrogen and progesterone receptors were positive in 81 and 64xa0%, respectively, Her-2/neu was positive in 10xa0%, and 36xa0% were axillary node positive. The sensitivity and specificity of ultrasound alone were 55 and 88xa0%, respectively. Predictors of abnormal ultrasound included size of metastasis, estrogen receptor and Her-2 status, tumor grade, and presence of lymphovascular invasion. Addition of FNAB increased the sensitivity and specificity to 69 and 100xa0%. In conjunction with FNAB, the positive and negative predictive values were 100 and 54xa0%, respectively. Ten percent of patients with nodal metastases demonstrated a positive FNAB. Patients with a positive FNAB did not harbor more nodal metastases or a greater proportion of gross extranodal disease compared to patients not subjected to FNAB.ConclusionsAxillary ultrasound with FNAB has an accuracy of >70% in this series. It is easily performed and may avoid unnecessary sentinel lymph node biopsy in a significant number of patients.

Gene-expression profiling of microdissected breast cancer microvasculature identifies distinct tumor vascular subtypes.

IntroductionAngiogenesis represents a potential therapeutic target in breast cancer. However, responses to targeted antiangiogenic therapies have been reported to vary among patients. This suggests that the tumor vasculature may be heterogeneous and that an appropriate choice of treatment would require an understanding of these differences.MethodsTo investigate whether and how the breast tumor vasculature varies between individuals, we isolated tumor-associated and matched normal vasculature from 17 breast carcinomas by laser-capture microdissection, and generated gene-expression profiles. Because microvessel density has previously been associated with disease course, tumors with low (n = 9) or high (n = 8) microvessel density were selected for analysis to maximize heterogeneity for this feature.ResultsWe identified differences between tumor and normal vasculature, and we describe two subtypes present within tumor vasculature. These subtypes exhibit distinct gene-expression signatures that reflect features including hallmarks of vessel maturity. Potential therapeutic targets (MET, ITGAV, and PDGFRβ) are differentially expressed between subtypes. Taking these subtypes into account has allowed us to derive a vascular signature associated with disease outcome.ConclusionsOur results further support a role for tumor microvasculature in determining disease progression. Overall, this study provides a deeper molecular understanding of the heterogeneity existing within the breast tumor vasculature and opens new avenues toward the improved design and targeting of antiangiogenic therapies.

Neuraxial anesthesia and intraoperative bilevel positive airway pressure in a patient with severe chronic obstructive pulmonary disease and obstructive sleep apnea undergoing elective sigmoid resection.

Objective: This case report describes the anesthetic management of a patient with severe chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) who underwent elective sigmoid resection under combined spinal-epidural anesthesia and bilevel positive airway pressure (BiPAP). Case Report: A 63-year-old man with diverticular disease presented for a sigmoid resection. His medical history included coronary artery bypass grafting, diabetes mellitus, gastroesophageal reflux, chronic renal failure, COPD, a paralyzed left hemidiaphragm, and OSA treated with nighttime BiPAP and oxygen. Sigmoid resection was performed under combined lumbar spinal-thoracic epidural anesthesia without general anesthesia and/or endotracheal intubation (intrathecal 3.5 mL isobaric bupivacaine 0.5% with 100 &mgr;g epinephrine and 200 &mgr;g morphine [Epimorph], epidural 60 mg bupivacaine, and 200 mg lidocaine). Intravenous ketamine was administered at a rate between 30 and 50 mg/h. Intraoperative BiPAP was applied using a setting of 12.5/8mm Hg with a backup ventilation rate of 10 breaths/min and an oxygen flow of 4 L/min. After surgery, epidural bupivacaine (0.1%) was infused over 3 days at 10ml/hr supplemented with oral acetaminophen, resulting in excellent pain relief. Postoperatively, the patient continued to use BiPAP when sleeping, and no adverse respiratory events were observed. The patient was discharged home 5 days after surgery. Conclusion: Combined spinal-epidural anesthesia was successfully used in a patient with COPD and OSA undergoing sigmoid resection. Perioperative administration of BiPAP, excellent pain control by continuous epidural infusion of local anesthetic, and the avoidance of endotracheal intubation may have contributed to this patients uncomplicated postoperative course.

