Surgical outcomes of pulmonary valve infective endocarditis: A US population-based analysis

BACKGROUND

Pulmonary valve infective endocarditis (PVIE) represents a rare subset of right-sided IE. This study aimed to evaluate the population-level surgical outcomes of PVIE in the United States.

METHODS

We performed a retrospective observational study using the 2002-2017 National Inpatient Sample database. We included hospitalizations with both IE and PV interventions. We excluded Tetralogy of Fallot, congenital PV malformation, and those who underwent the Ross procedure. The primary outcome was in-hospital mortality. The secondary outcomes included major complications and length of hospital stay.

RESULTS

We identified 677 PVIE hospitalizations that underwent surgical treatment, accounting for 0.06% of all IE hospitalizations. The mean age was 35.2 ± 1.7 years; 60.0% were White, 30.3% were women, and 11.4% were intravenous drug users. Most were treated in large-sized (70.1%) urban teaching (88.8%) hospitals. Close to 30% of patients received at least one concomitant valve procedure. The in-hospital mortality was 5.5% for the entire cohort, and the median length of stay was 16 days. Major complications included complete heart block (8.7%), acute kidney injury (8.1%), and stroke (1.3%). The differences in mortality and complications rate comparing PV repair and replacement were not statistically significant. PV repair was associated with a longer length of hospital stay compared to PV replacement (median: 25 vs. 16 days, p = 0.03).

CONCLUSIONS

This study defines the population-level in-hospital outcomes after surgical intervention of PVIE. Surgically treated PVIE patients are associated with relatively low mortality and morbidities. The outcomes between PV replacement and repair are similar.

Primary Pericardial Mesothelioma: A Population-Based Propensity Score-Matched Analysis

Primary pericardial mesothelioma is a rare malignancy of the mesothelial lining of the pericardium. This study aimed to evaluate the clinical characteristics and survival outcomes of these patients using a United States population-based cancer database. We queried the Surveillance, Epidemiology, and End Results program (1973-2015). Primary pericardial mesothelioma patients with complete follow-up data were included, and primary pleural mesothelioma patients were identified as controls. Propensity-score matching was used to balance individual characteristics. Kaplan-Meier analysis and log-rank tests were performed to compare overall survival. Forty-one primary pericardial mesothelioma and 15,970 primary pleural mesothelioma patients were identified. Before matching, when compared to the pleural mesothelioma counterparts, primary pericardial mesothelioma patients were younger (median 57 vs 73 years, P < 0.001), more likely to be female (46.3% vs 20.2%, P < 0.001), more likely to be nonwhite (24.4% vs 8.4%, P = 0.001), and less likely to have been diagnosed in the most recent study decade (2006-2015, 34.1% vs 43.5%, P = 0.002). The overall 1- and 2-year survival rates were 22.0% and 12.2%, with a median survival of 2 months (IQR: 1-6). After 1:2 nearest neighbor propensity-score matching, 38 pericardial mesothelioma and 76 matched pleural mesothelioma cases were identified. The 2 matched groups had comparable baseline characteristics, including age, sex, race, year of diagnosis, histological type, and cancer history. Compared to their pleural mesothelioma counterparts, primary pericardial mesothelioma patients were less likely to receive chemotherapy (23.7% vs 50.0%, P = 0.01) and had worse overall survival (median survival: 2 vs 10 months, log-rank P = 0.006). Primary pericardial mesothelioma has worse survival outcomes than pleural mesothelioma, with a median survival of only 2 months. These patients should seek care from experienced multidisciplinary teams at tertiary care centers that handle high volumes of mesothelioma patients.

The role of racial segregation in treatment and outcomes among patients with hepatocellular carcinoma

BACKGROUND

There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes.

METHODS

We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates.

RESULTS

Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD.

CONCLUSIONS

Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes.

Undertreatment of Gallbladder Cancer: A Nationwide Analysis

BACKGROUND

Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer.

METHODS

Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan-Meier and Cox proportional hazard methods.

