Simon Bergman

Positron emission mammography: initial clinical results.

Background: Evaluation of high-risk mammograms represents an enormous clinical challenge. Functional breast imaging coupled with mammography (positron emission mammography [PEM]) could improve imaging of such lesions. A prospective study was performed using PEM in women scheduled for stereotactic breast biopsy.Methods: Patients were recruited from the surgical clinic. Patients were injected with 10 mCi of 2-[18F] fluorodeoxyglucose. One hour later, patients were positioned on the stereotactic biopsy table, imaged with a PEM scanner, and a stereotactic biopsy was performed. Imaging was reviewed and compared with pathologic results.Results: There were 18 lesions in 16 patients. PEM images were analyzed by drawing a region of interest at the biopsy site and comparing the count density in the region of interest with the background. A lesion-to-background ratio >2.5 appeared to be a robust indicator of malignancy and yielded a sensitivity of 86%, specificity of 91%, and overall diagnostic accuracy of 89%. No adverse events were associated with the PEM imaging.Conclusions: The data show that PEM is safe, feasible, and has an encouraging accuracy rate in this initial experience. Lesion-to-background ratios >2.5 were found to be a useful threshold value for identifying positive (malignant) results. This study supports the further development of PEM.

Assessing the impact of the trauma team training program in Tanzania.

BACKGROUND In sub-Saharan Africa, injury is responsible for more deaths and disability-adjusted life years than AIDS and malaria combined. The trauma team training (TTT) program is a low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation. The purpose of this study was to assess the impact of TTT on trauma knowledge and performance of Tanzanian physicians and nurses; and to demonstrate the validity of a questionnaire assessing trauma knowledge. METHODS This is a prospective study of physicians and nurses from Dar es Salaam undergoing TTT (n = 20). Subjects received a precourse test and, after the course, an alternate postcourse test. The equivalence and construct validity of these 15-item multiple-choice questionnaires was previously demonstrated. After the course, subjects were divided into four teams and underwent a multiple injuries simulation, which was scored with a trauma resuscitation simulation assessment checklist. A satisfaction questionnaire was then administered. Test data are expressed as median score (interquartile ratio) and were analyzed with the Wilcoxons signed rank test. RESULTS After the TTT course, subjects improved their scores from 9 (5-12) to 13 (9-13), p = 0.0004. Team performance scores for the simulation were all >80%. Seventy-five percent of subjects were very satisfied with TTT and 90% would strongly recommend it to others and would agree to teach future courses. CONCLUSIONS After completion of TTT, there was a significant improvement in trauma resuscitation knowledge, based on results from a validated questionnaire. Trauma team performance was excellent when assessed with a novel trauma simulation assessment tool. Participants were very supportive of the course.

Nasal Chondromesenchymal Hamartoma: Report of a Case and Review of the Literature

The sinonasal region is the site of several hamartomatous lesions, the majority of which are mesenchymal, with vascular hamartomas predominating. The occurrence of hamartomas in the nasal cavity of infants and children is especially rare. Nasal chondromesenchymal hamartoma (NCMH) is a rare lesion of the intranasal sinuses generally diagnosed in the newborn period, with the eldest reported patient presenting at 16 years of age. This neoplasm is composed of mesenchymal-stromal and chondroid tissue in varying proportions. It is felt to be analogous to the mesenchymal hamartoma of the chest wall, a lesion of similar histology generally involving the ribs and chest wall of neonates. To the best of our knowledge, only 14 cases of NCMH have been reported to date. We report a case of NCMH in an 11-year-old boy.

Is parathyroid carcinoma indeed a lethal disease

BackgroundParathyroid carcinoma is a rare malignancy with a wide range of aggressiveness. There is no current staging system. Our primary aim was to review the presentation, diagnosis, surgical treatment, and outcomes of patients, with the goal of assessing the incidence of death related to parathyroid carcinoma.MethodsThe authors present a retrospective chart review on patients with parathyroid carcinoma from 1975 to 2004, identified by the tumor registry of a single tertiary-care center. Diagnoses were confirmed histologically, clinical and radiographical data were recorded, and statistical analyses were performed.ResultsTwenty-three cases were identified. The mean patient age was 54 years. The female:male ratio was 1.5:1. Follow-up ranged from 1 month to 23 years (median, 134 months). Mean preoperative calcium was 12.9 mg/dL. Median parathyroid hormone was 290 pg/mL. Two patients (9%) had an asymptomatic presentation, and five (22%) presented with a palpable neck mass. Only nine (39%) underwent initial comprehensive en-bloc resection. Median survival was 22 years. Five- and 10-year survival was 85.9% and 69.4%, respectively. Five- and 10-year survival with en-bloc resection was 90% and 67.5%, respectively. Local resection resulted in survival rates of 82.5% and 70.7%. Three of ten deaths were attributed to parathyroid carcinoma. In recurrent disease, computed tomography and scintigraphy had localization rates of 53% and 67%, respectively, with a concordance of 22%.ConclusionsLong-term survival is possible with parathyroid carcinoma. Death associated with parathyroid carcinoma was uncommon. A staging may be warranted despite the rarity of this disease.

