Search

Nonaccidental trauma (NAT) or child abuse is the deliberate or intentionally inflicted injury of a child and is a form of child maltreatment.1 One in four children experience some form of maltreatment in their lifetime.2 Annually, nearly one million children are victims of maltreatment in the United

Introduction Fibroadenomas are defined as benign breast lesions, usually formed during menarche (15-25 years of age), that can exist as a solitary mass or multiple masses in the breasts of women. In develpment, as lobular structures are added to the breast’s ductal system, yperplastic lobules are often present. Although lobules are associted with normal growth, analysis of the cellular components link yperplastic lesions to fibroadenomas. Fibroadenomas that measure 5 cm are commonly classified as giant fibroadenomas. When these nlarged masses are found in young female patients, they are often alled juvenile fibroadenomas. The lesions are rare, accounting for nly 0.5% of the total diagnosed fibroadenomas, and can grow to arge sizes and cause prominent asymmetry of the breasts. Other structural changes include both stretching of the areola complex and distortion of the dermal tissue. Clinicians are confronted with treatment decisions on whether to manage these rare cases by way of continued routine examinations or to surgically remove the fibroadenomas. Cosmesis and lactation preservation are the main concerns in this population because malignancy is rare in this age group. Malignancy is of lesser concern with giant fibroadenomas due to their more cellular and less lobular his

The significance of micrometastatic disease in the sentinel lymph nodes (SLN) of patients with invasive breast cancer has been questioned. The objective of our study was to review the impact of micrometastatic carcinoma detected by SLN biopsy.Between January 1997 and May 2004, 2,408 patients with invasive breast cancer and an SLN with micrometastatic (N0[i+], N1mi) or no metastatic (N0[i-]) disease were identified through our breast database. Slide review was performed and reclassified by the 6(th) edition of the American Joint Committee on Cancer Staging Manual. Of these, 27 were excluded from analysis because of evidence of macrometastatic disease on slide review or enrollment in the American College of Surgeons Oncology Group Z10 study.Of 2,381 patients, 2,108 were N0(i-), 151 were N0(i+), and 122 were N1mi. Overall and disease-free survivals of patients with an N1mi SLN were substantially worse than those in patients with an N0(i-) SLN (p0.001 and p=0.006, respectively). Additional positive non-SLNs were identified in 15.5% (15 of 97) of N1mi patients and 9.3% (10 of 107) of N0(i+) patients undergoing completion axillary lymph node dissection. Overall survival of the N0(i+) SLN patients not undergoing axillary dissection was substantially less than those undergoing axillary dissection (p=0.02).Detection of micrometastatic carcinoma (N1mi) in the SLNs of invasive breast cancer patients is a major indicator of poorer survival compared with N0(i-) patients. Although survival of patients with an N0(i+) SLN does not statistically differ from that of N0(i-) patients, 9.3% of these patients had additional axillary nodal disease on axillary dissection, and N0(i+) patients had a decreased survival when axillary dissection was omitted.

Locoregional chest wall recurrences involving ribs and/or sternum after primary surgical treatment predict a poor outcome in patients with breast cancer. The precise natural history and surgical outcome of these chest wall recurrences are not fully understood. The objective of this study is to clarify the clinicopathological features of chest wall recurrence of breast cancer and evaluate prognostic factors predicting survival after chest wall resection and reconstruction (CWRR). A total of 28 patients who underwent CWRR at the H. Lee Moffitt Cancer Center between December 1999 and September 2007 were retrospectively analyzed. Overall survival was calculated by the Kaplan–Meier method and the significance of prognostic variables was evaluated by log-rank and Cox regression analyses. The postoperative morbidity and mortality was 21% and 0%, respectively. Overall 5-year survival for the entire cohort was 18%. Disease-free interval

The current technique for locating nonpalpable breast lesions is wire localization (WL). Radioactive seed localization and intraoperative ultrasound were developed to improve difficulties with WL. The SAVI SCOUT surgical guidance system was developed to improve these methods. The SCOUT system is a non-radioactive, FDA-cleared medical device that uses electromagnetic wave technology to provide real-time guidance during excisional breast procedures. Consenting patients underwent localization and excision using an implantable electromagnetic wave reflective device (reflector) and a detector handpiece with a console. Using image guidance, the reflector was placed up to 7 days before the surgical procedure. The primary end points of the study were successful reflector placement, localization, and retrieval. The secondary end points were percentage of clear margins, reexcision rates, days of placement before excision, and physician comparison with WL. This study analyzed 50 patients. The reflectors were placed under mammographic guidance (n = 18, 36 %) or ultrasound guidance (n = 32, 64 %). Of the 50 patients, 10 (20 %) underwent excisional biopsy and 40 (80 %) had a lumpectomy. The lesion and reflector were successfully removed in all 50 patients, and no adverse events occurred. Of the 41 patients who had in situ and/or invasive carcinoma identified, 38 (93 %) had clear margins and 3 (7 %) were recommended for reexcision. These data suggest that the SCOUT system is safe and effective for guiding the excision of nonpalpable breast lesions and a viable alternative to standard localization options. A larger prospective, multi-institution trial of SCOUT currently is underway to validate these findings.

