Serdar Özbaş

Validation of breast cancer nomograms for predicting the non-sentinel lymph node metastases after a positive sentinel lymph node biopsy in a multi-center study

OBJECTIVE In the study, our aim was to evaluate the predictability of four different nomograms on non-sentinel lymph node metastases (NSLNM) in breast cancer (BC) patients with positive sentinel lymph node (SLN) biopsy in a multi-center study. METHODS We identified 607 patients who had a positive SLN biopsy and completion axillary lymph node dissection (CALND) at seven different BC treatment centers in Turkey. The BC nomograms developed by the Memorial Sloan Kettering Cancer Center (MSKCC), Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. Area under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for each nomogram and values greater than 0.70 were accepted as demonstrating good discrimination. RESULTS Two hundred and eighty-seven patients (287) of 607 patients (47.2%) had a positive axillary NSLNM. The AUC values were 0.705, 0.711, 0.730, and 0.582 for the MSKCC, Cambridge, Stanford, and Tenon models, respectively. On the multivariate analysis; overall metastasis size (OMS), lymphovascular invasion (LVI), and proportion of positive SLN to total SLN were found statistically significant. We created a formula to predict the NSLNM in our patient population and the AUC value of this formula was 0.8023. CONCLUSIONS The MSKCC, Cambridge, and Stanford nomograms were good discriminators of NSLNM in SLN positive BC patients in this study. A newly created formula in this study needs to be validated in prospective studies in different patient populations. A nomogram to predict NSLNM in patients with positive SLN biopsy developed at one institution should be used with caution.

Randomized Trial Comparing Locoregional Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at the Presentation (Protocol MF07-01): A Study of Turkish Federation of the National Societies for Breast Diseases

Abstract:  The MF07‐01 trial is a phase III randomized controlled trial which compares breast cancer patients with distant metastases at presentation who receive locoregional treatment for intact primary tumor with those who do not receive such treatment. The primary objective of the study is to assess whether locoregional treatment of the primary tumor provides a better overall survival. Secondary objectives include progression‐free survival, quality‐of‐life, and morbidity related to locoregional treatment. Locoregional treatments consist of either mastectomy or breast conserving surgery with level I‐II axillary clearance in clinically or sentinel lymph node positive patients. Radiation therapy to the whole breast follows breast conserving surgery. Standard systemic therapy is given to all patients either immediately after randomization in no‐locoregional treatment arm or after surgical resection of the intact primary tumor in locoregional treatment arm. The study is conducted in Turkey as a multicenter trial with central randomization. Total accrual target is 271. The trial was activated in October 2007 and authorized centers started to recruit patients since then. ClinicalTrials.gov identifier number is NCT00557986.

Sclerosing adenosis of the breast: radiologic appearance and efficiency of core needle biopsy.

PURPOSE To examine the mammography and ultrasonography findings of patients who have a final histopathological diagnosis of sclerosing adenosis after breast biopsy, and to evaluate the follow-up results of patients who underwent core needle biopsies. MATERIALS AND METHODS Seventy-six of the 723 patients who underwent breast biopsy in our institution were diagnosed with sclerosing adenosis on histopathological examination. Mammography and ultrasonography findings from these 76 lesions were analyzed retrospectively. Thirty-seven of these lesions were sampled by image-guided core needle biopsy; the remaining lesions were excised surgically. Mammograms and ultrasound images of the lesions were re-evaluated, and the post-biopsy medical records of these patients were evaluated. RESULTS Sclerosing adenosis was the main diagnosis in 41 patients and the complementary diagnosis in 35 patients. Among the first 41 lesions in which sclerosing adenosis was the main diagnosis, there were 18 (44%) mass lesions, 16 (39%) microcalcification clusters, two (5%) lesions with asymmetrical opacity, three (7%) lesions with architectural distortion, and two (5%) lesions with focal acoustical shadowing that was only detected by ultrasonography. No alterations suggesting malignancy were noted during the follow-up examinations of 35 patients who underwent core needle biopsy. CONCLUSION Sclerosing adenosis is a benign proliferative disease of the breast that can be confused with malignancy on clinical, radiological, and even histopathological examination. There is no typical radiological criterion for diagnosis. Core needle biopsy or excisional biopsy can be used, depending on the lesions characteristics. Core needle biopsy can be the first step in the diagnosis of sclerosing adenosis.

