Time Trends of Benign/Malignant Breast Biopsy Ratios a Multicenter Italian Study

Aims and background

Although they have been decreasing over time due to improved specificity of diagnostic assessment, benign biopsies of the breast are still common. Benign biopsies should be regarded as negative events, due to their economical and psychological cost and their possible negative impact on cosmesis and on further diagnostic evaluation.

Methods

Retrospective data on benign/malignant breast biopsies ratio (B/M) were collected in 9 Italian centers for a period of 10-15 years. The time trend of B/M and its association to age or to single centers was evaluated.

Results

Overall 31,001 cases were considered. A strong association of B/M to age was evident (average B/M values were 5.0, 1.3, 0.6, and 0.2 for women aged <40, 40-49, 50-59, and >59 years). A significant trend of decreasing B/M over time was observed only for one center. Age standardized B/M was significantly different (P<0.000001) between centers, ranging between 0.34 and 1.69. Multivariate analysis confirmed an independent significant association of age and center to B/M.

Conclusions

Marked differences in B/M are evident between centers, which cannot be explained by the confounding effect of age or by any apparent difference in the diagnostic protocol. The observed differences are likely ascribed to individual variations in diagnostic aggressivity. A progressive increase of the predictive value of calls for surgical biopsy may be achieved over time and centers with a high B/M should make every effort to optimize their performance. Acceptable (<40=5, 40-49=1.5, 50-59=0.75, >59=0.3) and desirable (2.5, 0.75, 0.35, 0.15) age specific reference standards for B/M are proposed.

Benign Breast Surgical Biopsies: Are They Always Justified?

Aim of the study

To evaluate the indications for open surgical biopsy of breast lesions resulting in a benign histologic report.

Methods

A consecutive series of 754 benign breast biopsies was collected from six Italian centers previously participating in a multicenter study on the benign/malignant biopsy ratio. Histologic diagnosis, diagnostic tests performed, final clinical diagnosis and the indication for surgical biopsy were compared.

Results

Fibrocystic alterations represented the most frequent histologic type (43.2%), followed by fibroadenomas (34.5%). Atypical hyperplasia, phyllode tumors and cancerlike lesions (radial scar, sclerosing adenosis) accounted for a minority of cases. The diagnostic approach was different among centers, with mammography, ultrasonography or cytology being underused in some of them. Suspicion of cancer was an indication for surgical biopsy in 66.7% of cases. In the remaining cases the final report was negative or benign, but biopsy was advised for growing lesions (11.3%) or for cosmetic (3%) or psychological reasons (8.2%). In 4% of cases surgical biopsy was presumably advised for the concurrent influence of high-risk conditions such as previous breast cancer (0.7%), family history of breast cancer (2%) or contralateral synchronous breast cancer (1.3%). In 6.8% of the cases biopsy was advised elsewhere for unknown reasons. The indications for biopsy differed among centers, with one center having a low rate of suspicious cases (37%) and a high rate of reported “cosmetic” or “psychological” reasons (47%).

Conclusions

Leaving aside differences in diagnostic approach and aggressiveness, two thirds of all lesions were biopsied in order to exclude cancer. The routine use of a more complete diagnostic protocol and/or alternative methods to obtain a histologic diagnosis (e.g. core biopsy) might substantially reduce the need for open surgical biopsy.

[Thymoma, aplastic anemia, hypogammaglobulinemia and malignant pulmonary neoplasm: a case report]

A 67 year old man presented with non-invasive thymoma, associated aplastic anemia and important hypogammaglobulinemia; the postoperative course has been characterized, three months later, by thrombocytopenia (kept under control with steroid therapy) and, two years later, by squamous lung cancer, not susceptible of surgical treatment. The patient died five years after operation because of progression of the lung cancer. Anemia improved only partially after operation; there where no effects on hypogammaglobulinemia. Thymoma has been reported in literature in 50% of patients with aplastic anemia, 7-13% of adult patients with hypogammaglobulinemia is affected by thymoma, in 21% of patients that presented with thymoma other tumors have been discovered through clinical history.

Prognostic significance of estrogen receptors in 405 primary breast cancers: a comparison of immunohistochemical and biochemical methods

Over the last few years, estrogen receptor determination by means of immunohistochemistry has been extensively used. The aim of this study was to compare this technique with estrogen receptor determination by means of dextran-coated charcoal, and to evaluate whether one of the two methods is more predictive of prognosis. Estrogen receptors were determined by means of both the dextran-coated charcoal method and immunohistochemistry in 405 patients with primary breast cancer; age, pathological tumor size, nodal status, and progesteron receptors by dextran-coated charcoal method were also recorded. The disease-free and overall survival probabilities were estimated using the product-limit method; Cox's proportional hazard model was used to evaluate the prognostic role of estrogen receptors as determined by the two methods. There appears to be a close association between estrogen receptor determination by the two methods (81.5% of concordant results) and their prognostic role was similar, even when the patients were divided into different groups (on the basis of their estrogen receptor status) and adjustments for the effect of other prognostic variables were taken into account. Our study shows that the two methods can be used indifferently to evaluate estrogen receptor status as a prognostic factor in breast cancer patients.