Background: Focused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients. Methods: From October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance. Results: Patients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; X 2 analysis showed significant discordance between FAST examination and CT scan (5.85%, p < 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries. Conclusion: Use of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.

With natural gas deposits now being extracted from previously unattainable shale formations, natural gas transmission networks throughout North America are required to be more dynamic in terms of transportation receipt/delivery points than anytime in the past 50 years. New production sources must access interstate transmission and storage lines to deliver natural gas to market. System modifications and constraints require that a regulated service business built on excess capacity must now demonstrate a high degree of system reliability. NiSource Gas Transmission & Storage (NGT&S) has adopted two complimentary strategies, each one to address reliability growth but with separate focus. Autonomous activity undertaken by operations and maintenance stakeholders throughout the system must engage in an effective defect elimination program and cultural transformation. The more small issues that are corrected today result in less planned and unplanned maintenance in the future. This strategy aims to deliver long term reliability growth. As the compliment, strategic reliability growth is sought through structured processes and procedures within four sub-topic areas: Critical Assessment and System Strategy (CASS), Core Reliability Processes, Real Time Data Systems (RTDS) and Modernization and Automation (M&A). Each of these focus areas are developed to work in the following manner: 1) CASS determines what assets are needed to be available to Gas Control (the central monitoring and control office that ensures customer demands are met) and define when they are needed 2) Core Reliability engineers conduct a macro level analysis of the magnitude of reliability required based on system constraints 3) Failure Reporting and Corrective Action System (FRACAS) data and site assessments provide information to be transformed into current state quantification of likelihood of achieving the desired state 4) Core Reliability, RTDS and M&A collaborate to derive projects, preventive and predictive actions, and long range plans to achieve the desired reliability levels 5) Senior leadership reviews these finding and balances the variant business factors to approve the migration plan in accordance with acceptable risk to the enterprise. A common platform architecture is being developed to serve as a central location for metrics, condition monitoring actions, operational values, etc. in a role based resolution independent of the data source. Partnerships with leading academic institutions are being developed to support progressive strategies and world class analytic procedures. With the U.S. natural gas infrastructure being critical to near and long term energy markets, reliable transmission and storage networks are essential to managing our energy future.

The term “sentinel node” was first used by Gould et al. in 1960 to describe the first node in the drainage pathway of a malignant tumor (1). In 1977, Cabanas proposed that sentinel lymph nodes could be removed and evaluated to determine the need for complete lymph node dissection in penile carcinoma (2). Landmark studies by Norman et al. in the early 1990’s redefined Sappey’s line physiologically and demonstrated the necessity of lymphoscintigraphy to accurately assess nodal basins in truncal and head and neck melanoma (3),(4). Morton and colleagues then observed that preoperative lymphoscintigraphy demonstrated a single lymph node receiving drainage from the primary melanoma (5),(6). Alex et al. and Krag et al. reported the use of a handheld gamma probe to identify sentinel lymph nodes following lymphoscintigraphy in both melanoma and breast cancer patients (7),(8). Giuliano demonstrated that blue dye accurately identified the sentinel lymph node in 174 breast cancer patients (9),(10). The early sentinel node mapping experience using single agents was associated with 65% to 70% accuracy rates (7)–(9), and in 1996 Albertini et al. described a combination technique that improved the success rate of sentinel node localization to 92% (11).

