Viviana Sollazzo

Acinic cell carcinoma of the breast: Review of the literature

INTRODUCTION The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. MATERIALS AND METHODS Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. RESULTS To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). CONCLUSION ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.

Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study

Background Despite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol. Methods The first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed. Results Type of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission. Conclusion Proper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

The first case of acinic cell carcinoma of the breast within a fibroadenoma: case report.

A case of acinic cell carcinoma of the breast is reported in a 26-year-old woman. She presented a lump in her right breast, that seemed to be a fibroadenoma. The open biopsy revealed a well-bordered fibroadenoma, together with a proliferation of cells characterized by serous acinar differentiation and eosinophilic cytoplasmic granules. Tumor cells stained for amylase, lysozyme, α-1-antichymotripsin, epithelial membrane antigen, S-100 protein, pan-cytokeratin, cytokeratin 7 and E-cadherin. Estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 overexpression, CD10, P63, smooth muscle actin, cytokeratin 5/6 were negative. The sentinel node was negative. 8 months after surgery she is in good clinical conditions without recurrence or metastases.

Lobular intraepithelial neoplasia arising within breast fibroadenoma

BackgroundFibroadenomas are the second most common breast pathology occurring in young women under the age of 35 years old. Fibroadenomas can be classified as simple or complex according to histological features. Complex fibroadenomas differ from simple fibroadenomas because of the presence of cysts (3 mm), sclerosing adenosis, epithelial calcifications, or papillary apocrine changes. Most fibroadenomas are clinically identifiable. In 25% of cases, fibroadenomas are non-palpable and are diagnosed with mammography and ultrasound. Differential diagnosis with well differentiated breast cancer is often necessary, particularly with medullary or mucinous tumors. Calcification findings within fibroadenomas by mammogram have to be investigated. The age of a lump is usually reflected by calcifications. Microcalcification can hide foci of carcinoma in situ when they are small, branching type, and heterogeneous. However, many morphological possibilities may not be reliable for deciding whether a certain calcification is the product of a malignant or a benign process. From a radiological point of view, fibroadenomas containing foci of carcinoma in situ can be indistinguishable from benign lesions, even if the incidence of carcinoma within fibroadenomas is estimated as 0.1–0.3%, and it could be a long-term risk factor for invasive breast cancer.Case presentationA 44-year-old woman presented with a 1.5-cm palpable, smooth, mobile lump in the lower-inner quadrant of her right breast. Standard mediolateral oblique and craniocaudal mammograms showed a cluster of eccentric popcorn-like calcifications within the fibroadenoma. After lumpectomy, a definitive histological examination confirmed the intra-operative diagnosis of a benign mass. However, lobular intraepithelial neoplasia foci were found, surrounded by atypical lobular hyperplasia.ConclusionsThe possibility of an old benign breast lump might be supported by fine needle aspiration biopsy or core biopsy before initiating follow-up. According to our experience, when patients are older than 40 years and have a familial history of breast cancer, we prefer to carry out lumpectomy with follow up to avoid the risk of underestimation in situ foci within the lump.

Confocal laser endomicroscopy in breast surgery: a pilot study

BackgroundBreast neoplasms include different histopathological entities, varying from benign tumors to highly aggressive cancers. Despite the key role of imaging, traditional histology is still required for a definitive diagnosis. Confocal Laser Endomicroscopy (CLE) is a new technique, which enables to obtain histopathological images in vivo, currently used in the diagnosis of gastrointestinal diseases. This is a single-center pilot feasibility study; the main aim is to describe the basic morphological patterns of Confocal Laser Endomicroscopy in normal breast tissue besides benign and malignant lesions.MethodsThirteen female patients (mean age 52.7, range from 22 to 86) who underwent surgical resection for a palpable breast nodule were enrolled. CLE was performed soon after resection with the Cellvizio® Endomicroscopy System (Mauna Kea Technologies, Paris, France), by using a Coloflex UHD-type probe; intravenous fluorescein was used as contrast-enhancing agent. The surgical specimen was cut along the main axis; dynamic images were obtained and recorded using a hand-held probe directly applied both to the internal part of the lesion and to several areas of surrounding normal tissue. Each specimen was then sent for definitive histologic examination.ResultsHistopathology revealed a benign lesion in six patients (46%), while a breast cancer was diagnosed in seven women (54%). Confocal laser endomicroscopy showed some peculiar morphological patterns. Normal breast tissue was characterized by a honeycomb appearance with regular, dark, round or hexagonal glandular lobules on a bright stroma background; tubular structures, representing ducts or blood vessels, were also visible in some frames. Benign lesions were characterized by a well-demarcated “slit-like” structure or by lobular structures in abundant bright stroma. Finally, breast cancer was characterized by a complete architectural subversion: ductal carcinoma was characterized by ill-defined structures, with dark borders and irregular ductal shape, formingribbons, tubules or nests; mucinous carcinoma showed smaller cells organized in clusters, floating in an amorphous extracellular matrix.ConclusionsThis is the first pilot study to investigate the potential role of confocal laser imaging as a diagnostic tool in breast diseases. Further studies are required to validate these results and establish the clinical impact of this technique.