[Rupture of the diaphragm caused by closed trauma. Case contributions and review of the literature]

AIM

Retrospective evaluation of 19 diaphragmatic ruptures due to blunt trauma.

MATERIALS AND METHODS

We collected all patients with thoracic and/or abdominal blunt trauma who were admitted to the department of surgery (Clinica Chirurgica and Chirurgia generale C) from 1970 to 1995. We selected patients with ascertained diaphragmatic rupture.

RESULTS

We considered 17 cases of TDR (15 males and 4 females). Mean age was 38 years (range 16-67). Radiologic findings were consistent with TDR in 10 cases out of 17 (58.8%). Right hemidiaphragm was injured in 6 cases (31.6%). 10 patients (52.6%) presented at operation with intrathoracic visceral herniation. 8 patients underwent laparotomy, 7 both laparotomy and thoracotomy, 4 thoracotomy alone. Perioperative mortality was 15.7% (3 patients).

DISCUSSION AND CONCLUSIONS

The clinical features were complicated by a large number of associated lesions; radiologic diagnosis is comparatively easy if visceral herniation into the thorax is present, repeated radiologic examinations facilitate diagnosis. The surgical access is determined by concomitant associated injuries which may require urgent operation.

Delayed traumatic hernia of the diaphragm presenting with hypertensive pneumothorax. Case report and review of the literature

The diagnosis of traumatic hernia of the diaphragm can be obtained at the time of injury or months-years after the trauma. The Authors report a case of traumatic hernia of the diaphragm, diagnosed 3 years after a blunt thoracic trauma in a 47-year-old man. The patient was admitted to the hospital for a pneumothorax caused by perforation of the herniated colon. He underwent colonic resection and reduction of the herniated viscera but unfortunately he died of septic shock on the 40th postoperative day. Pneumothorax is a very rare complication of traumatic diaphragmatic hernia and few cases are reported in literature. The diagnosis in the delayed phase is not easy since the correlation with the trauma is not always clear.

Mastectomy and immediate breast reconstruction: oncological considerations and evaluation of two different methods relating to 88 cases

The authors consider 88 cases of mastectomy and immediate breast reconstruction mainly performed using the skin expander plus prosthesis method or latissimus dorsi myocutaneous flaps. At the same time, 53 patients underwent contralateral mastopexy for symmetry. The mean follow-up was 21 months (range 2-102). Progressive disease was observed in nine cases: one patient presented scar relapse, one axillary relapse, two contralateral tumor, two contralateral tumor and distant metastasis, three distant metastases and one death from distant metastasis. Reconstruction complications were capsular contracture in 12 cases, infection in nine, skin necrosis in two, skin expander breakage in three and implant dislocation in one. The final result was judged good in 54 cases, fair in nine, poor in 11 and unevaluable in 14. In conclusion immediate breast reconstruction does not seem to interfere with the disease or oncological therapy. After analysing separately, and comparing the results and complications of the two main techniques used, latissimus dorsi seems to be the most reliable method in the majority of cases but skin expanders can be a good technique in patients with small and firm breasts and without complicating risk factors.

Retroperitoneal paragangliomas: role of immunohistochemistry in the diagnosis of malignancy and in assessment of prognosis

OBJECTIVE

To present our experience of 10 patients with extra-adrenal retroperitoneal paragangliomas, and assess prognostic tests.

DESIGN

Retrospective study of casenotes.

SETTING

University hospital, Italy.

SUBJECTS

10 Patients who presented with paragangliomas between 1970 and 1991.

MAIN OUTCOME MEASURES

Histological and immunohistochemical results, and outcome.

RESULTS

All tumours were completely resected and there was no operative mortality. Of the 8 patients who had no metastases at presentation 3 died of recurrence 3, 5, and 10 years later, respectively; 4 were alive and free of disease 2-7 years after diagnosis. The 2 patients with synchronous bone metastases at presentation died 1 and 4 years later. Immunohistochemical analysis of type I cells (chromogranin A and neurone-specific enolase) showed little correlation with progression of disease, but there was a correlation between the presence of type II cells (S100 protein) and good prognosis.

CONCLUSIONS

Excision is the treatment of choice for paraganglioma. Immunohistochemical techniques may provide useful information about prognosis, in particular about those patients who are at increased risk of recurrence. Long term follow up is essential, because successful management of recurrence is dependent on early recognition.

