Friday, December 15, 2017

OCMA Blog

OCMA Specialty Spotlight: Should Tissue from Mammoplasty be Examined by the Pathologist?

According to The American Society of Plastic Surgeons, 296,203 breast augmentations and 21,714 breast implant   replacements were performed in 2010. In 2011, after 60 cases of breast implant-associated anaplastic large cell lymphoma  (ALCL) became known to FDA, that agency issued a warning to patients who already had or were considering breast implants.1,2 Breast implant-associated ALCL is a rare type of lymphoma of T-cell lineage with clinical signs and symptoms of swelling, pain, pruritis and/or effusion around the implant.3According to a recent study in M.D. Anderson Cancer Center, patients who present with effusion without a distinct mass have an excellent nprognosis if the breast implant and fibrous capsule are removed. In contrast, patients who present with a distinct mass in the vicinity of the implant may have advanced stage or possibly systemic disease and poorer prognosis.4

One of 500,000 women receiving breast implants is estimated to develop implant-associated ALCL.5However, this frequency may be underestimated for the following reasons. Firstly, there are no standardized recommendations for pathologic examination of tissue excised during cosmetic surgery. The routine submission of tissue from that type of procedure is not typically considered the standard of care and is dictated by the individual and/or institutional policies. Secondly, there are no consensus recommendations for examination of the fibrous capsule surrounding the implant, where the lymphoma would be most commonly detected. According to a survey of 413 institutions in 1999, mostly in the United States, 10.7% had policies that exempted the submission of mammary   implants for pathology examination, and 63% had policies that recommended mammary implants for gross examination only, without distinguishing implants from capsulectomy specimens.6 Being more cognizant of the disease, one can surmise that the detection rate of ALCL will increase as more surgeons send the capsule and breast tissue surrounding the implant to pathology, and as pathologists submit more tissue for microscopic  evaluation.

In view of the above discussion, the following questions merit consideration. Should patients with breast implants have them removed for the fear of a malignancy? A negative response to this question would be appropriate; there is no ground for panic unless the patient experiences pain, swelling, retraction, or effusion around the implant. Should the implant, the surrounding capsule and breast tissue be submitted to pathology for both gross and microscopic examination, even though the likelihood of detecting a malignancy in this type of specimen is quite low? An affirmative response would be appropriate in this situation considering that in addition to ALCL, a very small    number of patients could harbor a clinically undetectable mammary carcinoma. 

Newport Coast Pathology (NCP), Inc. is committed to providing high quality care and exceptional anatomic pathology    services for the patient and the referring physician, respectively. Our pathologists treat every specimen as if it were their own or that of their family member. We strongly believe that the pathologist is an integral member of the team of physicians involved in the patient's care, and that communication between the pathologist and the clinician is essential to serving the needs of the patient. Our pathologists are available for consultation with referring physicians and their staff, any time. 

NCP offers a comprehensive menu of diagnostic tests, including: Histopathology, Histochemistry, Immunohistochemistry, Non-GYN Cytology, Cancer prognostic marker tests by various methods  

Newport Coast Pathology, Inc., was founded in 2010 by Mani Ehteshami, MD, a pathologist who recognized a need for a local laboratory that would provide personalized service. Dr. Ehteshami is certified in anatomic and clinical pathology by the American Board of Pathology, and has 17 years of post-fellowship experience and expertise in surgical pathology and cytopathology, specifically in gastrointestinal, liver, genitourinary and breast pathology. He earned a medical degree from Rosalind Franklin University of Medicine and Sciences in Chicago. Following the completion of his residency in anatomic and clinical pathology at the University of New Mexico School of Medicine in Albuquerque, Dr. Ehteshami was a fellow in oncologic surgical pathology at the University of Texas, M.D. Anderson Cancer Center in Houston, where he was trained by many internationally known academic pathologists including Drs. Kathy Foucar, Elvio Silva, Nelson Ordonez, and Ruth Katz. 

http://newportcoastpath.com/  T: (888) 463-3606 


Prior to relocating to Orange County, Dr. Ehteshami was the Medical Director and co-owner of a highly successful private anatomic pathology laboratory in northern California for 13 years. In addition, he held several key leadership positions including Medical Director of Clinical Laboratories, chair of the Pathology Department and chair of the Cancer Care committee at Shasta Regional Medical Center. He was interviewed by and published in Make [Me] Heal publication:"Checking for Breast Cancer when you Have Breast Implants", April 28, 2011 issue. He has affiliation with the following professional organizations: Fellow of the College of American Pathologists, Fellow of the American Society of Clinical Pathology, Member of the California Society of Pathologists, Member of the California Medical Association, Member of the Orange County Medical Association.

Before earning his medical degree, Dr. Ehteshami volunteered his services to educate and counsel patients with multiple sclerosis, and helped to establish housing for those patients. As the Chairman of the Patient Services Committee, a member of the Medical Advisory Committee, and a member of the Board of Trustees of National Multiple Sclerosis Society in Orange County, he was recognized for his outstanding volunteer service. Dr. Ehteshami is an avid runner who has raced in dozens of full and half marathons in the US and abroad. 


References

1. US Food and Drug Administration. Anaplastic large cell lymphoma (ALCL) in women with breast implants: preliminary FDA findings and analyses. 2011. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm. Accessed June 22, 2011.

2. US Food and Drug Administration. FDA medical device communication: reports of anaplastic large cell lymphoma (ALCL) in women with breast implants. 2011. Available at:  http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm240000.htm. Accessed January 26, 2011.

