Tommy A. Brown

Atypical hyperplasia in the era of stereotactic core needle biopsy.

Background and Objectives: To characterize both atypical hyperplasia (AH) and the malignancies typically present at open surgical biopsy in women diagnosed with AH by stereotactic core needle biopsy (SCNB).

Breast Papillomas in the Era of Percutaneous Needle Biopsy

BackgroundThe significance of breast papillomas detected on core needle biopsy (CNB) remains unclear. While those associated with malignancy or atypia are excised, no clear solution exists for benign papillomas. We sought to determine the indication for surgical excision, incidence of malignancy, significance, and natural history.MethodsIn this retrospective review, patients were divided into benign, atypical, or malignant cohorts based on initial results. While patients with malignant or atypical features were encouraged to undergo surgical excision, no standard recommendation was given for benign papillomas. Mammographic features, method of initial diagnosis, pathology results, and follow-up data were analyzed.ResultsBetween January 1994 to December 2005, 5,257 CNBs were performed at our tertiary level medical center. 206 patients were diagnosed with 215 breast papillomas. 174 (81%) papillomas were benign, 26 (12%) were associated with atypia, and 15 (7%) were associated with malignancy. Two benign papillomas (1.1%) developed into cancer over an average of 53 months. Average follow-up of those patients not undergoing excision for benign papilloma was 41 months; we had 92 patients with greater than two year follow-up and 57 patients with greater than four year follow-up. Of patients with atypia or malignancy associated with papilloma, there was a 26% and 87% associated rate of malignancy, respectively.ConclusionsBenign breast papillomas diagnosed by CNB have a low risk of malignancy and do not need excision. However, they should be considered high risk lesions which require serial radiographic monitoring. Papillomas associated with atypia or malignancy should continue to be excised.

Atypical Ductal Hyperplasia: Improved Accuracy with the 11-Gauge Vacuum-Assisted versus the 14-Gauge Core Biopsy Needle

BackgroundPercutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge.MethodsPatients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle.ResultsFrom June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses.Conclusion11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.

Dismounted complex blast injury report of the army dismounted complex blast injury task force

Abstract : The use of civilian expertise to assist the military medical corps during times of conflict is not a new concept. Perhaps, one of the most noted examples was the service of Edward D. Churchill, MD, who volunteered to serve as the chief surgical consultant in the North African and Mediterranean theaters during World War II. A colonel in the US Army, Dr. Churchill followed his deployed surgical unit from Harvard Medical School into the war zone, making major contributions to the care of the wounded, most notably in advocating for the use of whole blood for resuscitation. In addition to Churchill and DeBakey, other surgical giants who contributed to combat care during World War II included Loyal Davis, Fred Rankin, Isidor Ravdin, Robert Zollinger, Ben Eiseman, and J. Englebert Dunphy (former chief of surgery at the University of California, San Francisco). For a more in-depth review of the contributions of Dr. Churchill and others, interested readers are referred to the excellent article authored by Cannon et al. The war that has engaged US troops for the past 10 years in Iraq and Afghanistan is unique in American history. This prolonged war has been fought with an all-volunteer military service, including the members of the medical corps. A portion of the surgeons in theater are recent residency graduates and thus relatively inexperienced in trauma surgery. Other deployed surgeons may be reservists in the Army, Navy, or Air Force Medical Corps who have been deployed multiple times from their private or academic practices. Modern technology has brought the war into our living rooms and onto our computer screens, giving civilians a unique look at battlefield injuries. These considerations as well as many others culminated in the development of the Senior Visiting Surgeons (SVS) program composed primarily of civilian trauma surgeons.

Primary tumor location impacts breast cancer survival

BACKGROUND The prognostic significance of tumor location in breast cancer remains unclear. To better understand this relationship, we evaluated the Department of Defense tumor registry. METHODS Patients with infiltrating ductal adenocarcinoma or lobular carcinoma over a 10-year period were identified and analyzed. RESULTS Of the 13,984 tumors, 7,871 (58%) originated from the upper-outer quadrant or axillary tail, whereas the remainder were found at the nipple complex (9%), upper-inner quadrant (14%), lower-inner quadrant (9%), and lower-outer quadrant (10%). Univariate analysis of cancer-specific survival revealed a significant difference based on location of the primary breast cancer. Upper-outer quadrant lesions were associated with an independent contribution toward a survival benefit. CONCLUSIONS Upper-outer quadrant breast cancers have a more favorable survival advantage when compared with tumors in other locations. Factors that negatively impacted survival included high-grade tumors, advanced stage, and race.

Gallbladder duplication: evaluation, treatment, and classification ☆ ☆☆

Duplicate gallbladder is a rare congenital anomaly resulting from abnormalities in embryogenesis during the fifth and sixth weeks of gestation. Approximately 210 cases have been described. Variations include duplicate, triplicate, and septated gallbladder. We encountered a 15-year-old girl with both a duplicated gallbladder and a duplicated cystic duct who underwent successful laparoscopic cholecystectomy. This combination is extremely unusual, and based upon our findings in this case and a review of the literature, we propose the Unified Classification of Multiple Gallbladders.

