Smiljka Lambaša

Nipple-Areola complex preservation : Predictive factors of neoplastic Nipple-Areola complex invasion

Recently, skin-sparing mastectomy (SSM) with nipple–areola complex (NAC) preservation has been promoted as an oncologically safe procedure in practice for selected patients. The criteria of selection have not been yet defined precisely. The focus of this study was to investigate predictive factors of NAC-base neoplastic involvement to define the indications for NAC preservation. A prospective clinical study was conducted of 108 randomly selected female patients with invasive breast cancer. Analyzed markers of NAC involvement were tumor–nipple distance (TND), tumor size, localization, histologic type, grade, lymphovascular invasion (LVI), site, and axillary lymph-node status. The definitive histologic findings of the NAC base were compared with analyzed markers and the frozen section results. NAC base was positive in 23.15% patients at definitive histology with false-negative results in 4.63% patients at intraoperative frozen section. Significant differences were found in TND, tumor size, axillary lymph-node status, and LVI. There were no significant differences in tumor grade and site and not enough cases for statistical evaluation in histologic type and localization. Clinical indications for NAC preservation, according to this study, include tumors ≤2.5 cm, TND >4 cm, negative axillary lymph node status, and no LVI. Considering the possibility of pre- or intraoperative measurement, tumor size, and TND evaluation will result in the lowest possible mistakes in NAC preservation. Frozen section analyses of the NAC base, because of the “false-negative” possibility, could be deemed as a relative prognostic factor until definitive histologic findings. The presence of an extensive intraductal component (EIC) in the “borderline” cases of these criteria could be an additional argument for NAC removal.

SECONDARY HYPERPARATHYROIDISM AND BROWN TUMOR IN DIALYZED PATIENTS

Secondary hyperparathyroidism is one of the most common complications of chronic renal failure (CRF). Its pathogenesis is multifactorial and still not completely understood. Pathological mechanism of hypocalcemia, hyperphosphatemia and calcitriol deficiency are basic characteristics of CRF and main reason for morphological changes in parathyroid glands and hyperparathyroidism (HP). We present a case of a female patient born in 1975. At the age of 10, a urinary infection was diagnosed for the first time and treated. Six years later, as nausea and vomiting started, CRF based on bilateral reflux was diagnosed and the patient was included in the hemodialysis treatment. The patient was again examined in 1997, when biochemical parameters, including the level of parathyroid hormone, ultrasonography of the neck, scintigraphy of the skeleton and densitometry revealed secondary HP. Parathyreoidectomy was perfomed in 1998. During the follow up period, a tumefaction on a ramus mandibulae dex. was noticed, which was cytologically diagnosed as osteitis fibrosa, “brown tumor”, a rare complication of the secondary HP. Surgery was performed and PHD was granuloma gigantocelulare. Prevention and therapy of secondary HP is a problem that demands early actions to avoid possible complications.

Simultaneous conus medullaris ependymoma and cerebellar astrocytoma in the same patient.

Multiple primary tumors in the central nervous system of different histological cell types are uncommon. We report a patient who had pilocytic astrocytoma in the cerebellum and ependymoma in the cauda equina region, occurring simultaneously. The suggested mechanism of this association is that primitive multipotent cells might have been displaced in the different CNS areas and developed in different tumor cells. Multiplicity of primary CNS tumors should be considered in certain occasions, when clinical symptoms and signs are pointing in that direction.

