Faculty Bibliography

Nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast is rare and often indistinguishable from fibroadenoma, clinically and on aspiration biopsy smears. We report our observations in 10 patients with PASH, evaluated by fine-needle aspiration (FNA) biopsy and core biopsy.We retrospectively reviewed the clinical, radiographic, cytologic, and histologic findings in 10 cases of pure nodular PASH.Ten patients with a presumed clinical and radiologic diagnosis of fibroadenoma underwent aspiration biopsy. The aspiration smears were diagnosed as fibroadenoma (4 cases), cellular fibroadenoma (1 case), schwannoma versus neurofibroma (1 case), fibrocystic change (3 cases; 2 with atypia), and 'not specific for a lesion' (1 case). A diagnosis of PASH was not suspected in any case. A discrepant or imprecise cytologic diagnosis and /or the presence of dissociated spindle or epithelial cells, or cellular stromal fragments prompted a surgical excision in 7 of 10 patients (70%). The remaining 3 patients exhibited cytologic features of fibroadenoma and were diagnosed as such; however, surgical excision was recommended. Three patients underwent a subsequent core biopsy, with a diagnosis of PASH being made in 1 patient.FNA biopsy could not discriminate PASH from fibroadenoma in 4 of 10 patients (40%) or suggest a diagnosis of PASH in any case. On retrospective review, the finding of plump, spindle-shaped mesenchymal cells may be a cytologic clue to suggest a diagnosis of PASH. Diagn. Cytopathol. 2005;32:345-350. (c) 2005 Wiley-Liss, Inc

Early-stage breast cancer is a highly curable disease with well-established protocols, including surgery, and the adjuvant modalities of regional radiation therapy, chemotherapy, and hormonal therapy. Yet, there is clear evidence that these adjuvant modalities are underused significantly. This article reviews the evidence that supports the use of efficacious local and systemic therapies in early-stage breast cancer, reasons for underuse, and interventions that have proven to be effective in ensuring the delivery of appropriate breast cancer care and suggests strategies to improve the quality of breast cancer care

PURPOSE: To report the clinical and dose-volume histogram results of the first 47 patients accrued to a protocol of accelerated partial breast irradiation. Patients were treated in the prone position with three-dimensional conformal radiotherapy after breast-conserving surgery. METHODS AND MATERIALS: Postmenopausal women with Stage T1N0 breast cancer were eligible only after they had first refused to undergo 6 weeks of standard radiotherapy. Planning CT in the prone position was performed on a dedicated table. The postoperative cavity was defined as the clinical target volume, with a 1.5-cm margin added to determine the planning target volume. A total dose of 30 Gy at 6 Gy/fraction was delivered in five fractions within 10 days. RESULTS: The median age of the patients was 67.5 years (range, 51-88 years). The median tumor diameter was 9 mm (range, 1.3-19 mm). In all patients, the prescribed dose encompassed the planning target volume. The mean volume of the ipsilateral breast receiving 100% of the prescription dose was 26% (range, 10-45%), and the mean volume contained within the 50% isodose surface was 47% (range, 23-75%). The lung and heart were spared by treating in the prone position. Acute toxicity was modest, limited mainly to Grade 1-2 erythema. With a median follow-up of 18 months, only Grade 1 late toxicity occurred, and no patient developed local recurrence. CONCLUSION: These data suggest that this approach is well tolerated, with only mild acute side effects and sparing of the heart and lung

BACKGROUND: As we enter the 21st century, AIDS and breast cancer are two pressing issues in women's health. The spread of AIDS continues unabated. More than 21.8 million people have died of AIDS, and it is estimated that as of December 2000 an additional 36.1 million people, mostly in sub-Saharan Africa, were infected with the human immunodeficiency virus. In addition, women now constitute almost one half of all AIDS cases. With the widespread use of highly active antiretroviral therapy in the United States, the overall health and survival of HIV(+) individuals has improved dramatically. Thus, as the HIV(+) population matures, we will be called on to diagnose and treat more cases of breast cancer in seropositive women. What can we expect as the incidence of these two diseases begins to overlap? METHODS: Medline search, and review of the relevant literature. RESULTS: Forty-six published cases of breast cancer in HIV(+) individuals identified. CONCLUSIONS: Based on epidemiologic data from Western countries and Africa, HIV infection is not permissive for breast cancer. This is reflected in the paucity of available data. Early reports consisted of case reports, describing advanced cancers with unusual presentations and uniformly poor prognoses. Recent series describe more favorable prognoses and long-term survivors. It appears that hormonal therapy is well tolerated and effective, even in cases of locally advanced disease, and the toxicity from standard chemotherapy regimens is unacceptably high

Can long-term subcutaneous venous (Mediport) catheters be safely inserted without routine chest X-ray (CXR) verification? An estimated 500,000 Mediport catheters are inserted yearly in the United States, and elimination of unnecessary radiographs would result in substantial savings of increasingly limited health care resources. A total of 513 consecutive Mediport catheters were inserted by a single surgeon over a 5-year period using a standardized protocol and selective indications for follow-up CXR that included unilateral chest pain, aspiration of air, decreased breath sounds, and difficult catheter insertion. The 513 catheters were inserted in 498 patients with 271 patients (53%) undergoing postprocedure CXR. Of the 513 catheters 461 (90%) were placed by percutaneous approach to the subclavian vein. Six pneumothoraces (1.2% incidence) occurred, all in patients who met criteria for immediate CXR. The overall complication rate was 3.1 per cent and included eight instances of catheter-tip malposition (seven of the eight were successfully repositioned by vascular radiology), one mediastinal hematoma, and one chest-wall hematoma. This largest single-surgeon-reported series demonstrates that Mediport insertion can be safely accomplished with minimal complications following a standardized protocol using selective radiologic evaluation

BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury