Savaş Koçak

Recurrence after incisional hernia repair: results and risk factors.

A relatively low success rate in recurrent incisional hernia repair has prompted us to review the effects of certain risk factors on the long-term outcome of our cases. In this study, 109 recurrent incisional hernias were repaired and reviewed between 7 and 92 months after the operation. The recurrence rate was 45.0%. Many conditions that have been implicated as causal factors in the occurrence of incisional hernias were not found to be associated with recurrence after repair. However, chronic constipation was determined to be the most prominent risk factor associated with late recurrence.

Evaluation of vocal cord function after thyroid surgery.

OBJECTIVE To compare clinical evaluation and indirect laryngoscopy with videolaryngostroboscopy (VLS), which is a new method of diagnosing abnormalities and dysfunction of the vocal folds. DESIGN Prospective study. SETTING Teaching hospital, Turkey. SUBJECTS 218 patients who required thyroidectomy and who had no vocal abnormality preoperatively. INTERVENTIONS Clinical evaluation, indirect laryngoscopy, and VLS before operation and on the second postoperative day. MAIN OUTCOME MEASURES Sensitivity and specificity. RESULTS The specificity of all three investigations was 100%. The sensitivity of VLS was 100%, of clinical evaluation 81%, and of indirect laryngoscopy 67%. CONCLUSIONS Clinical evaluation and indirect laryngoscopy are safe ways of evaluating abnormalities of the vocal cords postoperatively. It would probably not be cost-effective to use VLS routinely, but for differential diagnosis and evaluation of prognosis of vocal abnormalities after thyroidectomy it is more accurate.

Treatment of External Biliary, Pancreatic and Intestinal Fistulas with a Somatostatin Analog

Somatostatin and its long-acting analog octreotide (SMS 201-995) inhibit several gastrointestinal functions. Their effects have been studied in the treatment of small numbers of external pancreatic, intestinal and biliary fistulas. We treated 8 biliary, 4 pancreatic and 5 intestinal cutaneous fistulas with octreotide. Mean decreases in fistula output before octreotide treatment were not significant (p > 0.01 for each group). On the 1st day of octreotide treatment, mean fistula output decreased from 412 +/- 60.4 to 234 +/- 57.7 ml in the biliary, from 457.5 +/- 57.5 to 217.5 +/- 11.8 ml in the pancreatic and from 564 +/- 49.2 to 217.5 +/- 11.8 ml in the enterocutaneous fistula groups (p < 0.01 for each). No serious side effects were recorded. We conclude that octreotide is an important adjunct in the conservative treatment of external biliary, pancreatic and intestinal fistulas, by decreasing their output.

Papillary microcarcinomas of the thyroid gland and immunohistochemical analysis of expression of p53 protein in papillary microcarcinomas

BackgroundThyroid papillary microcarcinoma (TPM) is defined according to WHO criteria as a thyroid tumor smaller than 1–1.5 cm. TPMs are encountered in 0.5–35.6 % of autopsies or surgical specimens where carcinoma had been unsuspected. The purpose of the present study was to evaluate patients who had TPMs in terms of clinical findings, histopathological features and immunohistochemical evidence of expression of the tumor suppressor gene p53.MethodsA total of 44 patients with TPMs less than 1.0 cm in diameter were included in the study. The patients were evaluated clinically and the tumors were evaluated in terms of their histopathological and immunohistochemical features, including expression of p53.ResultsThe female/male ratio was 2.8/1, and the median age at time of diagnosis was 49 years (range 20–71 years). The maximum diameter of the smallest focus was 0.1 mm, and that of the largest was 10 mm microscopically. The mean diameter of all tumors was 5.7 mm. There was no correlation between tumor size and age or gender. Of the TPMs, 72 % were found in the right lobe, 24 % in the left lobe and 4 % in the isthmus. Fine-needle aspiration biopsy provided the diagnosis of TPM in only 43.2 % of the patients. All patients were treated with surgery, with 20 undergoing conservative surgery, i.e. lobectomy or isthmusectomy, and 24 undergoing total thyroidectomy. Frozen section provided the diagnosis of TPM in only 56.8 % of the patients. We found lymphocytic thyroiditis in 13.6% of patients, follicular variants in 11.9%, capsular invasion in 26.8%, lymph node involvement in 11.9%, soft tissue metastases in the neck in 12.1% and multifocality in 31.7 %, and none of these were related to age or gender (p > 0.05). No distant metastases were observed during approximately 10 years of follow up. We found p53 positivity in 34.5 % of TPM tumors. However, p53 expression was not statistically related to age or gender.ConclusionOur findings imply that TPMs may not be entirely innocent since they are associated with signs of poor prognosis such as capsular invasion, multifocal presentation, lymph node involvement and p53 positivity. Therefore, TPMs should be evaluated and followed like classical papillary cancers.