Background Paget’s disease of the breast is an uncommon cancer. “Breast cancer” management has evolved to include sentinel lymph node biopsy (SLNB). Our objective is to determine utilization of SLNB in the surgical algorithm of Paget’s disease. Methods After institutional review board approval, a database review of patients with Paget’s disease was conducted. Patient demographics, tumor characteristics, treatment including use of SLNB, and survival were reviewed. Patient characteristics and outcomes were analyzed by using contingency table chi-square, pooled t tests, and log-rank tests for comparisons. Results Fifty-four patients with Paget’s disease were identified and divided into 2 cohorts (18 no SLNB and 36 SLNB). The mean age was 66 years for the no-SLNB group and 60 years for the SLNB group ( P = .17). Paget’s disease only was present in 33%, Paget’s disease + DCIS in 41%, and Paget’s disease + invasive cancer in 26%. The mean invasive tumor size was 1.62 cm in the no-SLNB group and 1.59 cm in the SLNB group ( P = .96). For invasive disease, ER/PR status was similar, but Her2 was more likely to be overexpressed in SLNB ( P = .04). Surgery choice ranged from “no surgery” to lumpectomy to mastectomy. Axillary staging was performed in 45 of 54 patients, with 11% in both cohorts having nodal disease. A sentinel lymph node was identified in 97% of patients. Five-year overall and disease-free survival was 100% in the no-SLNB group and 88% in the SLNB group ( P = .97) and 76% in the no-SLNB group and 84% in the SLNB group ( P = .88), respectively. Conclusions Paget’s disease remains rare but should be treated similar to other “breast cancer.” SLNB should be performed to evaluate the axilla when invasive disease is identified or a mastectomy is planned.

Sentinel lymph node biopsy (SLNB) has been widely accepted and used to determine axillary lymph node status for the past decade.1,2 Consequently, SLNB has been a valuable method for determining patients’ treatment options, such as whether or not a complete axillary lymph node dissection (CALND) would be necessary for local control and correct staging of the breast cancer patient. When extraordinary cases materialize, it is often difficult to determine a common treatment pathway for the patient. The rare finding and subsequent treatment of the intramammary sentinel lymph node (IntraMSLN) metastasis has become such in recent years. The argument lies in whether or not a positive IntraMSLN warrants a CALND or whether it can be spared, compared with a positive axillary sentinel lymph node, which would warrant a CALND. Two studies have examined the prognostic significance of positive intramammary lymph nodes (IntraMLN) from the presentinel node era and postulated treatment recommendations. Shen et al. reported that IntraMLN metastasis was an independent predictor of a worsened prognosis and that patients with IntraMLN metastases were significantly associated with a shorter disease-free survival and overall survival. Therefore, CALND was warranted.3 Similarly, Guth et al. reported that a CALND should be recommended for patients with positive IntraMLNs based on their findings that patients with IntraMLNs had more aggressive cancers including higher rates of lymphovascular invasion and axillary nodal disease, and these patients were more frequently multifocal and had a higher grade and stage of disease on final analysis.4 In contrast to previous studies reported in which IntraMLNs were detected on final pathology review, Dr. Intra and colleagues recently reviewed their institution’s data for patients with IntraMSLNs detected with mapping techniques. Twenty-two patients were found to have IntraMSLN and axillary sentinel lymph nodes (axSLN) present. Of the 22 patients, 15 had both IntraMSLNs and axSLNs excised, of which six IntraMSLNs were positive and all axSLNs were negative. In addition, two of the six patients had positive IntraMSLNs, and one patient with a negative axSLN had a CALND; in all three cases all axillary nodes were negative. After 24 months they found no recurrences. Based on these findings, Dr. Intra’s group argued that when both IntraMSLNs and axSLNs are present then both should be biopsied and that a CALND should be based on the status of the axSLNs.5 Dr. Intra and colleagues raise the question whether a CALND on patients should be done when positive or negative IntraMSLNs are found when axSLNs are not localized. The answer to which this author’s recommendation would be, yes perform the CALND due to mapping failure of the axilla. Between September 1994 and October 2005, 15,000 patients’ records in the Moffitt Cancer Center Breast Cancer database were retrospectively reviewed following institutional review board (IRB) approval. Only patients with T1–T2 invasive breast tumors were included. Ninety-one patients were identified with having IntraMLNs, of which eight patients (9%) had isolated IntraMLNs. All eight patients with isolated intraMLNs had negative axillary contents on pathology. Eighteen of the 91 patients (21%) had IntraMLN with axillary metastases. Sixty-two of 91 patients (69%) had a negative IntraMLN. There were 502 patients identified with (N1), axillary nodal metastasis and compared with patients with isolated IntraMLN positive patients. Patients with isolated IntraMLN metastases had 0 of 8 recurrences and 0 of 8 deaths after an average follow-up time of 2.63 years. Patients with solitary axillary metastasis had 36 to 502 recurrence (7%) and 44 of 502 (9%) died after an average of 2.0 years follow-up. When an isolated positive IntraMLN is found, these data suggest an improved prognosis over those patients with an isolated axillary SLN and would not be deemed a high-risk patient for metastasis to the remaining nodes in the axilla. This Moffitt Cancer Center series of IntraMSLNs reported at the 2005 Society of Surgical Oncology conference demonstrated that a positive isolated IntraMSLN compared with an isolated positive axSLN, actually had an improved prognosis. These data would confirm the study and recommendation of Intra et al.5 that a positive IntraMSLN with negative axSNL would not warrant CALND nor should it predict a worse prognosis than isolated axillary nodal disease.