RESULTS

The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p < 0.0001), private insurance (41.6% vs 27.1%; p < 0.0001), academic centers (50.4% vs 29.7%; p < 0.0001), and treatment location in the Northeast (22.8% vs 20.4%; p = 0.0011). Compared with no re-resection, re-resection was associated with pT stage (pT2: 47.6% vs 42.8%; p = 0.0139) and pN stage (pN1-2: 28.1% vs 20.7%; p < 0.0001), negative margins on final pathology (90.1% vs 72.6%; p < 0.0001), and receipt of chemotherapy (53.7% vs 35.8%; p < 0.0001). The patients who underwent re-resection demonstrated significantly longer overall survival (OS) than the patients who did not undergo re-resection (median OS, 44.0 vs 23.0 months; p < 0.0001). After propensity score-matching, re-resection remained associated with superior survival (median OS, 44.0 vs 31.0 months; p = 0.0004).

CONCLUSIONS

Re-resection for gallbladder cancer is associated with improved survival but remains underused, particularly for early-stage disease.

The Impact of Residential Segregation on Pancreatic Cancer Diagnosis, Treatment, and Mortality

BACKGROUND

Disparities in pancreatic cancer outcomes between black and white patients are well documented. This study aimed to use a more novel index to examine the impact of racial segregation on the diagnosis, management, and outcomes of pancreatic cancer in black patients compared with white patients.

METHODS

Black and white adults with pancreatic cancer in urban counties were identified using data from the 2018 submission of the Surveillance, Epidemiology and End Results (SEER) Program and the 2010 Census. The racial index of dissimilarity (IoD), a validated proxy of racial segregation, was used to assess the evenness with which whites and blacks are distributed across census tracts in each county. Multivariate Poisson regression was performed, and stepwise models were constructed for each of the outcomes. Overall survival was studied using the Kaplan-Meier method.

RESULTS

The study enrolled 60,172 adults with a diagnosis of pancreatic cancer between 2005 and 2015. Overall, the black patients (13.8% of the cohort) lived in more segregated areas (IoD, 0.67 vs 0.61; p < 0.05). They were less likely to undergo surgery for localized disease (relative risk [RR], 0.80; 95% confidence interval [CI], 0.76-0.83) and more frequently had a diagnosis of advanced-stage disease (RR, 1.09; 95% CI, 1.01-1.19) with increasing segregation. They also had shorter survival times (9.8 vs 11.4 months; p < 0.05).

CONCLUSIONS

Disparities in advanced-stage disease at diagnosis, surgery for localized disease, and overall survival are directly related to the degree of residential segregation, a proxy for structural racism. In searching for solutions to this problem, it is important to account for the historical marginalization of black Americans.

Cancer stage at presentation for incarcerated patients at a single urban tertiary care center

Patients who are incarcerated are a vulnerable patient population and may suffer from less access to routine cancer screenings compared to their non-incarcerated counterparts. Therefore, a thorough evaluation of potential differences in cancer diagnosis staging is needed. We sought to examine whether there are differences in cancer stage at initial diagnosis between non-incarcerated and incarcerated patients by pursuing a retrospective chart review from 2010–2017 for all patients who were newly diagnosed with cancer at an urban safety net hospital. Incarceration status was determined by insurance status. Our primary outcome was incarceration status at time of initial cancer diagnosis. Overall, patients who were incarcerated presented at a later cancer stage for all cancer types compared to the non-incarcerated (+.14 T stage, p = .033; +.23 N stage, p < .001). Incarcerated patients were diagnosed at later stages for colorectal (+0.93 T stage, p < .001; +.48 N stage, p < .001), oropharyngeal (+0.37 N stage, p = .003), lung (+0.60 N stage, p = .018), skin (+0.59 N stage, p = 0.014), and screenable cancers (colorectal, prostate, lung) as a whole (+0.23 T stage, p = 0.002; +0.17 N stage, p = 0.008). Incarcerated patients may benefit from more structured screening protocols in order to improve the stage at presentation for certain malignancies.