Phyllodes tumor of the breast: problems of differential diagnosis and therapeutic approach from an analysis of 17 cases

Retrospective analysis of 17 cases of phyllodes tumor with a follow-up of almost 1 year revealed no close correlation between histological pattern and clinical course, since local relapse occurs even after histological findings of benign lesion in the primary tumor. Phyllodes and fibroadenoma patterns are often associated in the same patient and extensive surgery is not recommended owing to the fact that recurrences are observed both after subcutaneous mastectomy and after simple resection. We conclude that local control of the disease by wedge resection and strict follow-up may be the most rational approach.

Estrogen and progesterone receptors in breast cancer: correlation with clinical and pathological features and with prognosis

Estrogen and progesterone receptor status was reviewed in 405 patients from prior adjuvant breast cancer trials at the University of Verona. Only 233 patients were actually examined with respect to hormone status and outcome. No relationship between hormone receptor status and most of the commonly followed prognostic signs, i.e. tumor size, nodal status, and age, was found. Overall survival was correlated with hormone receptor positivity for patients with more than 4 positive axillary nodes. Disease-free survival was correlated only with PgR positivity, in premenopausal and in T1 groups.

[Carcinoma of the male breast (our experience and a review of the literature)]

The authors consider their experience in male breast cancer. Making a review of the literature they point out the risk factors and the prognosis of this disease.

[Bullous emphysema of the lung (our experience)]

Ten patients (9 males and 1 female; mean age: 44.8 yrs) with bullous lung disease were treated. Frequent patient-history findings were smoking and spontaneous pneumothorax. Nine cases were treated surgically either by bullectomy or atypical resection. In one case, an attempt at endobullous aspiration failed owing to the patient's very poor general condition. Among the postoperative complications in three cases we observed difficult pulmonary re-expansion and infection of the surgical wound with consequent pleural empyema in another.

[Spontaneous rupture of the stomach (case report)]

The Authors show a case of a 68 year old woman underwent a successful operation for spontaneous stomach heavage. The linear solution of continuity, 5-6 cms long, was sutured on the small gastric curve. The treatment consisted in suturing the lesion and performing a decompressive gastrostomy.

[Primary lymphoma of the breast (apropos of a clinical case)]

Taking as their starting point the observation of a case of primary lymphoma of the breast, the Authors point out that this tumour constitutes a rare disease in the context of non-Hodgkin lymphomas arising in sites other than the lymph nodes. They emphasize the clinical and instrumental diagnostic difficulties which the disease poses, as well as the uselessness of radical surgical therapy and the need for radio-chemotherapeutic management along with periodic follow-up. The Authors go on to explain how difficult it is to formulate a reliable prognosis for this type of tumour in view of the lack of homogeneity and the limited numbers of cases reported in the literature.

[Clinical results after proximal selective vagotomy (considerations on 42 cases)]

The authors report the results of a 6-8 year follow-up of 42 patients treated by selective proximal vagotomy with pyloroplasty for gastric or duodenal ulcer disease. On the basis of Visick's classification, the patients broke down into the following categories: Cat. 1: 66.6%; Cat. 2: 26.1%; Cat. 3: 2.3%; Cat. 4: 4.7%, with 92.7% belonging to the first two categories. These data are in agreement with other data reported in the literature, and show no significant differences as compared to follow-up one year after surgery.

[Gastric metastasis of melanoma (report of a clinical case)]

The Authors report a case of gastric metastasis from melanoma of the skin, occurring 6 years after removal of the primary neoplasm. The metastasis, which was characterized by conspicuous alimentary tract haemorrhage, called for emergency surgery consisting in a total gastrectomy with oesophago-jejunal anastomosis according to Roux. The Authors then go on to review the literature on the subject, stressing the frequency of gastrointestinal metastases in skin melanomas with an incidence affecting up to 60% of cases in autopsy series. After examining the main clinical aspects, endoscopic appearances and r-ray findings, the Authors deal at some length with prognosis, pointing out that isolated metastases may constitute a surgical indication in view of the cases of fairly good long-term survival reported in the literature.

[Benign pathology of the breast. Diagnostic protocol and therapeutic indications]

The frequency of benign mammary disease and the need to differentiate between benign and malignant tumors without the indiscriminate use of instrumental examinations and biopsies have prompted the Cooperative Interdisciplinary Group on Mammary Neoplasms to adopt the diagnostic protocol and propose a number of therapeutic indications. Though involving a progressive reduction in biopsies, the use of the protocol has not led to failure to recognize carcinomas, the number of identified malignancies being maintained within the anticipated limits.

[Hepatic cystadenocarcinoma: presentation of a clinical case and review of the literature]

The finding of a case of cystadenocarcinoma supplies the opportunity for a reviewing of the literature concerning this rare liver neoplasm. From a diagnostical standpoint, the instrumental tests result non-specific. Only the needle-biopsy of papillary formations set forth through the echography within hepatic formations of cystic type is able to supply diagnoses of cystadenocarcinoma. Yet, the procedure is not exempt from risks. Decisive may be the peroperative histologic testing on fragments of the cyst wall. In consideration of the better prognosis of cystadenocarcinoma in respect of hepatocarcinoma and cholangiocarcinoma, and the risk of relapse, the election surgical treatment should be represented by hepatectomy.

[Treatment and prevention of postmastectomy lymphedema (our experience)]

The authors consider the incidence of arm lymphedema after mastectomy. Considering the temporary results which come from surgical practices, either from excision operations or lymphovenous anastomosis, they stress out the importance of the prevention measures and of the physiotherapeutic treatment. This is essential to keep lasting as long as possible the results of the operation when it is necessary because of serious functional deficit. Two cases of Thompson's operation are shown.

[Primary seminoma of the mediastinum: diagnostic and therapeutic approach]

The Authors show three cases of mediastinal seminoma, and discuss the epidemiologic, etiopathogenetic and clinical aspects of such neoplasms; they dwell upon the criteria allowing to define as primitive an extragonadal germinal tumour, and emphasize the importance of the multidisciplinary therapeutical approach in controlling these neoplasms, characterized anyhow in the pure forms by a remarkable sensitiveness to radium; promising looks the use of the tumoral markers (beta-HCG and AFP) for a diagnostical specification, for the choice of the treatment and for the evaluation of its effects.

[Multivariate statistical analysis in predicting bronchopulmonary complications after surgical interventions in cancer of the lung]

A multivaried statistic process, the linear discriminant analysis, applied to VEMS, CV, I.T., FEF 25-75, pH, PaO2, PaCO2, was used by the authors to foresee, in 42 patients suffering from bronchogenous carcinoma, the arising or absence of respiratory complications after operation. With such method, the falsely positive or negative previsions, resulted to be 13 with a total percentage of error as high as 30%. These results suggest that, even when elaborated through the multivaried analysis, the parameters studied do not allow to adequately discriminate the patients who would develop, after operation, bronchopulmonary complications from those who would be exent from them.

[Delayed recognition of traumatic rupture of the diaphragm. Diagnostic and therapeutic problems]

The Authors face the diagnostic and therapeutical problems involved in the tardy recognition of diaphragmatic breakages. On the basis of two clinical cases observed, they emphasize the relative frequency of this lesion, the variability of the clinical pictures, the limits of the clinical and radiological diagnostics, the utmost seriousness of the complications. They face the problem of the choice of the surgical way of approach and the techniques for repairing the diaphragmatic lacerations.

[Traumatic rupture of the diaphragm. Diagnostic problems and surgical therapy]

The Authors show 10 cases of traumatic disruption of diaphragm, subsequent to close or open trauma, all subjected to urgency operation. They discuss the problems concerning diagnosis and surgical tactics, and point out the frequency of visceral and osseous associated lesions and their importance in conditioning prognosis.

[Parenteral and enteral nutrition in esophageal stenosis. Initial clinico-experimental results]

The Authors study the pre- and post-operative nutritional treatment of the patients suffering from oesophageal stenosis, principally neoplastic, waiting to undergo the radical operation. Although the compensation of the nutritional situation of these patients through the enteral and parenteral nutrition results difficult to be effected, the results encourage to apply this clinical practice everywhere a demolitive operation, always long, heavy, and burdened by a high morbidity and mortality, is foreseen.

[Esophago-gastro-enteric manifestations of scleroderma. Apropos of a clinical case]

Starting from the observation of a case of scleroderma with oesophageal location, the Authors study the digestive troubles of such disease, and remark that, in some cases, the treatment with cimetidin can give good results as to symptomatology, in spite of the chronic evolution of the disease.

[A case of duodenal schwannoma (clinical study)]

Taking a case of duodenal schwannoma, that they had observed, as a starting point, on the base of their experience and the data of literature, the authors discuss the epidemiological, of classification and anatomo-pathological aspects of this rare neoplastic form. They particularly outline the clinical aspect, the diagnostic pre-operating iter and the correct and radical surgical behaviour that must be practiced during laparatomy.

[Incidence of recurrent nerve paralysis in personal cases of thyroid surgery]

The authors review their series of thyroid operations, totaling 383 cases in the last seven years. In that series the incidence of recurrent nerve lesions leading to permanent sequels was 1.07% (all treated without surgical preparation of the nerve); an additional 0.53% of the patients developed transient paralysis of the recurrent nerve--of which the authors discuss the possible etiology. The authors conclude by stating the need for careful recognition of the recurrent nerve in all surgical procedures involving the thyroid gland, except some enucleo-resections; they confirm the importance of branches of the inferior thyroid artery and the inferior horn of the thyroid cartilage as reference points.