Recurrent, spontaneous, postoperative small bowel perforations caused by invasive candidiasis

Dear Editor: Postoperative bowel perforations represent a serious medical condition with high morbidity and mortality. They are usually related to surgery itself; the anastomosis breakdown being considered the most common cause after bowel surgery; incidence maywidely vary, depending on type of primary surgery, anastomosis level and comorbidities. Iatrogenic injuries after abdominal surgery are also well-recognised causes of postoperative perforations; prompt diagnosis of such situations and eventually early reoperation are key factors for better prognosis. On the other hand, spontaneous and no-traumatic perforations may represent evenmore challenging clinical conditions, due to both difficulties in diagnosis and management. Underlying medical conditions are usually recognised as predisposing factors of spontaneous bowel perforations, such as ulcerative colitis, Crohn’s disease, jejunal perforation in celiac disease (if complicated by lymphoma or collagenous sprue), other than metabolic and vascular diseases; thus, even more uncommon conditions associated with spontaneous bowel perforation have been described such as Ehlers-Danlos syndrome. In recent years, the wide adoption of biological medications, such as monoclonal antibodies, has also led to new records of spontaneous bowel perforations, the most emblematic example being represented from bevacizumab, an inhibitor of vascular endothelial growth factor, used for several malignancies; few reports sent a warning on the possibility of bowel perforation after bevacizumab adoption, with an estimated incidence of about 3 %. A further chapter to be considered is represented by the infectious-related perforation: Cytomegalovirus (CMV) infection has been recognised has a cause of bowel perforation especially in immunocompromised patients, other than other bacterial, parasitic or fungal infections [1]. We here describe the case of a 76-year-old woman, who underwent a right hemicolectomy for a colon cancer and then developed multiple spontaneous postoperative small bowel perforations, requiring multiple reoperations: the only suspected cause of this being represented by a Candida infection which finally led to death. The patient had no significant comorbidities; the only anamnestic record being represented by a gallbladder resection plus biliary tract exploration for gallstones, 30 years before. A right hemicolectomy was performed by our surgical team to treat the cancer; it was a straightforward procedure and an ileocolic stapled end-to-end anastomosis was fashioned in a standard manner. The only immediate complication was represented by a pneumothorax due to CVC insertion by the anaesthesiologist team, requiring a thoracic tube insertion and ICU admission. On the third postoperative day, a bilious-enteric fluid became apparent from surgical drain, associated with fever; after a CT scan, the patient was reoperated for a generalised peritonitis, due to a proximal ileal perforation which was taken out as an ileostomy; it was a small perforation (around 1.5 cm diameter), with raised edges, while all the surrounding gut wall seemed to be healthy. G. Luglio (*) :G. D. De Palma : F. Liccardo :M. C. Giglio : V. Sollazzo : L. Bucci Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy e-mail: gaetano.luglio@gmail.com

Clinically cN0 breast cancer in elderly: What surgery?

INTRODUCTION Breast carcinoma is the most common cancer in women worldwide. The incidence increases with age. Elderly patients have more advanced disease than younger ones, but they have a more favorable biologic tumor profile overall. The management of breast cancer in elderly is controversial. We report our experience with breast cancer in older than 65 years in the last 5 years, in order to assess how many axillary dissection may have been avoided, according to disease free survival (DFS) and overall survival (OS). MATERIALS AND METHODS We enrolled in our retrospective study all over 65 year old patients referred to the Breast Unit of our Department of Clinical Medicine and Surgery at the University of Naples Federico II from January 2009 to December 2013. The end points were: evaluation of the rate of axillary treatment avoidable, DFS and OS. RESULTS We recruited 133 over 65 year old patients. Axillary lymph node was not palpable in 109 patients. The rate of involved axillae in patients without palpable nodes treated was 11.8%. The mean follow up was 35.7 months. At the time of data collection 3 patients had developed IBTR. No one had axillary recurrence, independently from the chosen treatment. 2 patients died for causes different from breast cancer. CONCLUSION DFS and OS are the same both in patients with treated and no treated axilla. Even if evidences about the treatment of breast cancer in elderly are still controversial, each patient deserves a multidisciplinary approach to discuss the best treatment option.

The role of MRI in predicting Ki-67 in breast cancer: preliminary results from a prospective study.

