Preoperative galactography increases the diagnostic yield of major duct excision for nipple discharge

BACKGROUND

Although most nipple discharge is due to a benign etiology, approximately 10-15% is due to breast carcinoma. The standard management of nipple discharge includes major duct excision, and although this procedure may eliminate future nipple discharge, a specific etiology is not always found. This study investigates the utility of preoperative galactography in targeting the causative lesion.

METHODS

During 1994-1996, 46 cases of major duct excision were identified from operating room records. All patients presented with spontaneous nipple discharge from a single duct. In 16 patients both a diagnostic galactogram and a preoperative galactogram with methylene blue were performed to localize the causative lesion and to enable intraoperative identification. Data were obtained by retrospective chart review. Statistical significance was determined by Fisher's exact test.

RESULTS

Preoperative galactography was obtained in 7 of 31 patients (23%) with bloody nipple discharge and 9 of 15 patients (60%) with guaiac negative discharge. All patients undergoing preoperative galactography were found to have either a filling defect and/or duct cutoff (n = 13) or duct ectasia (n = 3). All patients with a filling defect and/or duct cutoff on galactogram were found to have a carcinoma or papilloma at surgery. In the three patients with duct ectasia observed on galactogram, the diagnosis was confirmed at surgery. All patients who underwent preoperative galactography were found to have specific pathology that accounted for the nipple discharge versus 20 of 30 patients (67%) who did not undergo preoperative galactography (P = 0.009).

CONCLUSIONS

Although major duct excision for nipple discharge may eliminate the presenting symptomatology, a pathologic correlate is not always found. The data from the current study show that localizing the causative lesion by preoperative galactography increases the likelihood that specific pathology will be found at surgery, and suggests that preoperative galactography may be helpful in the evaluation and management of patients presenting with spontaneous nipple discharge. Cancer 1998;82:1874-80. 1998 American Cancer Society.

Cystic neoplasms of the pancreas--a review

Cystic neoplasms of the pancreas are rare entities, representing approximately 5% to 10% of all pancreatic malignancies. Seventy-five percent to 90% of all cystic lesions of the pancreas are pancreatic pseudocysts. Thus cystic neoplasms of the pancreas can be easily misdiagnosed and inappropriately treated by drainage. A persistent cystic lesion in the pancreas may pose a considerable diagnostic and therapeutic dilemma for the practicing clinician. This article reviews the various cystic neoplasms of the pancreas and their distinction from pancreatic pseudocysts.

Role of bactericidal permeability-increasing protein in the treatment of gram-negative pneumonia

BACKGROUND

Gram-negative infections are a major cause of morbidity and death. Bactericidal permeability-increasing protein (BPI) is an endotoxin-neutralizing protein that also exhibits potent bactericidal activity. This study compared the efficacy of a 23 kd recombinant N-terminal fragment of BPI (rBPI23) with that of antiendotoxin antibody E5 in a model of gram-negative sepsis.

METHODS

Sixty Swiss-Webster mice (Carworth farm) received an intratracheal inoculation of Escherichia coli (7 x 10(6) colony-forming units) and were randomized to three groups (20 per group). Starting immediately after inoculation, the groups received either rBPI23 (4 mg/kg intravenously every 2 hours for four doses), E5 (11 mg/kg intravenously every 24 hours for two doses), or an isotype control antibody B55 (11 mg/kg intravenously every 24 hours for two doses) and were followed up for survival. In a second survival study, 40 mice received the same intratracheal inoculation of E. coli and were randomized to two groups. Starting 2 hours after inoculation, the groups received either rBPI23 (4 mg/kg intravenously every 2 hours for four doses) or E5 (8 mg/kg intravenously every 12 hours for four doses) and were followed up for survival. In a third study, mice received an intratracheal inoculation of 3 x 10(6) colony-forming units E. coli, a sublethal dose, and were killed to determine pulmonary and blood clearance of bacteria.

RESULTS

rBPI23 conferred significantly greater protection from death than either E5 or B55 when started immediately (95% survival vs 20% and 10%, respectively; p < 0.001) or 2 hours after inoculation (65% survival vs 25% for E5; p < 0.05). Both pulmonary and vascular clearance of bacteria was enhanced significantly by treatment with rBPI23.

CONCLUSIONS

rBPI23 may be a novel therapeutic agent in the management of gram-negative sepsis.

Contained thoracic empyema presenting as an anterior chest wall abscess: empyema necessitatis revisited

Protean manifestation of pulmonary and pleural space infections can be expected in drug addicts. Because of the need to establish strict environmental protection for staff and patients, even simple drainage procedures should be performed in the operating room. Without testing, these patients should be considered as potential carriers of the AIDS virus. If a subcutaneous abscess is found to extend into the pleural space, drainage and full lung expansion are attempted through a limited rib resection. If this is unsuccessful, a full thoracotomy should be done to meet these surgical objectives.

Adhesions as a cause of persistent spontaneous pneumothorax

The authors present a case of a patient with a persistent spontaneous pneumothorax (after seven days of chest tube drainage) in whom a tear in an upper lobe bleb was held open by adhesions between the bleb and the chest wall. Radiographic findings which might indicate such a condition are presented, thus altering one to the need for early surgical intervention. Current theories regarding the pathophysiology of pneumothorax in the young and elderly patient are reviewed.

The surgical management of empyema thoracis in substance abuse patients: a 5-year experience

Postpneumonic empyema (EMP) may develop in substance abuse patients, requiring prolonged hospitalization. An algorithm that provides quality care and a rational basis for timely surgical intervention would be advantageous. We report our five-year experience with EMP in substance abuse patients and present such a treatment plan. Sixty-one substance abuse patients were treated for EMP. Posteroanterior, lateral, and decubitus x-ray studies were obtained before treatment to assess fluid movement. Chest tubes were placed to drain frank pus and to obtain material for positive smears. X-ray studies and computed tomography were done 24 hours later to assess parenchymal pathology and to detect any multiple loculations. Thirty-three substance abuse patients recovered following initial tube thoracostomy and 7 after a second chest tube was introduced. Twenty-one had multiple loculations and underwent thoracotomy. Twenty of the 21 required extensive debridement or decortication, or both; 2 required lobectomy and 1 pneumonectomy. Chest tubes were removed on an average of 6 +/- 1.5 days. Average postoperative stay was 10.7 +/- 2 days. There were 2 early deaths and 1 late death and no recurrent EMP. Bacteriology findings were nonspecific and often polymicrobial. We conclude that early thoracotomy can be lifesaving in the presence of a benign clinical course.