Senior resident versus fellow participation during complex cancer operations

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Background: Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. Despite ACGME dictums, attending surgeons may favor either residents or fellows assisting on operations of greater complexity, depending upon a variety of factors, including local surgical culture. This study investigates whether participation of a senior resident versus a fellow impacts outcomes of complex cancer surgery. Methods: Patients who underwent esophagectomy, or gastrectomy with assistance from either a senior resident (PGY-4 or 5) or a fellow (PGY-6 to 8) were identified from the American College of Surgeon’s National Surgical Quality Improvement Program (2007-2012). Analyses were performed separately for each operation. Propensity-scores were created for the odds of undergoing the operation assisted by a fellow. Patients were matched based on propensity score, and outcomes were compared after matching. Results: In total, 1,160 esophagectomies and 2,432 gastrectomies were identified. Senior resident participation was reported in 60.2% and 86.6%, respectively. Resident involvement was associated with non-white race (17.0% vs. 13.8%; p < 0.001), and lower rates of neoadjuvant chemotherapy (6.4% vs. 11.7%; p < 0.001). After matching, rates major complication rates were slightly higher for patients who underwent esophagectomies involving a resident compared to fellow (38.1% vs. 31.8%; p = 0.0447). However, major complications rates were similar for gastrectomy (21.2% vs. 22.1%; p = 0.775). In addition, operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.009) involving a resident compared to a fellow, but comparable for patients who underwent esophagectomy (327 vs. 337 min; p = 0.310). Conclusions: The results of this study suggest that senior resident participation in complex cancer operations does not negatively impact operative time or outcomes, compared to involvement of a surgical oncology fellow. Although confounding by operative autonomy may exist, these findings indicate that senior residents should be given the same opportunities as fellows to participate in these potentially more challenging operations.

Vitamin D deficiency and its relationship to cancer stage in patients who underwent thyroidectomy for papillary thyroid carcinoma

PURPOSE

As imaging technology improves and more thyroid nodules and malignancies are identified, it is important to recognize factors associated with malignancy and poor prognosis. Vitamin D has proven useful as a prognostic tool for other cancers and may be similarly useful in thyroid cancer. This study explores the relationship of Vitamin D to papillary thyroid carcinoma stage while accounting for socioeconomic covariates.

MATERIALS AND METHODS

The medical records of all patients who underwent thyroidectomy at one institution between 2000 and 2015 were reviewed. Subjects with non-papillary thyroid cancer pathology, prior malignancy, and without Vitamin D levels were excluded. The remaining 334 patient records were examined for cancer stage, Vitamin D levels, Vitamin D deficiency listed in history, and demographic and comorbid factors.

RESULTS

Vitamin D laboratory values showed no significant relationship to cancer stage (p = 0.871), but patients with Vitamin D deficiency documented in the medical record were more likely to have advanced disease (28.6% versus 14.7%; p = 0.028). The patients with documented Vitamin D deficiency also had lower 25-hydroxyvitamin D nadirs (21.5 ng/mL versus 26.5 ng/mL, p = 0.008) and were more likely to be on Vitamin D supplementation (92.6% versus 41.8%, p < 0.001).

CONCLUSIONS

The results suggest that Vitamin D deficiency may have value as a negative prognostic indicator in papillary thyroid cancer and that pre-operative laboratory evaluation may be less useful. This is important because Vitamin D deficiency is modifiable. While different racial subgroups had different rates of Vitamin D deficiency, neither race nor socioeconomic status showed correlation with cancer stage.

Clinical Outcomes After Unilateral Adrenalectomy for Primary Aldosteronism

Importance

In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects.

Objective

To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism.

Design, Setting, and Participants

A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded.

Main Outcomes and Measures

Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery.

Results

On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater.

Conclusions and Relevance

In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.

Racial/ethnic disparities in the use of high-volume centers for hepatobiliary and pancreatic cancer surgery

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Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p < 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p < 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p < 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

Correlating pre-operative vitamin D status with post-thyroidectomy hypocalcemia

OBJECTIVE

To examine the relationship between pre-operative vitamin D status and post-thyroidectomy hypocalcemia.

METHODS

Retrospective study examining 264 total and completion thyroidectomies conducted between 2007 and 2011. Subjects included had a recorded 25-hydroxyvitamin D (25[OH]D) level within 21 days prior to or 1 day following surgery, did not have a primary parathyroid gland disorder, and were not taking 1,25-dihydroxyvitamin D3 (calcitriol) prior to surgery. Some subjects were repleted with vitamin D pre-operatively if a low 25(OH)D level (typically below 20 ng/mL) was identified. Pre-operative 25(OH)D, concurrent neck dissection, integrity of parathyroid glands, final pathology, postoperative parathyroid hormone (PTH), calcium nadir and repletion, and length of stay were examined.