Radioguided occult lesion localization for minimally invasive parathyroidectomy: technical consideration and feasibility.

Purpose of the reportMinimally invasive parathyroidectomy (MIP) constitutes one of the main surgical approaches for the patient with primary hyperparathyroidism (PHPT) caused by a single parathyroid adenoma. The purpose of the study was to investigate the feasibility of radioguided occult lesion localization (ROLL) for MIP and the potential effects of the method in histopathologic evaluation. Materials and methodsTwenty-two patients, diagnosed with PHPT biochemically and candidates for surgery, underwent ROLL-guided MIP (ROLL-MIP). Parathyroid adenomas were searched for and identified with the guidance of an intraoperative gamma probe. The final diagnosis was confirmed by histopathologic analysis. All specimens were analyzed for the presence of parenchymal hemorrhage, congestion, neutrophil leukocyte infiltration, necrosis, cystic degeneration, subcapsular hematoma, subcapsular fibrin/neutrophil leukocyte infiltration, and disarray of the fibrous capsule of adenoma. ResultsAll injected lesions were effectively located over the skin with very high count rates depending on the injected activity and location of the lesion. Serum calcium and parathyroid hormone (PTH) levels normalized in all patients and stayed within the normal range during the follow-up period. None of the patients who underwent ROLL-MIP suffered temporary or permanent recurrent laryngeal nerve injuries. The mean operative time was 23±7 min. Parenchymal hemorrhage, congestion, subcapsular hematoma, and fibrin/neutrophil leukocyte infiltration were common histopathologic features. ConclusionThe use of ROLL-MIP in patients with PHPT due to a single parathyroid adenoma in the neck is technically safe and effective. It is more valuable in scintigraphy-negative patients when parathyroid adenoma is either demonstrated on ultrasonography by typical findings or confirmed by PTH washout. The ROLL-MIP technique does not impair the postoperative histopathologic examination of the parathyroid glands.

Predicting the Likelihood of Nonsentinel Lymph Node Metastases in Triple Negative Breast Cancer Patients With a Positive Sentinel Lymph Node: Turkish Federation of Breast Disease Associations Protocol MF09-01

BACKGROUND Triple negative (TN) tumor has a relatively high rate of recurrence and distant metastasis, but results of studies revealed that triple positive tumor is an independent predictor of axillary lymph node involvement. Our aim was to evaluate the frequency of nonsentinel lymph node metastasis (NSLNM) involvement in operable TN breast cancer with positive sentinel lymph node (SLN) and predicting the likelihood of NSLNM in this cohort of patients by using 4 different nomograms. METHODS A total of 128 patients with TN and SLN(+) underwent complete axillary lymph node dissection in 14 different centers in Turkey. For comparison, we used our previous multicenter MF08-01 Protocol, which identified 441 patients with estrogen receptor (ER(+)) who had a positive SLN biopsy and underwent subsequent complete axillary lymph node dissection. Turkish, Cambridge, and Stanford nomograms and the Tenon Score system were used to calculate the probability of NSLNM. RESULTS Patients with TN tumor had a larger tumor size. The actual percentage of NSLN positivity was 41% in the TN group and 47.1% in patient with ER(+). The Tenon Score was ≤3.5 in 12% of patients with TN and ER(+); the area under the curve in the receiver operating characteristics curve were 0.53 and 0.59, respectively. Based on the Turkish, Cambridge, and Stanford nomograms, areas under the curve were 0.54, 0.53, and 0.61, respectively in patients with TN, and were 0.79, 0.72, and 0.70, respectively, in patients with ER(+). CONCLUSION Using the Tenon Score system underestimates NSLN positivity, and tested nomograms are not good discriminators of NSLNM in patients with TN and positive SLN.

Radiologic-pathologic conference of the University of Ankara Medical School: metaplastic breast carcinoma with osteochondrosarcomatous differentiation.

