International Seminars in Surgical Oncology - Latest articles

Women with large breasts are at an increased risk of advanced breast cancer

Chaminda Sellahewa, Peter Nightingale and Amtul R Carmichael — 2008-06-30

Background: The risk of nodal metastasis is higher in women with bigger breast. It is not clear if this increase is due to the size of the breast (largely related to obesity) or is the result of larger tumour size at presentation (due to delayed diagnosis). It is hypothesised that women with large breasts are more likely to have node positive disease mainly attributable to their breast size. Patients and Methods One hundred and twenty consecutive patients who underwent mastectomy during the year 2004 and 2005 for primary breast cancers in a large Teaching Hospital were included in the study. Patientas variable and tumour variable were collected and analysed by SPSSA(R) computer programme. Result It was found that big breasted women (those patients with mastectomy weight greater than 800g) had a significantly greater tumour size than those with smaller breasts (p=0.019, Mann-Whitney test) but there was no significant difference in grade (Kendall's tau-b = 0.055, p=0.57) or lymph node positivity (Kendall's tau-b = 0.011, p=0.93) between the two groups. Although, the tumour size was significantly greater in those with lymph node metastases (p <0.001) but mastectomy weight was not found to be significantly greater in those with lymph node metastases (p=0.11). For patients with similar tumour sizes mastectomy weight was not significantly greater in those patients with lymph node metastases (p=0.28). Conclusion: It is concluded that increased incidence of lymph node positivity at presentation big-breasted women is because of larger size of the primary tumour and not due to the size of the breast alone.

Uterine leiomyomas with tubules

Teresa Pusiol, Annamaria Parolari and Francesco Piscioli — 2008-06-09

. We report two cases of uterine leiomyoma with tubules as a new pathological entity. Since these are biphasic neoplasms (composed by epithelial and mesenchimal elements), the differential diagnosis is between mixed mullerian tumours and uterine tumors resembling ovarian sex cord tumors (UTROSCTs). In the differential diagnosis, the mixed mullerian tumors are easily excluded because of their specific histological and immunohistochemical features. UTROSCTs are similar to the lesions we reported and the differential diagnosis requires positivity for immunohistochemical markers as inhibin, CD99, calretinin, Melan-A. Our conclusions are that to perform a diagnosis of UTROSCT at least two immunohistochemical marker have to be expressed. In the present case they did not, so we called the lesion leiomyoma with tubules.

Metastatic Hurthle Cell Carcinoma of the thyroid presenting as a Breast Lump: A Case Report

Yahya Al-Abed, Emma Gray, Konrad Wolfe, Gavin W Watters and Jonathan M Philpott — 2008-05-27

Background: Hurthle cell carcinoma of the thyroid is a rare form of thyroid cancer. It may present as a low grade tumour or can present as a more aggressive metastatic carcinoma. Hurthle cell carcinoma has the highest incidence of metastasis among all differentiated thyroid cancers. Most commonly haematogenous spread to lungs, bones and brain, however spread to regional lymph nodes is not uncommon. The breast is a rare site for metastasis from extramammary sources. We present the first case of breast metastasis from Hurthle cell carcinoma of the thyroid.Case presentationWe report a 77 year old lady who had total thyroidectomy and bilateral neck dissection followed by radiotherapy for a high grade metastatic Hurthle cell carcinoma of the thyroid. Ten months later she presented to the breast clinic with left breast lump and a lump at the left axilla. Fine needle aspiration cytology of the lumps and histology after wide local excision of the breast lump confirmed metastatic Hurthle cell carcinoma. Conclusion: The presence of breast lumps in patients with history of extramammary cancer should raise the possibility of metastasis.

The importance of margins status after breast conservative surgery and radiotherapy in node positive patients: a follow-up of 10–15 years

Isabella Besana-Ciani and Michael J Greenall — 2008-05-22

Background: Margin status is the main factor determining local recurrence (LR) after wide excision and radiotherapy for breast cancer. The aim of the study is to evaluate if positive margins are as great a risk factor for LR in node-positive as in node-negative patients, since the major risk in the former group is dissemination and whether there is a correlation between nodal status and margins in relation to prognosis. Methods: 773 patients underwent WLE and radiotherapy between 1988 and 1992 and were followed-up (> 10 years) to determine LR rates according to margin and nodal status. Margins were assessed by cavity-shave biopsies and the axilla was staged by sampling or clearance. Results: 461 patients were node negative and 312 node positive. In the node-negative group 415 patients had negative margins and 46 positive: LR after > 10 years was 12 % and 28 % respectively. Among the 312 patients in the node positive group, 267 were margin negative and 45 positive; the LR rate was 12 % and 18 % respectively. In the node negative-group there was a statistically significant difference between the positive and the negative margins with higher relapse rate and lower overall survival (p < 0.001), whereas in the node-positive group the equivalent comparison didn't show any statistical difference. Conclusion: Although re-excision should be always recommended, in node-negative patients positive margins are associated with a statistically higher LR rate and lower overall survival while in node-positive disease margins might be of less importance in determining prognosis as dissemination is more likely to occur.

Mirizzi Syndrome: an unexpected problem of cholelithiasis. Our experience with 27 cases

2008-05-21

PurposeMirizzi syndrome is a rare complication of long standing cholelithiasis. The purpose of this study is to retrospectively estimate the diagnostic and treatment methods applied in patients with Mirizzi syndrome.Materials and methodsOur experience with 27 cases with Mirizzi syndrome is presented. They were diagnosed either by imaging techniques, or during surgical operation. All of the patients were managed surgically. Results: 8 patients were diagnosed preoperatively and the rest intraoperatively. Morbidity rate after surgery was 18,5%, and mortality rate was zero. The patients presented free of symptoms three months after surgery during the follow-up. Conclusion: Mirizzi syndrome is rarely diagnosed preoperatively and US proved inadequate for this purpose. Surgery is the only therapy and usually provides additionally definitive diagnosis.

Exophytic growth of a neglected giant subcutaneous Leiomyosarcoma of the lower extremity. A case report

2008-05-21

Background: Superficial leiomyosarcoma is an exceedingly uncommon malignant tumor which could be located either to cutaneous or subcutaneous tissues. Increased mass size and depth, advanced tumor staging and inadequate surgical excision are the main prognostic factors for poor result.Case presentationWe report a rare case of a 71-year-old man with an extensive exophytic lesion (12 × 10 cm) in the anterior-medial side of the proximal right tibia. The lesion was painless and consistently neglected by the patient until a skin trauma caused ulceration of the affected area. Magnetic Resonance Imaging revealed a soft-tissue mass which was well defined from the surrounding bone and muscles. As initial biopsy in another hospital hadn't clarified the true nature of the lesion, new samples were taken and the diagnosis of leiomyosarcoma was established. Laboratory examination showed no distant metastasis and wide excision of the neoplasm was decided. After tumor resection, the remaining soft tissue and skin defect was covered with a gastrocnemius myocutaneous flap. The postoperative period was uneventful and wound healing was followed by local radiotherapy and systemic chemotherapy. At 3 years follow up, no recurrence or metastasis was identified and the patient was able to walk and stand without impairment of his ambulatory status. Conclusion: Proper surgical management of soft tissue leiomyosarcoma continues to remain the cornerstone of treatment efficacy and the most important prognostic factor for patients' survival. Reconstruction of the remaining soft tissue defect should be always performed at the same operative time when removal of giant size tumors leaves an uncovered cavity with an inadequate sleeve of muscular and skin tissues.

Intraosseous angiosarcoma with secondary aneurysmal bone cysts presenting as an elusive diagnostic challenge

2008-05-20

Angiosarcoma of bone is an exceedingly rare primary bone malignancy that can present as an aggressive osteolytic lesion. Histological diagnosis can be extremely challenging, as the pathological features often resemble that of aneurysmal bone cysts. We report an interesting and peculiar case of an intraosseous angiosarcoma that presented as a diagnostic dilemma and discuss the relevant radiological and pathologic findings.

The role of Herceptin in early breast cancer

Ashok Subramanian and Kefah Mokbel — 2008-04-28

Herceptin is widely regarded as the most important development in the treatment of breast cancer since Tamoxifen and the development of the multidisciplinary team (MDT). It is particularly exciting from an oncological polint of view as it represents success in the emerging field of specific targeted therapies to specific molecular abnormalities in tumour cells. This review will focus on the nature of the Her2 overexpression and the role of herceptin in the treatment of early breast cancer.

Paraneoplastic cerebellar degeneration as a presentation of breast cancer – a case report and review of the literature

2008-04-21

Paraneoplastic cerebellar degeneration is part of a rare spectrum of neurological syndromes whereby gynaecological, lung or breast cancers present primarily with neurological manifestations. The presence of onconeural antibodies and PET scanning help in the challenging diagnosis of these conditions but despite the treatment of the primary cancer, the prognosis for the neurological symptoms is poor.

Uterine PEComa: appraisal of a controversial and increasingly reported mesenchymal neoplasm

Oluwole Fadare — 2008-03-06

In recent years, a group of tumors that have been designated "perivascular epithelioid cell tumors" (PEComa) have been reported with increasing frequency from a wide variety of anatomic locations. The uterus and retroperitoneum appear to be the most frequent sites of origin for these lesions. PEComas belong to an identically named family of tumors comprised of conventional angiomyolipomas, clear cell sugar tumors, lymphangiomyomatosis and clear cell myomelanocytic tumor of the falciform ligament/ligament teres, and are also known as PEComa-NOS. This article is a primer for clinicians on the most salient clinicopathologic features of uterine PEComas, as most of the debate and discussion have taken place in the pathologic literature. The author appraises in detail the current state of knowledge on PEComas of the uterus based on a review of published data on the 44 previously reported cases, and comments on areas of controversy. The latter are centered predominantly on the significant morphologic and immunophenotypic overlap that exists between uterine PEComa and some smooth muscle tumors of the uterus. The clinicopathologic features of cases reported as epithelioid smooth muscle tumors and cases reported as uterine PEComas are compared and contrasted, and a practical approach to their reporting is proposed.