Extracranial propagation of glioblastoma with extension to pterygomaxillar fossa

BackgroundGlioblastoma multiforme is a highly malignant primary brain tumor that shows marked local aggressiveness, but extracranial spread is not a common occurrence. We present an unusual case of recurrent glioblastoma in 54-year old male that spread through the scull base to the ethmoid and sphenoid sinuses, to the orbita, pterygomaxillar fossa, and to the neck.MethodsA 54-year old male underwent left temporal resection because of brain tumor of his left temporal lobe. Operation was followed by external beam radiation combined with temozolomide. The tumor recurred eight months after first surgery. The patient developed swelling of left temporal region, difficult swallowing and headache. MRI of head showed recurrent tumor, which invaded orbita, ethmoid and sphenoid sinuses, nasal cavity, pterygomaxillar fossa.ResultsThe patient died ten months after initial diagnosis of glioblastoma multiforme, and two months after his second operation.ConclusionsThe aggressive surgical operation helped to downsize the tumor mass as much as possible, but did not prolonged significantly the life or improved the life quality of the patient. The current literature is reviewed, and the diagnostic approaches as well as therapeutic options are discussed.

Hemangiopericytoma arising at the site of the benign meningeoma 7 years after surgery.

Sir, In 1999, a 60-year-old male patient presented with depression, cognitive decline and left-sided weakness. Neurological examination revealed disorientation in time and place, left-sided hemiparesis with brisk reflexes, positive Babinski sign, and central facial paresis. Brain computed tomography (CT) revealed a temporoparietal solid cystic mass (4.5 9 3.3 cm) with perifocal edema, and compression of the right temporal lobe (Fig. 1). Post-contrast scans showed strong enhancement. Pre-operatively, the patient underwent pancerebral digital subtraction angiography, which showed tumor vascularization from the left maxillary artery. Frontotemporal craniotomy with total tumor resection was performed. The dural defect was closed with dural substitute (Liodura, Braun). The histopathologic diagnosis was meningioma (Fig. 2). Postoperative CT scan revealed no evidence of residual tumor and the post-operative course was uneventful. The patient was consequently followed up until 2005, with no evidence of disease recurrence and neurological status recovered completely. In 2006, the patient had an attack of general weakness with profuse sweating. Physical examination revealed only discrete left central facial paresis. Brain CT revealed a temporoparietal mass (4.5 9 4.2 cm) at the same site as before the first surgery (Fig. 3). Frontotemporal recraniotomy was performed to reveal a pinky, highly vascular mass. Intraoperatively, the left sphenoid ridge was seen to be infiltrated with the tumor. On histopathology, it was found to be a highly cellular and mitotically active tumor, with high density vascular mesh and tumor cells around it. Immunohistochemistry showed cells staining positive for CD34 and negative for CD31 and EMA (Fig. 4). These findings were consistent with hemangiopericytoma. Postoperative brain CT showed no evidence of residual tumor and the patient was referred to the oncologist for further irradiation treatment. Hemangiopericytoma is an uncommon neoplasm, usually occurring in the musculoskeletal system or skin, and arising from Zimmerman pericytes around capillaries and post-capillary venules. Hemangiopericytoma arising in the central nervous system is very rare; meningeal hemangiopericytomas account for approximately 2.5% of all meningeal tumors and 1% of all intracranial tumors [1, 2]. It is considered to be a mesenchymal and non-meningeal tumor according to the latest World Health Organization classification [3]. In our case, hemangiopericytoma developed at the site of a benign meningioma totally removed 7 years before. Hirose et al. describe a case of hemangiopericytoma arising at the site of fascial dural graft derived from the femoral quadriceps muscle 13 years after total removal of a benign meningioma. They concluded that the most probable origin of this tumor was the dural scar tissue of the graft and considered it to be a scar tumor [4]. In that case as well as in our patient, the recurrent tumor was misdiagnosed as recurrent meningioma. Our case appears to be the second case of hemangiopericytoma development at the site of T. Marinović G. Grahovac Department of Neurosurgery, University Hospital ‘‘Dubrava’’, Zagreb, Croatia

Sinus pericranii in the left frontal region involving the superior eyelid: a case report.