5Department of Surgery, Ankara University Medical School, Ankara, Turkey. 75-year-old woman presented with a 6-month history of painless palpable mass in her right breast. Mammography revealed a 4-cm oval calcified mass in the upper outer right breast (Figs. 1A and 1B). A second 1cm lobulated mass was detected in the 12o’clock region. The patient underwent incisional biopsy of the palpable mass, which revealed invasive ductal cancer with osteochondrosarcomatous differentiation (Fig. 1C). Chest radiography and a bone scan were negative for distant metastasis. The patient underwent a right mastectomy. Histopathologic evaluation revealed a second 1.5cm focus of osteochondrosarcomatous metaplastic cancer in the 12-o’clock position in addition to residual metaplastic cancer at the A

The Importance of Lifelong Follow-Up for Patients with Pheochromocytoma: Report of a Case

We report herein the case of a patient who developed a malignant recurrence of pheochromocytoma 13 years after undergoing complete resection of a histologically benign, unilateral, sporadic tumor. A discussion on the importance of lifelong follow-up for patients undergoing surgery for pheochromocytoma follows this case report.

Synchronize primary breast osteosarcoma and contralateral benign cystosarcoma phylloides: radiologic and pathologic imaging.

Alarge irregular lobulated mass with heterogeneous density in the right breast and a smooth dense mass in the left breast were detected on computerized tomography of the chest of a 44-year-old Caucasian woman with history of palpable masses in bilateral breast (Fig. 1). A tru-cut biopsy revealed undifferentiated malignant tumor. Staging studies failed to show any distant metastases. With a presumed diagnosis of breast cancer, she underwent lumpectomy of the left breast and MRM of the right one. Right-sided mastectomy material contained a 15 · 10 · 8 cm tumor. Hypercellular tumor with osteoid deposits is seen in the lower half of the field. Normal breast ductal elements compressed by the tumor bulk are noted above (H&E, 100·) (Fig. 2a). Osteosarcomatous component with atypical osteoblastic proliferation, nuclear pleomorphism, and osteoid deposits (arrows) separated from compressed mammary parenchyma and ductal structures (H&E, 400·) (Fig. 2b). Epithelial ductal cells or remnants of epithelial elements were not identified on multiple sectioning. Malignant glandular and solid areas were not determined. Histopathologic examination revealed morphologic features of typical osteosarcoma. Left-sided lumpectomy material showed a 45 · 35 · 28 mm yellowish white solid lesion. Ductal elements with narrow lumens compressed in hypocellular uniform stroma are seen (H&E, 100·) (Fig. 3a). Breast ductules are seen in fibroblastic stroma consisting of fusiform cells with no cellular atypia and no mitoses (H&E, 200·) (Fig. 3b). Histologic diagnosis of benign cystosarcoma phylloides was made. After the diagnosis, she received adjuvant chemotherapy and radiation therapy. She is alive and being followed up without any evidence of recurrence for 28 months. The prevalence of primary breast sarcoma is less than 1% of women with breast malignancies. Breast osteosarcomas can arise from normal breast tissue or occur as a metaplastic differentiation of primary benign or malignant breast lesion. Also benign and malignant lesions like fibroadenomas, carcinomas may contain bone and osteoid cells. Metastatic bone formation may occur in fibroadenomas and phylloid tumors. After extensive sampling, neoplastic epithelial component can be found in these lesions. We presented our case as a primary breast osteosarcoma Address correspondence and reprint requests to: Ugur Coskun, MD, 40. Cadde. 444. Sokak, 5 ⁄ 5 Ebru Apt., Cukurambar Ankara, Turkey, or e-mail: ugurcos@hotmail.com.

Invasive Ductal Carcinoma Developing From Fibroadenoma

Fibroadenomas are the most common benign breast lesions in adolescent and young women. It is most frequently observed in the 3rd decade. Although it is considered benign, evidence of malignant transformation is available. Cancer development may be from ground of fibroadenoma or near breast tissue. A case of a fibroadenoma coexisting with an invasive ductal carcinoma of the breast in a 31-year-old female is presented. The patient presented with the chief complaint of having a palpable mass in her right breast for the last 10 years. Mammography revealed a mass with microcalcifications. Core biopsy was performed, and the results indicated an invasive carcinoma. Breast-conserving surgery with sentinel lymph node biopsy was performed. The pathological features revealed a fibroadenoma coexisting with an invasive ductal carcinoma. This case suggests that clinicians and radiologists should always pay attention to the associated malignant imaging characteristics whenever a mass was followed up as fibroadenoma.