Negative Fine-Needle Aspiration in Patients with Goiter: Should We Doubt It?

BACKGROUND

Epidemiologic studies demonstrated higher incidence of thyroid cancer in patients with multinodular goiters compared to the general population. The aim of this study was to evaluate the risk of finding significant thyroid cancer in patients undergoing thyroidectomy for presumed benign disease.

METHODS

The records of 273 patients operated for indications other than cancer or indeterminate cytology were reviewed and analyzed.

RESULTS

202 (74%) patients had a preoperative fine-needle aspiration (FNA) performed. FNA was benign in 96% of patients and non-diagnostic in 4%. Malignancy was unexpectedly found in 50 (19%) patients. Papillary carcinoma constituted 94% of cancers and 86% of cancers were incidental microcarcinomas. Only 7 (2.6%) patients of the entire cohort had tumors greater than 1 cm, of those only 3 had a previous benign FNA (false-negative rate 1.5%).

CONCLUSIONS

The rate of significant thyroid cancer found unexpectedly in resected goiters is extremely low. A negative FNA excludes significant cancer with near certainty.

Concurrent Medullary, Papillary, and Follicular Thyroid Carcinomas and Simultaneous Cushing's Syndrome

BACKGROUND

Papillary thyroid carcinoma is the most common thyroid cancer (85%). Follicular thyroid carcinoma is the second most common type of thyroid cancer, accounting for up to 10% of all thyroid cancers. Medullary thyroid carcinoma accounts for only 5-8% of thyroid cancers. Concurrent medullary, follicular, and papillary carcinomas of the thyroid gland are extremely rare and reported scarcely.

CASE REPORT

A 72-year-old male presented with nonspecific neck pain. The workup revealed a nodular thyroid gland with a follicular lesion on fine-needle aspiration. Total thyroidectomy was performed and pathological examination identified a 25-mm follicular carcinoma, two papillary microcarcinomas, and two medullary microcarcinomas. The genetic workup was negative and no other family members were diagnosed with any endocrinopathy. Two months after surgery, the patient was diagnosed with Cushing's syndrome that was treated with laparoscopic left adrenalectomy. On 3-year follow-up, the patient is asymptomatic with no evidence of recurrent disease.

CONCLUSION

We present a rare case of a patient with follicular, papillary, and medullary thyroid carcinoma, and Cushing's syndrome. To date, no known genetic mutation or syndrome can account for this combination of neoplastic thyroid and adrenal pathologies, although future research may prove differently.

Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial

BACKGROUND

Current recommendations for treating acute calculus cholecystitis include the use of intravenous antibiotics, although these recommendations were never tested scientifically. The aim of this study was to evaluate the role of intravenous antibiotic therapy in patients with mild acute calculus cholecystitis.

METHODS

In this prospective, randomized controlled trial, 84 patients with a diagnosis of mild acute calculus cholecystitis were randomly assigned to supportive treatment only or supportive treatment with intravenous antibiotic treatment (42 patients in each arm). Patients were followed through their index admission and until delayed laparoscopic cholecystectomy was performed.

RESULTS

The two study groups did not differ in their demographic data or in the clinical presentation and disease severity. Analysis was conducted on the intent-to-treat basis. Patients in the intravenous antibiotics arm resumed a liquid diet earlier (1.7 vs. 2.2 days, p = 0.02) but did not significantly differ in resumption of regular diet (2.8 vs. 3.2 days, p = 0.16) or hospital length of stay (LOS) (3.9 vs. 3.8 days, p = 0.89). Patients in the intravenous antibiotics arm had rates of percutaneous cholecystostomy tube placement (12 vs. 5 %, p = 0.43), readmissions (19 vs. 13 %, p = 0.73), and perioperative course similar to those not receiving antibiotics. The overall hospital LOS, including initial hospitalization and subsequent cholecystectomy, was similar for both groups (5.6 vs. 5.1 days, p = 0.29). Eight (19 %) patients in the supportive arm were crossed over to the intravenous antibiotic arm during the index admission.

CONCLUSIONS

Intravenous antibiotic treatment does not improve the hospital course or early outcome in most of the patients with mild acute calculus cholecystitis.

Feeding jejunostomy for post-operative nutritional support

Enteral feeding by tube jejunostomy, inserted during definitive surgery, was used in 19 adult patients operated upon in a 24 month period. Jejunostomy feeding was associated with a low rate of minor complications enabling delivery of adequate caloric and protein input shortly after major abdominal operations and up to 9 months later. We feel that the insertion of a regular size jejunostomy tube during surgery is a simple, brief and safe procedure which offers efficient and inexpensive nutritional support, and thus has an important role in the post-operative management of selected patients. It is also easily used in the home setting if needed.

Differentiating benign from malignant thyroid nodules using micro ribonucleic acid amplification in residual cells obtained by fine needle aspiration biopsy

BACKGROUND

Fine needle aspiration biopsy (FNAB) is the most commonly used diagnostic tool to differentiate benign from malignant thyroid nodules. Nevertheless, some FNAB cytology results are not definite. In such cases diagnostic thyroid lobectomy is performed with malignancy rate on final histopathology ranging at 15%-75%. The aim of this study was to improve on the accuracy of FNAB-based cytology by amplification of microRNAs (micro ribonucleic acids [miRs]) from the residual cells left in the FNAB needle after submission for cytology.

METHODS

Residual cells were collected from the needle cup after FNAB cytology of 77 consecutive patients with thyroid nodules. miR-enriched RNA was extracted for all patients with cytology showing either follicular lesion or suspicion for malignancy (n=11). The expression of miR-21, -31, -146b, -187, -221, and -222 was determined using real-time polymerase chain reaction. Results were compared with final surgical histopathology.

RESULTS

RNA was successfully extracted from all FNAB specimens. Five patients had FNAB cytology suspicious for malignancy. The miR panel was positive in all five (100%). Six patients had follicular lesions on FNAB. The miR panel was positive in three of four patients (75%) with confirmed malignancy and was negative in two of two (0%) patients with benign pathology results. This corresponded to a specificity of 100%, sensitivity of 88%, and accuracy of 90%.

CONCLUSIONS

RNA extraction from FNAB residual cells is feasible, and a miR panel amplified from the extracted RNA seems like a promising diagnostic tool in this limited number of patients.

Fragmentation of general surgery: burning to death or rising from the ashes

General Surgery is losing its appeal and is facing a critical shortage of surgeons. It therefore has to change and adapt to this new reality and we surgeons are responsible for meeting this challenge. If we want students and residents to embrace surgery we need to show them the rewards and satisfaction that we derive from the profession. A 5 year curriculum is needed to train the "abdominal surgery" or "general surgery specialist," who will maintain and teach comprehensive care of the surgical patient and practice a more limited scope of surgical procedures. In addition, we should train a limited number of disease-oriented specialists by means of 1-2 year fellowships.

Mature Results of a Prospective Randomized Trial Comparing 5-Flourouracil with Leucovorin to 5-Flourouracil with Levamisole as Adjuvant Therapy of Stage II and III Colorectal Cancer- The Israel Cooperative Oncology Group (ICOG) Study

Objective: Survival benefit with adjuvant therapy was shown in patients with Stage III colorectal cancer (CRC). This study evaluates long-term (10-year) outcome in patients with CRC randomly assigned to adjuvant 5-Fluorouracil/Leucovorin (5FU+LV) or 5-FU/Levamisole (5FU+LEV).

Methods: Between 1990 and 1995, 398 patients with curatively resected Stage II-III CRC were randomly assigned to adjuvant 5FU+LV or 5FU+LEV for 12 months.

Results: No difference was evident in 10-year relapse-free or overall survival between study groups. Grade III toxicity was similar between groups; however, neurotoxicity was significantly greater with 5FU+LEV (p=0.02) and gastrointestinal toxicity with 5FU+LV (p=0.03). Female patients treated with 5FU+LEV had improved overall survival.

Conclusions: Adjuvant treatment of CRC is still based on leucovorin modulated fluorouracil. The long-term follow-up results of this trial indicate that the adjuvant treatment of Stage II-III CRC with 5FU+LV or 5FU+LEV is equally effective. The finding of improved survival in female subjects treated with 5FU+LEV warrants further study to determine if Levamisole is a better modulator of 5-FU than Leucovorin in this patient subset.

Development of a microRNA-based molecular assay for the detection of papillary thyroid carcinoma in aspiration biopsy samples

BACKGROUND

Although thyroid nodules are common and diagnosed in over 5% of the adult population, only 5% harbor malignancy. Patients with clinically suspicious thyroid nodules need to undergo fine-needle aspiration biopsy (FNAB). The main limitation of FNAB remains indeterminate cytopathology. Only 20%-30% of the indeterminate nodules harbor malignancy, and therefore up to 80% of patients undergo unnecessary thyroidectomy. The aim of this study was to identify and validate a panel of microRNAs (miRNAs) that could serve as a platform for an FNAB-based diagnostic for thyroid neoplasms.

METHODS

The study population included 27 consecutive patients undergoing total thyroidectomy for FNAB-based papillary thyroid cancer (n = 20) and benign disorders (n = 7). Aspiration biopsy was performed from the index lesion and from the opposite lobe normal tissue in all study patients at the time of operation. RNA was extracted from all aspiration biopsy samples. Quantitative polymerase chain reaction on a panel of previously selected miRNAs was performed. Polymerase chain reaction results were compared with final histopathology. miRNA from tumor tissues was amplified using the highest value of each miRNA expression in normal tissue as a threshold for malignancy detection.

RESULTS

Diagnostic characteristics were most favorable for mir-221 in differentiating benign from malignant thyroid pathology. mir-221 was overexpressed in 19 patients (p < 0.0001) with a sensitive yield of 95%. Specificity, negative and positive predictive value, and accuracy of the miRNA panel were 100%, 96%, 100%, and 98%, respectively.

CONCLUSIONS

miRNA quantification for differential diagnosis of thyroid neoplasms within aspiration biopsy samples is feasible and may improve the accuracy of FNAB cytology.

Asymptomatic pancreatic perivascular epithelial cell tumor (PEComa) in a male patient: report and literature review

CONTEXT

Perivascular epithelial cell tumors (PEComas) are a family of rare mesenchymal neoplasms which share cellular, immunohistochemical and ultrastructural characteristics but are found in different visceral and soft tissue sites. PEComas of the pancreas are extremely rare neoplasms.

CASE REPORT

We describe a 49-year-old male who was incidentally diagnosed with a pancreatic mass. Endoscopic ultrasound-guided biopsy suggested a PEComa. An uneventful pylorus-preserving pancreaticoduodenectomy was thus performed. The tumor was a solid well-circumscribed mass in the pancreatic head with dilatation of the main pancreatic duct. Histopathology revealed a well-circumscribed and vascularized neoplasm, measuring 32x27x30 mm, composed of epithelioid smooth muscle cells with clear cytoplasm rich in glycogen. The tumor exhibited immunoreactivity to alpha-smooth muscle actin and to melanoma-associated antigen HMB-45.

CONCLUSIONS

Although rare, pancreatic PEComas should be included in the differential diagnosis of a pancreatic mass. Currently, the paucity of cases published makes it impossible to predict the behavior and prognosis of these tumors or to advocate an optimal therapy.

Multifocality in well-differentiated thyroid carcinomas calls for total thyroidectomy

BACKGROUND

Multifocality is an important factor when recommending surgery for papillary thyroid cancer (PTC). The aim of this study is to assess the incidence and characterize the spread pattern of multifocal PTC (mPTC) in patients undergoing total thyroidectomy.

METHODS

All thyroidectomies performed between 2003 and 2008 were reviewed identifying 289 patients. Data were obtained for demographics, clinical data, and histopathological findings.

RESULTS

Of the patients with papillary carcinoma, mPTC was identified in 150 patients (57%), of which 71% had lesions in the contralateral lobe. There were no significant differences in multifocality rate for gender, pathology type, and all tumor size subgroups including ≤1 cm. Pathology examination of representative sections versus the entire gland examination resulted in a significantly lower incidence of contralateral disease (P = .04).

CONCLUSIONS

Multifocal and contralateral lesions are common in PTC and their incidence is not related to tumor size. Pathology entire gland examination is strongly recommended to properly assess the rate of mPTC.

Medical students and general surgery--Israel's National Survey: lifestyle is not the sole issue

BACKGROUND

In recent years, a significant decline in the number of medical school graduates who choose general surgery as a career has been noted in Israel. The aim of this study is to characterize the factors that deter Israeli medical students from choosing general surgery. Previous studies in the United States identified lifestyle and financial issues as the most important factors.

METHODS

A web-based survey was distributed to graduating medical students throughout Israel. The survey covered different factors and aspects affecting career choice, requiring participants to rate their choices with a 1-5 score.

RESULTS

In all, 218 surveys were completed; 72 (33%) students considered general surgery before the surgical clerkship versus only 48 (22%) students after. Professional interest and satisfaction (4.7) were ranked as the most important factors for choosing a residency, followed by an amiable working atmosphere (4.3). The 2 strongest deterrents from general surgery were doctors' inter-relationships (3.5) and compromised lifestyle (3.3). The decision to avoid surgery can be reversed by improving both lifestyle (3.5) and inter-relationships (3.0), but it is less influenced by a substantial increase in residents' salary.

CONCLUSIONS

More medical graduates would consider general surgery as a career option if the lifestyle and inter-relationships were perceived as better. An increase in monetary reward did not seem to have a paramount impact among Israeli medical graduates. The surgical clerkship is an important turning point in the students' attitude toward surgery as a career and efforts must be made to improve students' experience significantly during this clerkship.

From Mount Sinai to Mount Scopus: differences in the role and value of fine needle aspiration for evaluating thyroid nodules

BACKGROUND

Fine needle aspiration is the main diagnostic tool used to assess thyroid nodules.

OBJECTIVES

To correlate FNA cytology results with surgical pathological findings in two teaching medical centers across the Atlantic.

METHODS

We retrospectively identified 484 patients at Hadassah Hebrew University Medical Center, Jerusalem and Mount Sinai Hospital, New York, by means of both preoperative FNA cytology and a final histopathological report. Results compared FNA diagnosis, histological findings and frozen section results (Mt. Sinai only).

RESULTS

The sensitivity value of FNA at Hadassah was 83.0% compared with 79.1% at Mt. Sinai (NS). Specificity values were 86.6 vs. 98.5% (P < 0.05), negative predictive value 78.7 vs. 77.6% (NS) and positive predictive value 89.7 vs. 98.6% (P < 0.05), respectively. "Follicular lesion" was diagnosed on FNA in 33.1% of the patients at Hadassah and in 21.5% at Mt Sinai (P < 0.005) with a malignancy rate of 42.5 vs. 23.1% (P < 0.05), respectively. Frozen section was used in 190 patients at Mt. Sinai (78.5%) with sensitivity and specificity values of 72.3% and 100%. Frozen section results altered the planned operative course in only 6 patients (2.5%). Follicular carcinoma was diagnosed in 12 patients at Hadassah vs. 2 patients at Mt. Sinai (P < 0.05).

CONCLUSION

The sensitivity of FNA at the two institutions was comparable. While malignancy on frozen section is highly specific, it should be used selectively for suspicious FNA results. Follicular lesions and the rate of malignancy in such lesions were more common at Hadassah, favoring a more aggressive surgical approach.

Application of a novel severity grading system for surgical complications after colorectal resection

BACKGROUND

Uniform and accurate reporting of surgical complications is the basis for quality control. We developed a computerized system for reporting and grading surgical complications in colorectal surgery. This study was conducted to evaluate this computerized reporting system.

STUDY DESIGN

A retrospective chart review was conducted of all surgical complications in patients who underwent resection of the colon or rectum at our institution between the years 1999 and 2004 (n = 408). All complications were recorded using the computerized reporting system and compared with complications reported in the literature.

RESULTS

Elective operations were performed in 75.7% of patients, and 24.3% required emergency operations. Of the 408 patients in the study, 239 (58.6%) had an uneventful recovery without complications. At least 1 complication was recorded in 169 (41.4%) patients. Grades 1 and 2 complications were recorded in 83 (20.3%) and 105 (25.7%) patients, respectively, requiring observation or medical treatment only, and 59 patients (14.5%) had grades 3 to 5 complications. The three leading complications were surgical site infection, intraabdominal abscess, and hemorrhage requiring blood transfusion. The grades 3 to 5 complication rate was within the range described in the literature, and the rate of grades 1 and 2 complications was substantially higher. These grades 1 and 2 complications were associated with a substantially longer hospital stay.

CONCLUSIONS

This novel complication reporting system was found feasible and proved to have a higher sensitivity for recording minor but meaningful complications that tend to prolong hospital stay.

Lithium-associated hyperparathyroidism: report of four cases and review of the literature

CONTEXT

Lithium-associated hyperparathyroidism (LAH) was first described in 1973 but many issues remain in question regarding the pathophysiology as well as the appropriate management of this condition.

OBJECTIVE

Report of four new cases and review of the literature.

RESULTS

We describe two males and two females, treated for more than 10 years with lithium due to bipolar disorder, who developed LAH. All underwent parathyroidectomy. In three cases (75%), pathology revealed multiglandular disease, with hyperplasia or two parathyroid adenomas. We observed a cure status in three (75%) of the operated patients. The fourth patient had a residual disease, but had controlled hypercalcemia under the calcimimetic drug cinacalcet. We also observed the association of LAH with incidental papillary thyroid carcinoma in two patients. Review of the literature identified a higher prevalence of LAH in women than men (four out of one) and a controversy in regard to the prevalence of multiglandular disease. As a result, there is no consensus regarding the preferred surgical procedure. The use of cinacalcet as an effective treatment of LAH was previously described in only five cases.

CONCLUSION

In our view, there are apparently two different mechanisms leading to LAH: exacerbation of a pre-existing state of hyperparathyroidism and multiglandular disease. For uncontrolled hypercalcemia, parathyroidectomy is recommended. The issue of routine four-gland exploration and subtotal parathyroidectomy versus intraoperative PTH-determination-guided excision of enlarged glands is still unresolved. The use of the recently developed calcimimetics may offer an alternative to patients who are not candidates for surgery.

Laparoscopic inguinal hernia repair on a general surgery ward: 5 years' experience

BACKGROUND

Laparoscopic hernia repair has been gaining acceptance as an alternative to open repair. The aim of this study was to present the experience of a general surgery ward with laparoscopic inguinal hernia repair.

MATERIALS AND METHODS

A retrospective search of all laparoscopic inguinal hernia repairs between January 1999 and December 2003 was obtained. Data, including perioperative course, postoperative complication, and long-term follow-up, was documented.

RESULTS

A total of 423 hernias were repaired in 220 patients. Long-term follow-up was performed by questionnaire, clinic visit, or both in 182 of the 220 patients (82.7%). Median follow-up time was 27.5 (range, 4-61) months. Two hundred and three (92.3%) hernias were bilateral. Fifty-seven patients (25.9%) had recurrent hernias. There was no conversion to an open hernia repair. There were 10 recurrences (2.3%). Minor complications (e.g., abdominal wall hematoma, epigastric vessels injury, and urinary retention requiring catheterization) occurred in 17 (7.7%) patients. A bladder injury occurred in 1 patient (0.45%). There was no mortality. Mean postoperative stay was 1.1 days (range, 1-10). Satisfaction with the laparoscopic repair was expressed by using a scoring system of 1 to 5, with 85.2% being very satisfied (score of 4-5) and 8.2% being dissatisfied (score of 1-2).

CONCLUSIONS

The laparoscopic herniorrhaphy offers a safe and effective repair with acceptable complication and recurrence rates. Good results with the total extraperitoneal technique can be achieved by general laparoscopists and not only in highly specialized hernia centers. It is especially suited for bilateral repair and for recurrent hernias.

Expression of P53, P27 and KI-67 in colorectal cancer patients of various ethnic origins: clinical and tissue microarray based analysis

BACKGROUND

This study was conducted to determine survival according to the expression of molecular markers in colorectal cancer (CRC) patients of various ethnic origins.

METHODS

Resection of primary tumor was conducted on 171 patients with CRC. Corresponding archived paraffin-embedded blocks were retrieved and tissue microarray (TMA) constructed. Immunohistochemical staining of the TMA for p53, p27 and Ki-67 was quantified by two independent pathologists. Survival was analyzed using the Kaplan-Meier product limit method.

RESULTS

With a median follow-up of 65 months, 56 patients (32.7%) died of disease. AJCC stage correlated with disease-free (DFS, P < 0.0001) and overall survival (OS, P < 0.0001). IHC staining was positive for Ki-67 in 77.4%, p53 in 55.8% and p27 in 54.2% of patients. Primary tumor marker expression did not correlate with DFS or OS. The 5-year DFS for Ashkenazi Jews was 75%, significantly higher than Sephardic Jews (SJ) 64% and Palestinian Arabs (PA) 38%, P = 0.001.

CONCLUSIONS

Ethnicity among Ashkenazi and SJ and PA appears to have a significant impact on disease outcome in patients with CRC patients, while primary tumor expression of p53, p27 and Ki-67 was unrelated to disease outcome.

Cholinergic properties of soy

OBJECTIVES

Soybeans have been shown to have numerous health benefits, but the underlying mechanisms are poorly understood. The aim of this study was to characterize some pharmacologic properties of active substances in aqueous soy extract.

METHODS

The pharmacologic actions of the extract were tested by measuring mechanical activity of isolated guinea-pig ileum in an organ bath.

RESULTS

The ileum contracted in response to soy extract in a concentration-dependent manner. This response was unaffected by the nerve blocker tetrodotoxin (10(-6) M) but was completely inhibited by atropine (10(-9) M), indicating an action via muscarinic receptors on the muscle. In the presence of the M(3) muscarinic antagonist 1,1-dimethyl-4-diphenylacetoxypiperidinium iodide and to a lesser extent in the presence of the M(2) muscarinic antagonist 11-([2-[(diethylamino)methyl]-1-piperidinyl]acetyl)-5,11-dihydro-6H-pyrido[2,3-b][1,4]benzodiazepine-6-one, the response was decreased. When acetylcholine (ACh) esterase inhibitors were added to the medium before the addition of soy extract, the response to the extract was potentiated. Preincubation of the extract with exogenous ACh esterase reduced its activity. The response to choline, ACh, and phosphorylcholine was also tested, and none of these substances accurately replicated the response to soy extract. However, some qualitative similarities were observed between the effect of choline and ACh to that of the extract.

CONCLUSION

These results indicate the presence of an ACh-like substance in soy. Due to the abundance and importance of muscarinic receptors, the presence of a cholinergic substance in soy could have numerous implications. The role of this substance in the beneficial effect of soy on various body systems merits further investigation.

Cytohistologic correlation of thyroid nodules

BACKGROUND

Fine-needle aspiration (FNA) is widely used as a diagnostic tool to assess thyroid nodules. This study correlates FNA cytology results with surgical pathologic findings.

METHODS

All thyroidectomies performed between 1994 and 2004 were reviewed, identifying 242 patients. Data were obtained for FNA diagnosis, demographics, findings on ultrasound, and histologic findings.

RESULTS

Among 89 patients with a carcinoma on FNA, 89% of cases were verified on final histopathology. Of 78 patients with "follicular lesion" on FNA, only 36% of cases were verified to be malignant at surgery. Only 13% of the 75 cases diagnosed as benign, mostly colloid nodules, on FNA were found to have a carcinoma on histopathology.

CONCLUSION

A cytologic diagnosis of papillary carcinoma has a highly predictive of thyroid cancer. When dealing with follicular lesions the predictive value of FNA drops considerably. However, we found a 13% false positive result to occur in FNA declared benign lesions.

Prospective randomized study comparing sentinel lymph node evaluation with standard pathologic evaluation for the staging of colon carcinoma: results from the United States Military Cancer Institute Clinical Trials Group Study GI-01

BACKGROUND

The principal role of sentinel lymph node (SLN) sampling and ultrastaging in colon cancer is enhanced staging accuracy. The utility of this technique for patients with colon cancer remains controversial.

PURPOSE

This multicenter randomized trial was conducted to determine if focused assessment of the SLN with step sectioning and immunohistochemistry (IHC) enhances the ability to stage the regional nodal basin over conventional histopathology in patients with resectable colon cancer.

PATIENTS AND METHODS

Between August 2002 and April 2006 we randomly assigned 161 patients with stage I-III colon cancer to standard histopathologic evaluation or SLN mapping (ex vivo, subserosal, peritumoral, 1% isosulfan blue dye) and ultrastaging with pan-cytokeratin IHC in conjunction with standard histopathology. SLN-positive disease was defined as individual tumor cells or cell aggregates identified by hematoxylin and eosin (H&E) and/or IHC. Primary end point was the rate of nodal upstaging.

RESULTS

Significant nodal upstaging was identified with SLN ultrastaging (Control vs. SLN: 38.7% vs. 57.3%, P = 0.019). When SLNs with cell aggregates < or =0.2 mm in size were excluded, no statistically significant difference in node-positive rate was apparent between the control and SLN arms (38.7% vs. 39.0%, P = 0.97). However, a 10.7% (6/56) nodal upstaging was identified by evaluation of H&E stained step sections of SLNs among study arm patients who would have otherwise been staged node-negative (N0) by conventional pathologic assessment alone.

CONCLUSION

SLN mapping, step sectioning, and immunohistochemistry (IHC) identifies small volume nodal disease and improves staging in patients with resectable colon cancer. A prospective trial is ongoing to determine the clinical significance of colon cancer micrometastasis in sentinel lymph nodes.

[The prognostic value of CA 19-9 in the preoperative work-up of pancreatic cancer patients]

Carbohydrate antigen (CA) 19-9 is produced by adenocarcinomas of the pancreas, stomach, gall bladder, colon, ovary and lung. Serum CA 19-9 is considered the most sensitive marker for pancreatic cancer, being elevated in 75% or more of patients with pancreatic cancer. In all three cases of pancreatic cancer presented, patients died of their disease quite shortly after diagnosis. Preoperative imaging was unsuccessful in exposing the actual advanced state extent of the disease and even during surgery its real extent was underestimated. The only prognostic indicator of the observed rapid disease progression was a very significant elevation of preoperative serum CA 19-9.

Multimarker RT-PCR assay for the detection of minimal residual disease in sentinel lymph nodes of breast cancer patients

The presence of metastases in lymph nodes is the most powerful prognostic factor in breast cancer patients. Routine histological examination of lymph nodes has limited sensitivity for the detection of breast cancer metastases. The aim of the present study was to develop a multimarker reverse transcriptase-polymerase chain reaction (RT-PCR) assay for the detection of minimal residual disease in sentinel nodes of breast cancer patients. RNA was extracted from 30 sentinel lymph nodes (SLN) obtained from 28 patients, three primary breast cancers (positive controls), three lymph nodes from patients with benign diseases, and peripheral blood lymphocytes of 10 healthy volunteers (negative controls). RT-PCR was performed using the following markers; cytokeratin (CK)-19, NY-BR-1 and mammaglobin B. RT-PCR results were compared to enhanced histopathologic examination and immunohistochemistry (IHC). All three positive controls showed strong PCR amplification for all three markers. None of the 13 negative controls was amplified by any of the three markers. Among the 30 SLN analysed, breast cancer metastases were detected in six SLNs by routine histology, in eight by IHC and in 15 by RT-PCR. We conclude that a multimarker RT-PCR assay probing for NY-BR-1, mammaglobin-B, and CK-19 is more sensitive compared to enhanced pathologic examination. This method may prove to be of value in breast cancer staging and prognosis evaluation.

In-hospital resource utilization during multiple casualty incidents

OBJECTIVE

To suggest guidelines for hospital organization during terror-related multiple casualty incidents (MCIs) based on the experience of 6 level I trauma centers.

SUMMARY BACKGROUND DATA

Most terror-related MCIs are bombings. The sporadic nature of these events complicates in-hospital preparation.

METHODS

Data were collected at all level I Trauma centers during/after MCIs for the Israel National Trauma registry. Patients were included if they were admitted or died in hospital following injury in suicide bombings (October 1, 2000 to June 30, 2003), which fulfilled Ministry of Health suggested criteria for MCIs (number of admissions, severity of injury).

RESULTS

Included were 325 casualties from 32 events, 34% of which had an Injury Severity Score >16. A third of the admissions arrived within 10 minutes and 65% within 30 minutes. Forty percent of the patients underwent CT scans directly from the ED. Operative procedures were performed on 60% of patients and 36% were transferred directly from the ED to the OR. Initiation of surgical procedures peaked at 1 to 1.5 hours, mainly multidisciplinary abdominal, thoracic, and vascular surgery. Orthopedic and plastic surgery predominated later. A third of the patients were admitted to ICUs, often (31%) directly from the ED.

CONCLUSIONS

High staffing demands for ED, OR, and ICU overlap. Anesthesiologists, general, thoracic, and vascular surgeons are in immediate demand. ICU admissions occur simultaneously with ongoing patient arrival to the ED. Most patients operated within the first 2 hours require multidisciplinary surgical teams. Demand for orthopedic and plastic surgery and anesthesiology services continues for >24 hours.

Failure of medical treatment in an adult cystic fibrosis patient with meconium ileus equivalent

Meconium ileus equivalent is one of the lesser-known manifestations of cystic fibrosis. It manifests as distant small bowel obstruction caused by meconium-like stool plugs and occurs mostly in adult patients. With the improved overall survival of patients with cystic fibrosis, general surgeons may encounter this condition more often in the future. We treated a 19-year-old woman with cystic fibrosis who presented with complete distal small bowel obstruction. Medical therapy with Gastrografin and N-acetylcysteine failed to resolve the obstruction. At surgery, a meconium-like plug in the distal ileum was manually pushed into the colon with subsequent relief of symptoms. Meconium ileus equivalent should be considered and treated in cystic fibrosis patients presenting with small bowel obstruction.

Electrical impedance scanning of thyroid nodules before thyroid surgery: a prospective study

BACKGROUND

Electrical impedance scanning (EIS) is a novel imaging technique based on differential electrical conductivity and capacitance of malignant and normal human tissues. The aim of this study was to evaluate the accuracy of EIS in the detection of thyroid malignancies.

METHODS

Patients with thyroid nodules scheduled for thyroid surgery were eligible for the study. Enrolled patients underwent EIS with a T-Scan 2000ED. Nodule location, size, and type (cystic vs. solid) measured by ultrasound, cytology results, thyroid conductivity, and capacitance calculated by EIS were recorded. EIS results were interpreted as positive or negative for malignancy and compared with final histopathology results. Study end points included EIS accuracy, sensitivity, specificity, negative and positive predictive values, and false-positive and false-negative rates.

RESULTS

Sixty-four patients were enrolled onto the study, and all underwent either lobectomy-isthmusectomy (20%) or total thyroidectomy (80%). The mean tumor diameter was 2.64 +/- 14.8 mm. Thyroid cancers were identified by histology in 30 patients (46.9%). There were 11 false-positive and four false-negative cases. The overall diagnostic accuracy of EIS was 76.6% (49 of 64 correct diagnoses). The sensitivity and specificity of EIS were 86.7% (26 of 30 true positive) and 67.6% (23 of 34 true negative), respectively. The corresponding positive and negative predictive values were 70.3% and 85.2%.

CONCLUSIONS

EIS is a potentially useful imaging modality for differentiating thyroid neoplasms. If these results are confirmed in large-scale trials, EIS may be an important part of the evaluation of thyroid nodules.

Clinical profile of breast cancer in Arab and Jewish women in the Jerusalem area

BACKGROUND

The clinical profile of breast cancer may vary among different ethnic groups living in the same country and therefore affect the yield of a breast cancer screening program. The present study attempts to better characterize the breast cancer clinical profile of Arab women compared with Jewish women in the greater Jerusalem area with a future aim of establishing a comprehensive and effective screening program for this population.

METHODS

Retrospective chart review was conducted and the following covariates were correlated with survival: ethnicity, age at diagnosis, and American Joint Committee on Cancer (TNM) stage at diagnosis.

RESULTS

A total of 312 women were operated on for breast cancer between 1994 and 1999; 51% were Ashkenazi Jews (AJ), 26% were Sephardic Jews (SJ), 21% were Palestinian Arabs (PA), and 2% patients did not fit into those ethnic groups. The mean age at diagnosis was 51.5 years for the PA group, 53.4 +/- 1.5 for the SJ group, and 55.9 years for the AJ group (P <0.03 PA versus AJ). The tumor size (mean +/- SEM) was 38.8 +/- 3.7 mm, 31.1 +/- 2.4 mm, and 24.5 +/- 1.6 mm for the PA, SJ, and AJ groups, respectively (P = 0.03 for PA versus SJ and P <0.001 for PA versus AJ). Five-year overall survival was 77 %, 72%, and 58% for the AJ, SJ, and PA groups, respectively (P = 0.02); and 5-year disease-free survival was 72%, 51%, and 50% for the AJ, SJ, and PA groups, respectively (P = 0.03, AJ versus SJ).

CONCLUSIONS

Our data demonstrate younger age and larger primary tumor size for the Arab patients compared with the Jewish patients. These findings were associated with lower 5-year survival and disease-free survival of the Arab patients.

Decreased density of ganglia and neurons in the myenteric plexus of familial dysautonomia patients

BACKGROUND

Familial dysautonomia (FD) is a hereditary disease of the autonomic and sensory nervous system. A prominent manifestation of FD is gastrointestinal dyscoordination, which contributes to the morbidity and mortality in FD.

AIM

As the myenteric plexus is an essential factor in gastrointestinal motility control, we compared its morphology in appendices of FD patients and controls.

METHODS

Appendices from FD patients (N=19) were obtained during surgery of fundoplication and gastrostomy; normal appendices (N=17) were obtained from patients suspected to suffer from acute appendicitis, in whom, however, the appendix was found to be normal. Specimens were stained histochemically for NADPH diaphorase (NADPH-d) and in a blinded manner examined under a light microscope for seven morphologic parameters: ganglionic density, neuronal density, ganglionic area, number of stained neurons per ganglion, nerve bundle width, ratio between nervous tissue area and total area, and neuronal area.

RESULTS

Ganglionic density was 10.13 per mm(2) in controls versus 5.01 per mm(2) in FD (p<0.05). Neuronal density was 70.12 per mm(2) in controls, compared with 22.09 per mm(2) in FD (p<0.01). The other parameters were not different between the two groups.

CONCLUSION

Densities of myenteric ganglia and neurons of FD patients were significantly lower than in controls. This deficiency may contribute to the pathogenesis of FD gastroenteropathy.

Evacuation priorities in mass casualty terror-related events: implications for contingency planning

OBJECTIVE

To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning.

SUMMARY BACKGROUND DATA

Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances.

METHODS

A retrospective analysis of medical evacuations from MCIs (29.9.2000-31.9.2002) performed by the Israeli National EMS rescue teams.

RESULTS

Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15-20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001).

CONCLUSIONS

Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care.

Age-related changes in the morphology of the myenteric plexus of the human colon

Aging is believed to affect the structure and function of the enteric nervous system, but little specific information on this topic is available, particularly in humans. The aim of this study was to investigate the effect of age on the structure of myenteric ganglia in the human colon. We examined myenteric ganglia in colonic specimens obtained from 168 patients aged 10 days to 91 years. Nerves were stained in whole mount preparations using the vital fluorescent dye 4-(4-dimethylaminostyryl)-methylpyridinium iodide (4-Di-2-ASP) and other staining methods. Human myenteric ganglia were classified into three types: normal, those containing empty spaces ('cavities') and those containing large nerve fiber bundles. We found a statistically significant increase with age in the proportion of ganglia with cavities. Conversely, there was a decrease with age in the proportion of normal ganglia. The proportion of fiber-containing ganglia did not change with age. These findings indicate that there is an increase with age in the number of abnormally appearing myenteric ganglia in the human colon, which may contribute to the disturbed colonic motility in the aging population.

Current controversies in sentinel lymph node biopsy for breast cancer

Despite the widespread use of sentinel lymph node biopsy (SLNBx) in the surgical management of breast cancer patients, several areas remain controversial. The following controversies are reviewed: Learning curves and validation studies. There clearly is a learning curve, and a completion ALND should be done until adequate proficiency is exhibited, both in terms of identification and false-negative rates. Location of injection. Intradermal injection offers superior identification rates compared with peritumoral injection, with comparable false-negative rates. Subareolar injection is as accurate as peritumoral injection. The value of scintigraphy. Routine scintigraphy does not enhance identification or false-negative rates. Mapping agents. Blue dye and radioactive tracer combined to provide a higher identification rate than either used alone.SLNBx in DCIS. In patients with a high risk of microinvasion, such as large tumors, a mass or high-grade DCIS-SLNBx is justified.SLNBx following neoadjuvant chemotherapy. Although there is evidence that SLNBx after neoadjuvant chemotherapy may be accurate, these data should be applied cautiously. Implications of non axillary SLN, especially internal mammary nodes. Data do not support routine resection of internal mammary sentinel lymph nodes outside a clinical trial. Implications of micrometastases in the sentinel lymph node seen only on immunohistochemistry. Since the significance of such metastases is unclear, decisions regarding treatment of these patients should be individualized. The value of completion axillary lymph node dissection. Is being addressed in clinical trials. Until those studies mature, completion ALND should be performed for patients with SLN metastases, but may be abandoned for patients with a negative SLN.

Coupling among interstitial cells of Cajal in the human ileum

Current knowledge on the morphology and physiology of interstitial cells of Cajal (ICC) is mostly based on animal studies, and information about the function of these cells in humans is scarce. There is ultrastructural evidence that ICC in the myenteric region (ICC-MP) of the small intestine of several species are connected by gap junctions, but these were not observed in the human small intestine. The aim of the present study was to determine whether functional coupling also exists among ICC-MP in the human ileum. We visualized ICC-MP in live tissues using Nomarski optics, and verified their identity by staining for c-Kit. ICC were injected intracellularly with the fluorescent dye Lucifer yellow, which crosses gap junctions. In most cases the labelled cells had oval somata with two primary processes. At normal pH (7.3-7.4) only 20.2% (21/104) of the injected ICC were coupled to other ICC. However, at pH 7.8-7.9 coupling incidence increased to 74.5% (35/47, P < 0.0001). The injected cells were coupled to one to 35 other ICC. Octanol blocked coupling in all cases. Apparently, gap junctions interconnect ICC in the human small intestine. Coupling was enhanced by a small increase in pH, suggesting that it may be under physiological control.

Comparison of bursting pressure of abdominal wall defects repaired by three conventional techniques

Still debated are the appropriate techniques for the repair of abdominal wall defects and the methods used to measure their strength. Although tension has been used in many studies to test wound strength, bursting pressure reflects more accurately the pathophysiology of wound dehiscence. The aim of the current study was to evaluate three different techniques for closure of abdominal wall defects using a new and more accurate device for bursting pressure measurements. Full thickness abdominal wall defects measuring 2 cm2 were created in 43 anesthetized rats randomly assigned to three groups: simple primary closure (n = 15), Mayo repair (n = 14), and primary closure reinforced with a mesh (n = 14). Thirty days after surgery, the rats were sacrificed. The abdominal wall was fully excised and placed over a bursting chamber made of a metal cylinder connected to a carbon dioxide source with a control valve and a manometer. Gas was gradually released while the pressure was recorded until bursting occurred. Disruption of all closures occurred at the point where the suture itself penetrated the tissue. The average bursting pressure was 1383 +/- 299 mm Hg for the primary closure group, 1200 +/- 409 mm Hg for the mesh reinforcement group, and 1607 +/- 337 mm Hg for the imbrication repair (Mayo) group (P < 0.03). The data suggests an advantage for the Mayo repair over the other two repairs. The bursting chamber tested is a new and more reliable method to study techniques and conditions influencing the strength of abdominal wall closure.

Comparison of Bursting Pressure of Abdominal wall Defects Repaired by Three Conventional Techniques

Still debated are the appropriate techniques for the repair of abdominal wall defects and the methods used to measure their strength. Although tension has been used in many studies to test wound strength, bursting pressure reflects more accurately the pathophysiology of wound dehiscence. The aim of the current study was to evaluate three different techniques for closure of abdominal wall defects using a new and more accurate device for bursting pressure measurements. Full thickness abdominal wall defects measuring 2 cm2 were created in 43 anesthetized rats randomly assigned to three groups: simple primary closure (n = 15), Mayo repair (n = 14), and primary closure reinforced with a mesh (n = 14). Thirty days after surgery, the rats were sacrificed. The abdominal wall was fully excised and placed over a bursting chamber made of a metal cylinder connected to a carbon dioxide source with a control valve and a manometer. Gas was gradually released while the pressure was recorded until bursting occurred. Disruption of all closures occurred at the point where the suture itself penetrated the tissue. The average bursting pressure was 1383 ± 299 mm Hg for the primary closure group, 1200 ± 409 mm Hg for the mesh reinforcement group, and 1607 ± 337 mm Hg for the imbrication repair (Mayo) group ( P < 0.03). The data suggests an advantage for the Mayo repair over the other two repairs. The bursting chamber tested is a new and more reliable method to study techniques and conditions influencing the strength of abdominal wall closure.

Suppressive effect of aspirin on aberrant crypt foci in patients with colorectal cancer

BACKGROUND

and aims: Aspirin and other non-steroidal anti-inflammatory drugs have been shown to reduce the risk of colorectal cancer (CRC). Animal models have shown that aspirin is also effective in reducing the density of aberrant crypt foci (ACF). The aim of the study was to evaluate the effect of chronic administration of aspirin on the distribution pattern and histological characteristics of ACF in patients with CRC.

METHODS

Our study compared the distribution patterns and histomorphological characteristics of ACF between a group of CRC patients treated with low dose aspirin (n=59) and a control group without aspirin (n=135). ACF were visualised on methylene blue stained macroscopically normal mucosa, microdissected, and serially cut.

RESULTS

ACF were found in 75.8% of mucosal samples from the control group and in 36% of mucosal samples from the aspirin treated group, indicating a 47% decline in prevalence of ACF in colonic samples of patients treated with aspirin. A significant reduction from 92.5% to 40% (p<0.0001) was found in distal large bowel samples containing one or more ACF. Similarly, the aspirin treated group showed a reduction in ACF density of 64% and 82%, respectively, in both proximal and distal parts of the colon, indicating a significant reduction in ACF/cm(2) in distal colon samples (p<0.01). The aspirin treated group displayed a 52% reduction in dysplastic ACF although this difference was not statistically significant.

CONCLUSIONS

Our study has provided evidence of the effective chemopreventive action of low dose aspirin on ACF in humans.

[Screening mammography for early diagnosis of breast cancer: facts, controversies, and the implementation in Israel]

BACKGROUND

Breast cancer is the leading cancer among Israeli women. Mammography is the most widely used tool for early diagnosis of breast cancer. Eight published randomized controlled trials followed nearly 500,000 women over 7 to 18 years. Most trials found that screening mammography decreases breast cancer mortality by 20 to 40%. A recent study examined the methodology of the randomized clinical trials and found that most trials were flawed in the methodology of data collection and analysis in a way that might have influenced the results of those trials.

PURPOSE

To review the studies, clarify the issues, and reach a conclusion regarding the utility of screening mammography in reducing breast cancer-related mortality in Israel.

METHODS

A review of the world literature, and analyses of the Israeli data.

RESULTS

Seven out of eight published randomized controlled trials found a significant decrease in breast cancer mortality among women who underwent screening mammography. A meta-analysis of the trials also supports the utility of screening mammography in decreasing breast cancer mortality. The criticism over the methodology of these trials does not necessarily invalidate their conclusions.

CONCLUSIONS

The data indicate that screening mammography does indeed assist in early diagnosis, and most published studies show a significant reduction in breast cancer-related mortality in the screened population. Due to the high incidence of breast cancer in the Israel, especially among young women, the national screening program should continue. Moreover, consideration should be given to expanding it to women starting at age 45, instead of 50, as is practiced today.

Retroperitoneoscopic lumbar sympathectomy

We present a series of 27 consecutive unselected patients who underwent 29 retroperitoneoscopic lumbar sympathectomies. There were 21 male patients and six female patients, with a mean age of 45 years (RANGE, 21 to 28 years). Twenty-two patients had ischemia of the lower limb, and five patients had severe reflex sympathetic dystrophy. The retroperitoneal space was developed with a balloon trocar inserted through a small incision in the flank. Additional trocars used for endoscopic instruments. The sympathetic chain from the ganglia second lumbar vertebrae to the fourth lumbar vertebrae was resected. The procedure was successfully accomplished in all the patients without any operative or postoperative complications. The mean operative time Was 136 minutes, and the mean hospital stay was 1.4 days. All the patients had significant improvement of pain or dystrophic changes. Retroperitoneoscopic lumbar sympathectomy successfully combines the advantages of minimally invasive surgery with the effectiveness of the open procedure.

Direct inhibitory effect of erythromycin on human alimentary tract smooth muscle

BACKGROUND

Erythromycin was found to stimulate motor activity in the upper gastrointestinal tract. However, in several smooth muscle preparations, it also elicited an inhibitory effect. Our aim was to study the effect of erythromycin in various human alimentary tract smooth muscles.

METHODS

Using force measurements, we assessed the effect of erythromycin on electrically and chemically evoked contractions of isolated muscle strips of human gallbladder, small intestine, and colon.

RESULTS

The muscarinic receptor agonist carbachol evoked contraction in gallbladder, ileum, and colonic smooth muscle that were reduced by erythromycin at 10(-4) M to 72% +/- 24%, 77% +/- 22%, and 76% +/- 22% of control values, respectively. Erythromycin did not affect contractions evoked by noncholinergic agents. Erythromycin's inhibitory effects were not altered by nerve blockade, indicating a direct muscle effect. Eryrthromycin also reduced contractions evoked by electrical stimulation at frequencies of 5, 10, and 20 Hz in the human gallbladder, ileum, and colon preparations. These contractions were reduced by erythromycin in a reversible and dose-dependent manner.

CONCLUSIONS

Erythromycin antagonized direct cholinergic effects on various smooth muscles from the human alimentary tract in a concentration-dependent manner.

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

BACKGROUND

The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients.

METHODS

The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999.

RESULTS

The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury.

CONCLUSIONS

The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.