BACKGROUND Sinus pericranii is a rare asymptomatic communication between the intracranial and extracranial venous drainage pathways. The venous flow in this condition circulates through abnormal dilated veins in both directions. PATIENT/METHODS We describe an unusual location of an accessory sinus pericranii that involved the left frontal bone along with the superior orbital rim and the upper eyelid, with special focus on therapy. RESULTS The patient did not have any complication during the first and second surgery. Final outcome was excellent. The patient did not show any evidence of disease recurrence 1 year after the surgery. CONCLUSION We propose a multidisciplinary approach in the treatment of such lesions with a two-step surgery. Excision of the sinus pericranii is possible if the sinus pericranii is not a major venous outflow channel of the brain, which can be evaluated by angiography.

Unrecognized hemangiopericytoma of posterior cervical region with intracranial extension

Hemangiopericytoma of the posterior cervical space and occipital bone is an uncommon lesion which should be considered in the differential diagnosis of a lumpy and highly vascular lesion of the posterior cervical space. We report the case of a 47-year-old woman who experienced sudden and painful occipital and posterior cervical swelling. She underwent a blind biopsy which was complicated by profuse bleeding. The palpable lesion was not properly diagnosed preoperatively, and the endocranial extension of the lesion was overlooked by her surgeon who performed a blind biopsy without adequate diagnostic imaging who inadvertently invaded the posterior cranial fossa during biopsy. We would like to emphasize the need for appropriate non-invasive diagnostic investigations before any biopsy of head and neck lesions that may extend deeply.

Tumor and breast volume ratio as a predictive factor for axillary lymph node metastases in T1c ductal invasive breast cancer: prospective observational clinico-pathological study.

OBJECTIVE The status of the axilla is the single most important prognostic indicator of overall survival in patients with breast cancer. Sentinel-node biopsy has false-negative rates of 5-10%. The aim of this study was to assess the importance of tumor and breast volume ratio as a predictive factor for axillary lymph node metastases in patients with T1c ductal invasive breast cancer. METHODS This study included 136 consecutive patients with T1c ductal invasive breast cancer. Three tumor diameters were measured. Tumor volume was calculated by the formula for ellipse. Breast volume was measured preoperatively. Tumor and breast volume ratio was calculated and shown per thousand. RESULTS Tumor and breast volume ratio is a new independent predictive factor for axillary lymph node metastase in T1c ductal invasive breast cancer. CONCLUSIONS This predictive factor could help to define a subgroup of patients who will be at a higher risk for axillary lymph node metastase and would benefit from additional close follow up or axillary lymph node dissection.

Važnost citološke analize intraoperacijskog otiska baze mamile kod mastektomiranih pacijentica zbog karcinoma dojke

Karcinom dojke kod žena je na prvom mjestu po pojavnosti i uzroku smrti. Nastaje kada normalne žljezdane stanice dojke promijene svoja svojstva te p

Breast carcinoma metastasis in retrosternal fat tissue.

A 58-year-old woman presented at her oncology specialist’s office with the symptoms of dyspnea, difficulty in breathing and a vague feeling of retrosternal unease. Eight years before, she was diagnosed with a right breast cancer, an invasive lobular carcinoma (ILC), and underwent surgery (right breast quadrantectomy). She received four courses of adjuvant chemotherapy (cyclophosphamide/doxorubicin), four cycles of docetaxel, local-regional radiotherapy, and tamoxifen hormonal therapy. Following mentioned symptoms, chest x-ray and radiography of sternum were taken which revealed no cause for patient’s symptoms. Mammography and breast ultrasound showed normal findings. Subsequently, a breast dynamic magnetic resonance imaging was performed, which showed status after right quadrantectomy without signs of recidivism or residual tumor tissue but also revealed ill-defined retrosternal lesion in the fat tissue of the anterior mediastinum, 11 9 8 cm in size and spreading to the left with inhomogeneous postcontrast enhancement (Fig. 1). A multislice computed tomography of the sternum and retrosternal space showed inhomogeneous thickening in the retrosternal soft tissues at the level of sternal body, with absorption coefficients of solid tissue along with areas of dense liquid content, posteriorly insepa-