Purpose: In the last decade contrast-enhanced magnetic resonance imaging (MRI) has gained a growing role as a complementary tool for breast cancer diagnosis. Currently the relationship between the kinetic features of a breast lesion and pathologic prognostic factors has become a popular field of research. Our aim is to verify whether breast MRI could be considered a useful tool to predict Ki-67 score, thus resulting as a breast cancer prognosis indicator. Methods: From June to December 2014, we enrolled patients with breast cancer who underwent preoperative dynamic contrast-enhanced MRI at the local health agency. We analyzed the time-signal intensity curves calculating the mean values of the following parameters: the basal enhancement (Ebase), the enhancement ratio (ENHratio), the maximum enhancement (Emax), and the steepest slope of the contrast enhancement curve (Smax). Scatterplots and Pearson correlation test were used to investigate the eventual associations among these parameters. Results: A total of 27 patients underwent breast MRI during the study period. The mean ± SD Ki-67 percentage was 27.03 ± 16.8; the mean Emax, Smax, Ebase, and ENHratio were 433.9 ± 120.2, 267.3 ± 96.8, 165.5 ± 77.1, and 187.1 ± 94.8, respectively. Scatterplots suggest a positive correlation between Ki-67 and both Emax and Smax. The correlation tests between Ki-67 and Emax, Ki-67 and Smax showed statistical significance. Conclusions: Our preliminary data suggest that enhancement pattern is closely linked to breast cancer proliferation, thus proving the relationship between more proliferating tumors and more rapidly enhanced lesions. This is hypothesis-generating for further studies aimed at promoting breast MRI in the early estimation of cancer prognosis and tumor in vivo response to chemotherapy.

Venous anomalies of the axilla: a single-institution experience

AimSurgical treatment is still the cornerstone in the treatment of breast cancer, a very common neoplasia, particularly affecting the female elderly population. Axillary dissection is crucial in the treatment of some tumours, but variations in axillary vessels anatomy are poorly described in standard anatomy and surgical textbook. We aimed to describe anatomical variations in axillary vessels found in our institutional experience.Patients and methodsA prospective 3-year study was conducted in our institution from January 2012 to December 2014. Sixty-one consecutive axillary lymph node dissections (ALNDs) were performed in 61 patients who underwent surgery for stage II and III invasive breast cancer. Anatomical details of axillary vascular anatomy and its variations have been evaluated, described and stored in a prospective database.ResultsSixty-one ALNDs have been performed in the study period. The anatomy of lateral thoracic vein, angular vein and axillary vein was studied and compared with standard anatomical description. Eighteen percentage of venous variations were found out of the 61 dissection performed.ConclusionsVascular anatomy of axilla is complex and variable. A better knowledge of all possible variations might be helpful in preventing injuries during ALND.

165. Can we safely avoid axillary clearance when sentinel node is minimally involved in early breast cancer

Background: In the UK there has been a nationwide movement towards patient led follow up care after breast cancer treatment. This open access follow up has been found to be more effective, enabling cancer survivors to take control of their condition and get on with their lives. This study aimed to assess the impact of an open access follow up system for breast cancer patients at East Surrey hospital. Instead of a routine appointment, follow up patients with a benign mammogram would be given open access telephone contact with breast care nurses and offered a hospital appointment only when necessary. Materials and methods: Mammogram results were reviewed for follow up breast cancer patients attending clinic for their annual review. Results were divided into those reported as benign and those as indeterminate or suspicious. Patient selection for entrance to open access was determined by questionnaire consent. Following the introduction of open access, breast care nurses monitored phone calls received over a one month period. Questionnaires were used to grade the appropriateness of the queries and any actions required to resolve them. Results: Of 100 clinic encounters analysed, 69 had mammograms that were reported as benign and 31 as indeterminate or suspicious. On average, 2080 breast cancer patients are seen in follow up clinics at East Surrey hospital per annum. Of these approximately 69%, or 1435 patients, will have a benign mammogram. Following introduction of open access, an increase in call volume was reported by breast care nurses. However, further analysis showed that 98% of telephone encounters were entirely managed by breast care nurses and none required a hospital appointment. The cost of a single follow up clinic appointment is £150, so £215,250 per year is spent at East Surrey hospital on patients who may not have needed to attend. Conclusions: This study demonstrated that open access follow up provided adequate and timely support for patients after breast cancer treatment, while simultaneously preventing unnecessary hospital attendances. Furthermore, there are clear financial benefits to the introduction of open access follow up for this patient group. As a result, open access is being proposed by the East Surrey Breast Unit for follow up patients with a benign mammogram. Further analysis is needed to evaluate the long term impact. Nevertheless, the initial results are promising. No conflict of interest.