RESULTS

The mean pre-operative 25(OH)D for all subjects was 25 ng/mL, and the overall rate of post-operative hypocalcemia was 37.5%. Lower pre-operative 25(OH)D did not predict postoperative hypocalcemia (P = .96); however, it did predict the need for postoperative 1,25-dihydroxyvitamin D3 administration (P = .01). Lower postoperative PTH levels (P = .001) were associated with postoperative hypocalcemia.

CONCLUSION

Pre-operative 25(OH)D did not predict a postoperative decrease in serum calcium, although it did predict the need for 1,25-dihydroxyvitamin D3 therapy in hypocalcemic subjects. We recommend that 25(OH)D be assessed and, if indicated, repleted pre-operatively in patients undergoing total thyroidectomy.

Minimally invasive management of lesser sac bronchogenic cyst

This is a rare case of a bronchogenic cyst found below the diaphragm within the lesser sac successfully resected by laparoscopic means.

Bronchogenic cysts rarely develop in the abdomen they typically reside in the mediastinum. We present a unique case of a bronchogenic cyst within the lesser sac. Endoscopic ultrasound proved to be a critical diagnostic tool, and the patient underwent a laparoscopic resection of the lesion.

Treatment options for Graves disease: a cost-effectiveness analysis

BACKGROUND

First-line treatment for Graves disease is frequently 18 months of antithyroid medication (ATM). Controversy exists concerning the next best line of treatment for patients who have failed to achieve euthyroidism; options include lifelong ATM, radioactive iodine (RAI), or total thyroidectomy (TT). We aim to determine the most cost-effective option.

STUDY DESIGN

We performed a cost-effectiveness analysis comparing these different strategies. Treatment efficacy and complication data were derived from a literature review. Costs were examined from a health-care system perspective using actual Medicare reimbursement rates to an urban university hospital. Outcomes were measured in quality-adjusted life-years (QALY). Costs and effectiveness were converted to present values; all key variables were subjected to sensitivity analysis.

RESULTS

TT was the most cost-effective strategy, resulting in a gain of 1.32 QALYs compared with RAI (at an additional cost of 9,594 US dollars) and an incremental cost-effectiveness ratio of 7,240 US dollars/QALY. RAI was the least costly option at 23,600 US dollars but also provided the least QALY (25.08 QALY). Once the cost of TT exceeds 19,300 US dollars, the incremental cost-effectiveness ratio of lifelong ATM and TT reverse and lifelong ATM becomes the more cost-effective strategy at 15,000US dollars/QALY.

CONCLUSIONS

This is the first formal cost-effectiveness study in the US of the optimal treatment for patients with Graves disease who fail to achieve euthyroidism after 18 months of ATM. Our findings demonstrate that TT is more cost effective than RAI or lifelong ATM in these patients; this continues until the cost of TT becomes > 19,300 US dollars.

Occlusive colon carcinoma: virtual colonoscopy in the preoperative evaluation of the proximal colon

PURPOSE

To evaluate the use of preoperative virtual colonoscopy to examine the proximal colon in patients with distal occlusive carcinomas, defined as cancers that cannot be traversed endoscopically.

MATERIALS AND METHODS

Twenty-nine patients with occlusive colorectal carcinomas underwent preoperative virtual colonoscopy with use of a standard protocol. Patients with acute bowel obstruction were excluded. Results of virtual colonoscopy were compared with the findings of preoperative colonoscopy, preoperative barium enema examination, intraoperative colon palpation, histopathologic outcome, and postoperative colonoscopy and barium enema examination, where possible.

RESULTS

Virtual colonoscopy helped identify all 29 occlusive carcinomas and demonstrated two cancers and 24 polyps in the proximal colon. Both synchronous cancers were confirmed intraoperatively and resected. Postoperative conventional colonoscopy in 12 patients confirmed 16 polyps identified at virtual colonoscopy and demonstrated two subcentimeter polyps missed at virtual colonoscopy. Postoperative barium enema examination was performed in two patients and helped confirm two polyps identified at virtual colonoscopy. Virtual colonoscopy successfully demonstrated the proximal colon in 26 of 29 patients examined compared with preoperative barium enema examination, which failed to adequately demonstrate the proximal colon in any patient examined.