OBJECTIVE: To define preliminary guidelines for the use of lymphatic mapping techniques in patients with breast cancer. SUMMARY BACKGROUND DATA: Lymphatic mapping techniques have the potential of changing the standard of surgical care of patients with breast cancer. METHODS: Four hundred sixty-six consecutive patients with newly diagnosed breast cancer underwent a prospective trial of intraoperative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or a hot node with a 10:1 ex vivo gamma probe ratio of SLN to non-SLN. All SLNs were bivalved, step-sectioned, and examined with routine hematoxylin and eosin (H&E) stains and immunohistochemical stains for cytokeratin. A cytokeratin-positive SLN was defined as any SLN with a defined cluster of positive-staining cells that could be confirmed histologically on H&E sections. RESULTS: Fine-needle aspiration (FNA) or stereotactic core biopsy was used to diagnose 195 of the 422 patients (46.2%) with breast cancer; 227 of 422 patients (53.8%) were diagnosed by excisional biopsy. The SLN was successfully identified in 440 of 466 patients (94.4%). Failure to identify an SLN to the axilla intraoperatively occurred in 26 of 466 patients (5.6%). In all patients who failed lymphatic mappings, a complete axillary dissection was performed, and metastatic disease was documented in 4 of 26 (15.4%) of these patients. Of the 26 patients who failed lymphatic mapping, 11 of 227 (4.8%) were diagnosed by excisional biopsy and 15 of 195 (7.7%) were diagnosed by FNA or stereotactic core biopsy. Of interest, there was only one skip metastasis (defined as a negative SLN with higher nodes in the chain being positive) in a patient with prior excisional biopsy. A mean of 1.92 SLNs were harvested per patient. Twenty percent of the SLNs removed were positive for metastatic disease in 105 of 440 (23.8%) of the patients. Descriptive information on 844 SLNs was evaluated: 339 of 844 (40.2%) were hot, 272 of 844 (32.2%) were blue, and 233 of 844 (27.6%) were both hot and blue. At least one positive SLN was found in 4 of 87 patients (4.6%) with noninvasive (ductal carcinoma in situ) tumors. A greater incidence of positive SLNs was found in patients who had invasive tumors of increasing size: 18 of 112 patients (16%) with tumor size between 0.1 mm and 1 cm had positive SLNs. However, a significantly greater percentage of patients (43 of 131 [32.8%] with tumor size between 1 and 2 cm and 31 of 76 [40.8%] with tumor size between 2 and 5 cm) had positive SLNs. The highest incidence of positive SLNs was seen with patients of tumor size greater than 5 cm; in this group, 9 of 12 (75%) had a positive SLN (p < 0.001). CONCLUSIONS: This study demonstrates that accurate SLN identification was obtained when all blue and hot lymph nodes were harvested as SLNs. Therefore, lymphatic mapping and SLN biopsy is most effective when a combination of vital blue dye and radiolabeled sulfur colloid is used. Furthermore, these data demonstrate that patients with ductal carcinoma in situ or small tumors exhibit a low but significant incidence of metastatic disease to the axillary lymph nodes and may benefit most from selective lymphadenectomy, avoiding the unnecessary complications of a complete axillary lymph node dissection.

IT WAS DIFFICULT to believe the tidings that have only just reached me, the news that Stanley Snaith died in Dorset on December 19 last, a few days after his 73rd birthday. The rising generation of librarians may say ‘Who was Stanley Snaith?’, so all the more reason for this tribute.

To the Editor.— I read with shock and dismay the Letter to the Editor by Dr Weaver1published in the April 15 issue ofJAMA, in reply to the article by Dr Lundberg and Mr Bodine.2In Dr Weaver's letter, he describes the indigent as "derelicts" and "bums." He also accuses them of being "drunks, addicts, illiterates, beggars, and thieves." I, frankly, am appalled that a physician would have such an opinion about the poor of this country and I am amazed that he is willing to voice his opinion in public in the form of a letter to the editor.. Unfortunately, the attitude that the poor and illiterate are that way by lack of effort on their part is an attitude that has been too often repeated by our present administration in Washington. While it is true that some individuals are impoverished owing to their own lack