Yucel Aritas

Granulomatous Lobular Mastitis: A Complex Diagnostic and Therapeutic Problem

BackgroundGranulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. Clinical and radiological features may mimic breast carcinoma. Since this entity was first described, several clinical and pathologic features of the disease have been reported, but diagnostic features and treatment alternatives are still unclear. The purpose of this study is to evaluate diagnostic difficulties and discuss the outcome of surgical treatment in a series of 21 patients with granulomatous lobular mastitis.MethodsA retrospective review of 21 patients with histologically confirmed granulomatous lobular mastitis treated in our center between January 1995 and May 2005 was analyzed to identify issues in the diagnosis and treatment of this rare condition.ResultsThe most common presenting symptoms were a mass in the breast and pain. Four patients had no significant mammographic findings (MMG), but on ultrasound (US), 2 had irregular hypoechoic mass, and 2 hypoechoic nodular structures had abnormalities—one parenchymal distortion and 1 mass formation in 2 of these 4 patients’ magnetic resonance imaging (MRI). In recurrent cases, limited excision under local anesthesia was performed, as the clinical examination suggested carcinoma.ConclusionsAlthough some findings on MMG and US are suggestive of benign breast disease, these modalities do not rule out malignancy. MRI may be helpful in patients who do not have significant pathology at MMG or US. Fine-needle aspiration cytology may be useful in some cases but diagnosis is potentially difficult because of its cytologic characteristics. Wide excision, particularly under general anesthesia, can be therapeutic as well as useful in providing an exact diagnosis.

Portal Vein Resection for a Portal Vein Thrombus Caused by Nonfunctioning Islet Cell Carcinoma: Report of a Case

We report a case of nonfunctioning islet cell carcinoma of the pancreas causing a tumor thrombus in the portal vein. The patient was a 60-year-old woman whose presenting symptoms were abdominal pain, vomiting, and weight loss. We performed a subtotal pancreatectomy and splenectomy combined with partial resection of the portal vein. Histopathological studies confirmed the diagnosis of nonfunctioning islet cell carcinoma of the pancreas with a tumor thrombus in the portal vein. The patient’s postoperative course was uneventful and she is doing well 25 months after the operation.

Grasper-assisted versus traditional laparoscopic splenectomy in the management of hematologic disorders.

OBJECTIVE To compare the technical benefits of grasper-assisted laparoscopic splenectomy (LS) with traditional LS. METHODS The study comprised 27 consecutive patients who were admitted to our hospital from 1998 to 2002 and underwent LS: 13 patients underwent traditional LS (group 1), and 14 had grasper-assisted LS (group 2). RESULTS In both groups, the most common indication for LS was idiopathic thrombocytopenic purpura. There was no difference between the groups in the demographic characteristics of patients. All splenectomies were performed in the right semidecubitus position, using four or five trocars. Conversion to open surgery was required in one patient (7.7%) in group 1 and in one patient (7.1%) in group 2. Both conversions occurred during the initial 16 operations and no conversion occurred during the subsequent 11 operations. The mean operating time was significantly shorter for group 2 (132 minutes) than for group 1 (154 minutes) (P <.005). Mean estimated blood loss (201 vs. 282 mL) was also lower in group 2 than in group 1 (P <.05). The mean length of hospital stay was 3.3 days in group 1 and 2.4 days in group 2 (P >.05). CONCLUSION Grasper-assisted LS is both safe and feasible in patients with hematologic diseases. This technique can be preferred in order to grasp and position the spleen during the surgery.

Malignant Change in Heterotopic Bone Formation Following Suprapubic Cystolithotomy

We report the first case of heterotopic bone formation with malignant changes. The development of this lesion shortly after excision of a benign heterotopic bone lesion at the same site is another distinctive feature of this case.