Do physician communication skills influence screening mammography utilization

BackgroundThe quality of physician communication skills influences health-related decisions, including use of cancer screening tests. We assessed whether patient-physician communication examination scores in a national, standardized clinical skills examination predicted future use of screening mammography (SM).MethodsCohort study of 413 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996, with follow up until 2006. Administrative claims for SM performed within 12 months of a comprehensive health maintenance visit for women 50–69 years old were reviewed. Multivariable regression was used to estimate the relationship between physician communication skills exam score and patients’ SM use while controlling for other factors.ResultsOverall, 33.8 % of 96,708 eligible women who visited study physicians between 1993 and 2006 had an SM in the 12 months following an index visit. Patient-related factors associated with increased SM use included higher income, non-urban residence, low Charlson co-morbidity index, prior benign breast biopsy and an interval >12 months since the previous mammogram. Physician-related factors associated with increased use of SM included female sex, surgical specialty, and higher communication skills score. After adjusting for physician and patient-related factors, the odds of SM increased by 24 % for 2SD increase in communication score (OR: 1.24, 95 % CI: 1.11 - 1.38). This impact was even greater in urban areas (OR 1.30, 95 % CI: 1.16, 1.46) and did not vary with practice experience (interaction p-value 0.74).ConclusionPhysicians with better communication skills documented by a standardized licensing examination were more successful at obtaining SM for their patients.

The Operative Dictation: A Review of How This Skill is Taught and Assessed in Surgical Residency Programs

BACKGROUNDnThe operative dictation (OD) is the cornerstone of surgical communication, yet there appears to be a lack of formal education of this skill by training programs. We conducted a review of the literature to assess the teaching and quality of OD in surgical residency programs.nnnSTUDY DESIGNnMultiple databases were searched for studies pertaining to OD, surgical education, and formal teaching. Of 50 the studies, 13 were retained and assigned to one or more of the following categories: (1) surveys of the surgical community evaluating current perceptions of formal OD education (n = 5), (2) studies assessing the quality of OD performed by residents (n = 5), and (3) educational interventions for improving OD skills (n = 4).nnnRESULTSn(1) Between 12% and 25% of survey respondents reported formal teaching of OD skills in their surgical programs. Surveyed residents and program directors were in favor of the implementation of structured teaching 60% to 91% of the time. (2) Multiple studies demonstrated significant deficiencies in residents ODs, with key information missing in up to 76% of cases. The completeness of OD did not consistently correlate with level of training. (3) In one of the studies, a formal educational session was found to improve OD quality scores (p < 0.001). In 2 studies, the use of synoptic report maximized the completion rate of OD up to 92% from less than 70%. Synoptic reports were significantly more complete than conventional ODs with regard to general information (p < 0.001) and procedural aspects (p < 0.001). A single randomized trial demonstrated an improvement in junior residents ODs after the implementation of a template (p = 0.02).nnnCONCLUSIONnCurrent evidence suggests that only a small proportion of residency programs offer formal OD instruction, despite a demonstrable need for improvement in residents OD skills. Educational interventions and synoptic reporting present possible solutions, although this continues to be an area of evolving interest.

The Breast Cancer Patient Navigation Kit: Development and User Feedback

Our interdisciplinary team developed a written cancer patient education tool, the Breast Cancer Navigation Kit, to respond to the information needs of patients and family members and that meet patient literacy levels. A literature review and a focus group provided content development for four modules: “About Breast Cancer,” “Body–Mind–Spirit,” “After Treatment Ends,” and “Practical Information.” An evaluation by 31 women showed the kit to be easy to understand, very useful, and informative. However, all agreed that it could not replace the dialogue with health care professionals. An interdisciplinary approach involving patient feedback is key to develop appropriate patient education tools.

Nephrectomy in patients with Caroli's and ADPKD may be associated with increased morbidity.