The usefulness of cytogenetic analysis in fine needle aspirates for the histologic subtyping of sarcomas

Conventional cytogenetic analysis performed from open biopsy tissue samples may be a useful adjunct for the histologic subtyping of bone and soft tissue sarcomas. However, its diagnostic utility in fine needle aspiration biopsy (FNAB) specimens is unclear. We retrospectively reviewed 24 consecutive FNAB bone and soft tissue sarcoma specimens, procured from 1995 to 2003, in which aspirated material was obtained for cytogenetic analysis. The study sample included eight Ewing sarcomas, six synovial sarcomas, five rhabdomyosarcomas, two myxoid liposarcomas, and one each of myxoid chondrosarcoma, osteosarcoma, and atypical lipoma. Cytogenetic analysis confirmed the t(X;18) in all six synovial sarcomas and the t(11;22) in three Ewing sarcomas. The t(2;13) was strongly suggested in one alveolar rhabdomyosarcoma. For two of these cases (both of which were synovial sarcomas), cytogenetic analysis was necessary for definitive diagnosis. While the positive cytogenetic results were supportive in the remainder, all were initially and accurately subtyped based on cytomorphology and/or immunohistochemistry. Cytogenetic analysis was noncontributory (eg no growth) in 14 sarcoma cases, but excluding the case of atypical lipoma, this did not preclude the rendering of an accurate diagnosis. Cytogenetic analysis can be performed on FNAB specimens from bone and soft tissue sarcomas and may be a useful diagnostic aid in difficult cases. However, when cell block material is available for immunohistochemistry, the majority of such cases are successfully subtyped.

Pulmonary Extramedullary Hematopoiesis

Extramedullary hematopoiesis (EMH) is the formation and development of blood cells outside of the bone marrow. Of particular interest to chest physicians and radiologists is the occurrence of EMH in the lungs and pleura. There have been several reports of patients presenting with pulmonary EMH published in the literature and the majority are due to a secondary process, such as myeloproliferative disorders, hemolytic anemias, hereditary spherocytosis, and Gaucher disease. We present a case report of pulmonary EMH and a review of the literature concentrating on the etiology, clinical presentation, pathophysiology, diagnosis, and therapy for this uncommon disorder.

Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines

OBJECTIVE In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines. METHODS In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1-74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons. RESULTS The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05). CONCLUSIONS This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts.

Perioperative systemic chemotherapy for appendiceal mucinous carcinoma peritonei treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

The role of systemic chemotherapy (SC) in conjunction with cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in appendiceal mucinous carcinoma peritonei (MCP) is unknown.

E-Cadherin-Negative Primary Small Cell Carcinoma of the Breast Report of a Case and Review of the Literature

Primary small cell carcinoma of the breast is exceedingly rare, with fewer than 25 reported cases. The case presented herein is that of a 61-year-old woman with a 2.5-cm mass of the left breast. She underwent mastectomy with axillary node dissection. Histologic examination revealed sheets and nests of small, hyperchromatic, malignant cells with indistinct nucleoli and scant cytoplasm. High-grade solid and comedo ductal carcinoma in situ also was present. Two of 5 axillary lymph nodes contained metastatic disease. Immunohistochemical analysis demonstrated weak immunoreactivity for cytokeratin, neuron-specific enolase, and bcl-2. This histologic and immunohistochemical profile was consistent with that of a primary small cell carcinoma. Interestingly, this neoplasm lacked immunoreactivity for E-cadherin. E-cadherin expression has been documented in all 11 (100%) of 11 previously reported cases of primary small cell carcinoma of the breast, suggesting that this tumor is a form of ductal carcinoma. To our knowledge, this is the first reported case of E-cadherin-negative small cell carcinoma of the breast, which raises the question of a possible lobular histogenesis in some of these neoplasms.

Laparoscopic Splenectomy: Learning Curve Comparison Between Benign and Malignant Disease

Background. New surgical techniques should be formally evaluated for feasibility and safety. As a model for this evaluation, this study examines the authors’ institution’s experience with splenectomy for benign and malignant hematologic disease since the introduction of laparoscopic splenectomy (LS) in 1996. The authors present the evaluation of the recognized surgeon/institutional learning curve using CUSUM (cumulative sum) analysis. Methods. This is a single institution retrospective chart review of consecutive splenectomies for hematologic disease performed between 1996 and 2008. The primary outcome was conversion to open splenectomy. The learning curve for LS was evaluated using CUSUM analysis. Results. A total of 123 splenectomies were performed for benign (51.2%) or malignant (48.7%) hematologic disease. 58% of patients underwent planned LS, with a 21% conversion rate. The surgeon’s overall learning curves for LS, as well as that for malignant disease, were maintained within acceptable conversion thresholds. However, the learning curve for benign disease did cross the unacceptable conversion threshold at case 29. With additional experience, the curve again approached the acceptable conversion threshold. Patients with malignant disease were significantly older (P = .0004), had larger spleens (P = .0004), were more likely to undergo open splenectomy (P = .001), and had longer lengths of stay (P = .01). However, there was no significant difference in operative time, transfusion requirements, morbidity rates, or mortality rates between patients with benign and malignant disease. Conclusion: LS, for benign or for malignant hematologic disease, is associated with a significant learning curve. This evaluation model illustrates that careful patient selection and ongoing quality assessment is essential when introducing a new technique.