The Importance of the Tumor Basement Membrane Laminin and LRP/MVP Receptors in Breast Cancer

To the Editor: The prognostic variability in breast cancer patients prompted the authors to investigate specific biologic markers for the identification of high-risk breast cancer groups. One component, the large glycoprotein laminin, is thought to play an important role in mediating the attachment of epithelial cells to their underlying basement membrane (1,2). It seems reasonable to suggest therefore that loss of adhesion resulting from disruption or loss of basement membrane is an important factor in the detachment of cells from the primary tumor and the development of distant metastases (3). Marco et al. (4) found a significant association between the absence of laminin receptors and a lower frequency of axillary recurrences. These findings suggest that in patients in whom the role of axillary dissection is controversial, evaluation of laminin receptors in the tumor may yield clues for axillary recurrence and prognosis. Major vault protein (MVP) is associated with resistance to chemotherapy in many cancers. For example, it is called lung resistant-related protein (LRP) in lung cancers. LRP/MVP receptors have not been extensively studied in breast cancers. Schneider et al. (5) found a correlation between LRP/MVP receptor positivity and the presence of nodal metastases; however, receptor positivity did not show a significant correlation with response to treatment. Taking these data into consideration, we investigated the contributions of laminin and LRP/MVP receptor status in predicting prognosis by evaluating the relationships between these receptors and other prognostic factors in stage I, II, and III invasive ductal carcinomas. Fifty cases of invasive ductal breast carcinoma were evaluated for the immunohistochemical expression of laminin and LRP/MVP receptors. Immunohistochemical findings were compared with conventional pathologic parameters including tumor size, axillary lymph node (LN) metastasis, lymphovascular invasion, and TNM staging. In our study there were significant correlations between tumor size, and laminin and LRP/MVP receptors positivity ( p < 0.05). The number of metastatic lymph nodes increased with laminin receptor positivity. In contrast, the relationship between lymph node involvement and LRP/MVP receptors was not significant ( p > 0.05). We also found a significant correlation between lymphovascular invasion and laminin receptor positivity ( p < 0.05). These findings suggest that laminin receptor positivity may be used to predict axillary lymph node and lymphovascular invasion status. We can say that there were strong correlations between the laminin receptors and prognosis of breast carcinoma. But further studies on larger series are required to define the role of laminin and LRP/MVP receptors in clinical practice.

Carcinosarcoma of the breast: clinicopathologic and radiologic findings in an unusual case.

A 74-year-old woman presented with a left breast mass and erythema. Mammography demonstrated an increased density with smooth contour corresponding to the palpable mass. By magnetic resonance mammography, it was evaluated as malignant tumor because the time versus signal intensity curve of the solid components of the mass reached to plato after rapid eclipse of contrast (Fig. 1). Fine-needle aspiration cytology and intraoperative frozen section demonstrated and confirmed malignancy. She underwent modified radical mastectomy. Gross pathologic examination of the specimen revealed a heterologous tumor that measured 8 cm × 6 cm × 5 cm. Microscopically the tumor was mainly composed of two components, carcinoma and sarcoma (Fig. 2). Immunohistochemical studies showed that the epithelial components were positive for keratin and mesenchymal components were positive for vimentin. She is alive with axillary recurrence 20 months after the initial diagnosis. Breast carcinosarcoma is a rare breast tumor, with an incidence of less than 1%. The macroscopic appearance of these tumors is dependent on the variety of possible components. While epithelial components may be formed by undifferentiated carcinoma, adenocarcinoma, in situ carcinoma, or squamous carcinoma, mesenchymal components may contain a variety of components of connective tissue cells, fibroblastic, chondroblastic, and osteoblastic cells. The epithelial component displays a positive reaction for epithelial antigens such as Kermix, keratin, and CAM5.2, whereas the mesenchymal component may react with actin, vimentin, or S-100 protein. Overall carcinosarcomas appear to have a poor prognosis, most likely due to the fact that these lesions tend to be poorly differentiated tumors (1–4).

Cholecystectomy without Drainage

A study was planned to investigate the necessity of routine drainage after a cholecystectomy. Two surgical teams and two groups of 100 patients each were established. The first surgical team used drai