Autosomal dominant polycystic kidney disease (ADPKD), characterized by multiple bilateral renal cysts, is the most common inherited disorder of the kidney and an important cause of end-stage renal disease (ESRD). Carolis disease is a much less frequent condition with ectasia of the intrahepatic biliary system. A clear association between autosomal recessive and Carolis disease has been described, but only 4 cases of ADPKD and Carolis disease have been reported with 2 postoperative mortalities. The aim of this case is to increase the awareness of intra-operative and postoperative complications. A 66 year-old male was diagnosed with ADPKD and Carolis disease with hepatosplenomegaly and 4 episodes of ascending cholangitis. After 3 years of hemodialysis for ESRD, he received a cadaveric renal allograft. Subsequently, he developed paroxysmal atrial fibrillation. Upon anticoagulation, he developed multiple episodes of gross hematuria from the left native kidney. After the anticoagulation therapy was discontinued, he underwent bilateral nephrectomies of his native kidneys. Intra-operatively, a splenic laceration could not be managed conservatively. Therefore, splenectomy was performed. In addition, he developed ascending cholangitis post-operatively that was treated with antibiotics. He was discharged on postoperative day 18. Genetic testing revealed that the patient is heterozygote for a large deletion in PKD1 gene, which encompasses all tested exons (exons 1-44).

Fibroepithelial breast lesions diagnosed by core needle biopsy demonstrate a moderate rate of upstaging to phyllodes tumors

BACKGROUNDnFibroepithelial lesions of the breast (FEL) are atypical lesions diagnosed on core-needle biopsy. The purpose of this study was to determine the rate at which FELs are upstaged to phyllodes tumor on excision, and to examine the clinical and radiological factors that may be predictive of upstaging.nnnMETHODSnA retrospective review from the medical records of patients diagnosed with FEL on CNB at a single institution between 2010 and 2015 was performed. Patients diagnosed with benign or borderline phyllodes tumors were compared to those diagnosed with fibroadenoma.nnnRESULTSnOf 74 patients diagnosed with FEL, 48 underwent excision (64.9%). Of the 48 lesions excised, pathology revealed 30 fibroadenomas (62.5%), 14 benign phyllodes tumors (29.2%), and 4 borderline phyllodes tumor (8.3%). No malignant phyllodes tumors were identified. On preoperative ultrasound, heterogeneous echotexture (pxa0=xa00.03) and lack of internal vascularity (pxa0=xa00.03) were significantly associated with upstaging to phyllodes tumor.nnnCONCLUSIONSnSurgical excision of FELs yield a pathological diagnosis of benign and borderline phyllodes tumor in 37.5% of cases. A high BIRADs score (≥4b), heterogeneous echotexture and lack of internal vascularity on ultrasound may help predict upstaging to phyllodes tumor.

Serotonergic antidepressants and increased bleeding risk in patients undergoing breast biopsy.

Objectives: Recent investigations have shown that serotonergic antidepressant (SAd) use may increase the risk of peri-operative bleeding events. Our objective was to evaluate the possibility of a similar association in patients undergoing radiologic breast biopsies. Methods: We used data from 3890 patients undergoing 6300 biopsy procedures between January 2011 and October 2014 in the Breast Clinic of McGill University Health Centre, Montreal, Canada. In this case-control study, cases were patients reported to have abnormal bleeding during their biopsy by board-certified radiologists. A control group of nonbleeders was selected using matching according to age and type of biopsy. The correlation between abnormal bleeding and SAd use was assessed using bivariate and multivariate statistical analyses. Results: There were 97 patients with abnormal bleeding and 137 matched controls; 10 bleeders (cases) were on SAds (7 citalopram, 3 paroxetine) while only 1 nonbleeder (control group) was on a SAd (low-dose sertraline, 25 mg/day). SAds were significantly associated with increased bleeding risk (10.3% versus 0.7%, Fisher’s Exact p = 0.001). Moreover, after adjusting for confounding factors (age, type of biopsy, size of biopsy, needle caliber, pathology result and nonsteroidal anti-inflammatory drug use, multivariate logistic regression confirmed that SAds were associated with elevated bleeding risk (16.2, 95% confidence interval 1.87–140.1, p = 0.01). Conclusions: This is the first study demonstrating increased bleeding events in breast biopsy patients using SAds. Clinicians should be aware that SAds may be associated with peri-operative bleeding risk, even in relatively minor procedures such as breast biopsies.