CONCLUSION

Virtual colonoscopy is a feasible and useful method for evaluating the entire colon before surgery in patients with occlusive carcinomas.

Loss of expression of a 55 kDa nuclear protein (nmt55) in estrogen receptor-negative human breast cancer

We have identified and characterized a 55 kDa nuclear protein (referred to as nmt55) from human breast tumors and MCF-7, human adenocarcinoma breast cell line, using site-directed monoclonal antibodies. Measurements of estrogen receptors (ER) and progesterone receptors (PR), by ligand binding assays, in cytosols of 63 human breast tumors permitted classifications of these tumors into four phenotypes (ER+/PR+, ER+/ PR-, ER-/PR-, ER-/PR+). Nuclear protein (nmt55) expression in these tumors, as determined from Western blot analyses, showed a statistically significant association (p = 0.001) with tumor hormonal phenotype. Review of the pathologic characteristics of tumors analyzed suggested that lack of nmt55 expression was significantly associated with mean tumor size (p < 0.03), mean ER (p = 0.001) and mean PR (p < 0.002), but was not associated with tumor stage, grade, or type. To further study this protein, we cloned and sequenced a 2.5 kb cDNA using a monoclonal antibody to nmt55. The complete predicted open reading frame encodes a protein with 471 amino acids and a calculated molecular mass of 54,169 Da. The deduced amino acid sequence exhibited unique regions rich in glutamine, histidine, arginine, and glutamic acid. Northern blot analysis of RNA from MCF-7 cells and ER+/PR+ human breast tumors showed a 2.6 kb mRNA. Southern blot analysis suggested the presence of a single copy of this gene. Chromosomal mapping, using fluorescent in situ hybridization (FISH), located nmt55 gene to the X chromosome, region q13. The extensive homology between nmt55 and RNA binding proteins suggested that nmt55 may be involved in hnRNA splicing. The strong association observed between expression of nmt55, tumor hormonal phenotype, mean tumor size, mean ER, and mean PR content suggests that loss of nmt55 expression may be related to events involved in hormone insensitivity, tumor differentiation, and unregulated tumor cell growth and metastases.

A complementary role for thallium-201 scintigraphy with mammography in the diagnosis of breast cancer

Physical examination and mammography are currently the only proven and reliable methods of early detection of breast cancer. Although both procedures are highly sensitive, their limited specificity often requires surgical biopsy in order to differentiate between malignant and benign lesions. The purpose of this prospective study is to investigate the diagnostic specificity of thallium imaging for breast cancer and to determine its efficacy as a complement to mammography. Two groups were studied: Group A: Patients found to have breast abnormalities and scheduled for biopsy or surgery and Group B: Patients who were suspected to have a recurrence of cancer after mastectomies or lumpectomies. In Group A, thallium scans of 32 breasts in 30 patients were performed prior to biopsy or surgery, yielding pathological diagnoses of 31 breasts in 29 patients. Results for Group A included seven true-positive thallium scans, twenty-two true-negative scans, two false-negative scans, and one false-positive scan. In Group B, seven patients were scanned to evaluate subcutaneous nodules for breast cancer following mastectomy or lumpectomy. Results for Group B included five true-positive scans, one true-negative scan, one false-negative scan and no false-positive scans. Thallium breast scanning was shown to have high specificity for cancer (specificity 96% and sensitivity 80%), suggesting that this technique should be evaluated in additional patient studies to determine its role in clinical situations.

Novel approach to iatrogenic bile peritonitis

Bile peritonitis after injury to the biliary tree is a serious complication that requires exploratory laparotomy. Our patient had an obstructing ampullary carcinoma, and generalized bile peritonitis developed from attempted percutaneous transhepatic cholangiography. The patient's condition was managed by peritoneal lavage and endoscopic transampullary stenting, with immediate relief of pain and toxicity. Exploratory laparotomy was avoided, and an eventual pylorus-sparing Whipple resection was the definitive treatment. We believe this to be the first report of successful nonoperative treatment of a patient with bile peritonitis with obstructive jaundice.