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.

Abscess of the spleen

Abscess of the spleen is a very rare lesion. In this study, 4 cases of splenic abscess are presented and discussed along with the literature. The cases were between 16 and 55 years-old and two of them had hematologic malignancy. All of them had been operated on because of acute abdomen, and in two cases splenic rupture was present. Only in one of the cases was salmonellosis detected by microbiological methods. By histological examination, expansion and congestion in splenic sinusoids, and foci of abscess including wide areas of necrosis and inflammatory infiltration by neutrophils were seen in all cases. The most frequent cause of splenic abscess is septic embolism arising from bacterial endocarditis. There are also a few splenic abscess cases seen with malignancies. While splenic abscess is seen rarely, it has a high rate of mortality when it is diagnosed late.

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.

Sonographic features of histopathologically benign solid breast lesions that have been classified as BI-RADS 4 on sonography

To describe the sonographic (US) features associated with ultrasonography BI‐RADS category 4 lesions that have a benign histopathological outcome.

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.

What would be left behind if subtotal thyroidectomy were preferred instead of total thyroidectomy

BACKGROUND The choice between subtotal thyroidectomy (STT) and total thyroidectomy (TT) for multinodular goiter (MNG) remains controversial. METHODS Thyroid tissue samples of 34 patients who underwent TT for multinodular disease between October 2005 and June 2007 in Pamukkale University Hospital, Department of General Surgery were evaluated. Thyroid tissues weighing 2 g each from either side were separated from the main specimen to simulate the tissues that would be left behind if a subtotal resection were performed instead of a total resection. Ki-67 staining was performed. RESULTS The mean age of subjects was 49.3 +/- 12 years and 25 (73.5%) were females. Papillary microcarcinomas were found in 4 patients, 1 of which was in a residual thyroid specimen (RTS). Micronodule formations were found in 73.5% of specimens simulating residual thyroid. While Ki-67 indexes of residual thyroid tissues were 4.65% in nodules and 1.91% in normal areas (P < .05), they were 5.42% and 2.84%, respectively, for nodular and normal areas in the main specimens (P < .05). CONCLUSION Remnant thyroid tissues, following STT, have a high percentage of micronodule formation with a remarkable cellular proliferative activity.

Minimally invasive parathyroidectomy without using intraoperative parathyroid hormone monitoring or gamma probe

OBJECTIVE Minimal invasive parathyroidectomy (MIP) is a common surgical technique for the treatment of primary hyperparathyroidism (PHPT) and is usually done in conjunction with positive imaging techniques. We aimed to assess the results of this technique, performed without the use of intraoperative tests, in cases with PHPT caused by a single parathyroid adenoma. MATERIAL AND METHODS The data for patients who were diagnosed with PHPT were assessed retrospectively. Only those who had undergone a parathyroid adenoma localization study with ultrasonography (US) and parathyroid scintigraphy (PS) before the surgery, along with those patients for whom the MIP technique was routinely performed with frozen pathology, were included. RESULTS The study group was made up of 65 patients who had undergone the MIP technique. The mean age of the patients was 56±14 (20-81), with most being females [M/F: 19 (29.2%)/46 (70.8%)]. The mean calcium values before the operation were 11.24±1.26 mg/dL (8-15.5) (normal range: 8.4-10.2), and the parathyroid hormone (PTH) values were 388 pg/mL (249-707.75). These same values, measured 24 hours after the operation, were determined as 9.04±1.04 mg/dL (6.8-13.9) and 27 pg/mL (6-86), respectively. The follow-up period for the patients was an average of 26.6±9.4 (3-76) months, and only 3 (4.6%) cases of persistent hyperparathyroidism were detected within this period. CONCLUSION Our success rate with MIP in PHPT cases was determined to be 95.4%; therefore, this technique may be applied with a high success rate without any assistance from intraoperative tests, such as rapid serum PTH (rPTH) assays or gamma probes, in the presence of localization results of PS and US.