Does telomerase activity add to the value of fine needle aspirations in evaluating thyroid nodules

BACKGROUND Telomerase replaces DNA sequences that are lost with cell division. Increased activity has been documented in malignant cells. Fine needle aspiration (FNA) has a 90% sensitivity for diagnosis of papillary carcinomas, but a specificity of 52%. This often leads to unnecessary surgery. METHODS Telomeric repeat amplification protocol assays were performed on FNA specimens of thyroid nodules in 19 patients. These results were compared with the surgical pathology using chi-square analysis. RESULTS There were 5 malignant and 14 benign nodules. Telomerase activity was found in 3 of 5 malignant (60%) and 9 of 14 benign (64%): sensitivity was 60%, specificity was 36%. CONCLUSION Telomerase assays did not add any additional information to FNA alone. Inflammatory changes associated with benign and malignant lesions can possess telomerase activity independent of the malignant state.

Training Surgeons and the Informed Consent Process: Routine Disclosure of Trainee Participation and Its Effect on Patient Willingness and Consent Rates

OBJECTIVES To examine patient perceptions and willingness to participate in resident education and to assess the effect on patient willingness and consent rates. DESIGN Anonymous questionnaire designed to capture demographics, overall opinions of teaching programs, and willingness to consent to various scenarios of trainee participation. Descriptive and univariate analyses were performed. SETTING Tertiary-level referral center. PATIENTS Three hundred sixteen individuals scheduled for elective surgery. MAIN OUTCOME MEASURES Consent rates for various scenarios. RESULTS Of the 316 patients who completed the questionnaire, most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure. However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients also were more willing to consent to the participation of a senior resident (83.1%) vs a junior resident (57.6%) or an intern (54.5%). Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent. CONCLUSIONS Most patients expressed approval of teaching facilities and resident education. However, consent rates were significantly altered when more detailed information was provided and they declined with increasing levels of resident participation. Providing detailed informed consent is preferred by patients but it could adversely affect resident participation and training.

Transcriptional Analysis of Novel Hormone Receptors PGRMC1 and PGRMC2 as Potential Biomarkers of Breast Adenocarcinoma Staging

BACKGROUND The expression of progesterone receptor membrane component 1 (PGRMC1) in breast cancer has generated interest in this recently discovered protein because of its role in tumorigenesis. However, correlations between patient age, PGRMC1 gene expression, breast cancer morphology, and breast cancer stage have not been adequately studied. Furthermore, very little is known about possible roles for other PGRMC isoforms in breast cancer, like PGRMC2. Thus, we examined the expression of PGRMC1 and PGRMC2 mRNA by relative quantitative PCR (RelqPCR) and determined whether transcript levels correlate with age, breast cancer staging, estrogen receptor alpha (ERα) status, and other morphometric features routinely used during the pathological examination of breast ductal adenocarcinomas. METHODS Twenty-eight frozen or paraffin embedded breast cancer samples (ductal carcinoma in situ and stages I thru IV invasive ductal adenocarcinoma) and 10 control benign breast tissue samples were randomly selected and interrogated by RelqPCR to determine PGRMC1, 2, and ERα mRNA transcript levels. To control for slight variations in sample preparation, receptor transcript was normalized to the housekeeping gene phosphoglycerate kinase 1 (PGK1). Descriptive statistics and ANOVA of multiparametric datasets were used to correlate transcript levels with pathological staging parameters. RESULTS PGRMC1 mRNA levels decreased significantly with patient age (Pearsons correlation -0.369; P=0.035), whereas PGRMC2 levels did not. Although the mean relative expression of PGRMC1 significantly decreased in stage II breast cancer compared with controls (P=0.050), it was no longer significant when age was considered a covariance (P=0.371). On the other hand, PGRMC2 mRNA transcript was significantly decreased in stage II breast cancer when compared to stage III cancer (P=0.028) in a manner independent of age (corrected model Bonferroni pair wise comparison, P=0.036). Furthermore, PGRMC2 levels positively correlated with ERα mRNA transcripts in patients with ER positive tumors (Pearsons correlation 0.503, P=0.096). CONCLUSIONS Decreases in PGRMC1 mRNA are partially explained by increasing patient age. On the other hand, compared to stage III, PCRMC2 mRNA was significantly decreased in stage II adenocarcinoma of the breast in an age-independent manner. Additionally, PGRMC2 mRNA levels displayed a positive correlation with ERα transcripts. Thus, in addition to morphometric pathologic staging criteria, measurements of PGRMC2 mRNA may be useful for distinguishing low stage tumors from higher stages that require more aggressive clinical management, and may be a useful test when tumor ER IHC results are equivocal.

Improved rates of colorectal cancer screening in an equal access population

BACKGROUND National colorectal cancer (CRC) screening averages 50% to 60%. We aimed to identify screening prevalence in select Department of Defense (DOD) beneficiaries with equal access to care. METHODS December 2007 cross-sectional data of patients over 50 years of age included patient demographics, screening modality, and compliance. RESULTS Of 17,252 patients (52% male; mean age 63.2 +/- 8.1 years), 12,229 (71%) were up-to-date with national screening guidelines. Modalities included colonoscopy (83.0%), flexible sigmoidoscopy with fecal occult blood testing (FOBT) (32.2%), and air-contrast barium enema (0.7%). African American or Hispanic background (70% African American, 68% Hispanic vs 73% Caucasian), younger patients (66.1% <65 years vs 78.6% >65 years), and male gender (69.9% vs 72.1%; all P < .001) all had lower rates. Compared to 2005, more patients were current with guidelines (71% vs 64%) and colonoscopic screening (83% vs 71%). CONCLUSIONS Although ethnicity-, gender-, and age-related disparities were observed, screening rates are improved in an equal access healthcare system.