3. Keech JA Jr, Creech BJ. Anaplastic T-cell lymphoma in proximity to a saline-filled breast implant. Plast Reconstr Surg. 1997;100:554-555.

4. Anaplastic Large Cell Lymphoma Associated With Breast Implants: A Report of 13 Cases.  Aladily, Tariq N.; Medeiros, L. Jeffrey; Amin, Mitual B.; Haideri, Nisreen; Ye, Dongjiu; Azevedo, Sergio J.; Jorgensen, Jeffrey L.; de Peralta-Venturina, Mariza; Mustafa, Eid B.; Young, Ken H.; You, M. James; Fayad, Luis E.;  Blenc, Ann Marie; Miranda, Roberto N. American Journal of Surgical Pathology. 36(7):1000-1008, July 2012.

5. Kenkel JM. Discussion: anaplastic large cell lymphoma and breast implants: a systematic review. Plast Reconstr Surg. 2011;127:2151-2153.

6. Zarbo RJ, Nakhleh RE. Surgical pathology specimens for gross examination only and exempt from submission: a College of American Pathologists Q-Probes study of current policies in 413 institutions. Arch Pathol Lab Med. 1999;123:133-139.


OCMA Specialty Spotlight: The Gavin Herbert Eye Institute

The Gavin Herbert Eye Institute at the University of California, Irvine, refers to both an academic specialty eye care practice and research group already in existence and to a high-technology patient care facility under construction on the UC Irvine main campus on Bison, just off the 73. 

The institute itself comprises 17 full-time clinician faculty, covering all subspecialties, with offices at both UC Irvine Medical Center in Orange and at Gottschalk Medical Plaza on the Irvine campus; 9 basic science faculty researchers located at the UC Irvine School of Medicine in Irvine; 9 residents and 9 post-residency subspecialty fellows; plus volunteer faculty and post-doctoral researchers. The Gavin Herbert Eye Institute provides the only full-service academic specialty care between San Diego and Los Angeles, with a full range of advanced diagnostic imaging and surgical specialty technologies.

The new clinical building on the UC Irvine campus will fulfill a vision that Gavin Herbert has worked for over 30 years to accomplish. The founder of Allergan, Mr. Herbert first recruited the internationally eminent Irving Leopold, MD, from New York to be the first chair of the ophthalmology department in the newly created UC Irvine School of Medicine. Now, Mr. Herbert has led the drive to raise the philanthropy for an outstanding   facility to deliver world-class patient care and simultaneously be the fulcrum for translational research that brings basic research into innovative new therapy. The project is funded 100% through philanthropy, with no state or university dollars. Currently $29.5M has been raised toward the total opening cost of $37M.

Roger F. Steinert, MD, was recruited from Harvard 8 years ago with the allure of the opportunity of helping to achieve this project. For Dr. Steinert, a Massachusetts native, a summa cum laude graduate of Harvard College and an Alpha Omega Alpha graduate of Harvard Medical School, and a faculty member of Harvard Medical School and the Massachusetts Eye and Ear Infirmary, the potential of the eye institute project and the draw of Orange County nevertheless was irresistible.

"I had frequently visited Orange County over several decades as part of my research in lasers and cataract   surgery," commented Dr. Steinert. "The potential for world-class innovation in prevention and treatment of blinding disorders is clear. Orange County has the highest concentration of eye technology industry in the world. When you combine that with a highly supportive community and a world-class university, the ability to make a difference is clear."

"Our vision is to provide leading eye care to Orange County, right here, right now, while also, by collaboration with the Orange County community and the university, be a global leader in developing the new technology of tomorrow. Simultaneously, we will support our profession with accessible continuing medical education and train the leaders of the next generation."

The new building just celebrated the traditional "Topping Out" event, recognizing the completion of the    highest level of the building. Full occupancy and patient care is scheduled for Summer 2013. The new building comprises 70,000 square feet, and includes patient care offices, translational and clinical research spaces,  ambulatory surgery, laser and oculoplastic reconstructive surgery, and conference and teaching spaces. Extensive work has gone into creating innovative architecture, including collaboration with the Braille Institute to minimize architectural barriers to patients with limited vision. High definition video can be transmitted over the internet to teaching sites in the Institute but also throughout the world. Medical records are fully electronic, facilitating communication to referring physicians. 

The location of the clinical facility is just 500 feet away from the 2 laboratories conducting basic research in stem cell therapy for age-related macular degeneration and the inherited blinding disorder known as retinitis pigmentosa; innovative immunological studies on developing the first effective vaccine against herpes simplex virus; laser imaging of microstructures in the eye that will guide understanding of disease processes and therapy; and the pediatric blinding condition of cystinosis.



Roger F. Steinert, MD, graduated from Harvard College and Harvard Medical School, going on to complete his ophthalmology training at the Massachusetts Eye and Ear Infirmary. His career-long clinical interests are corneal surgery, cataract and implant surgery, and refractive surgery. He maintains a consultation practice in these areas. His research has centered on optics, with an emphasis on lasers and related technology. Dr. Steinert's current appointment is the Irving Leopold Professor of Ophthalmology, Chair of the Department of Ophthalmology, Professor of Biomedical Engineering, and Director of the Gavin Herbert Eye Institute, as well as Vice President and President-Elect of the Medical Staff of UC Irvine Medical Center. He has published 5 textbooks, including Cataract Surgery, currently in its 3rd Edition, as well as over 90 book chapters and over 140 peer-reviewed scientific publications. He is past president and current program chair of the American Society of Cataract and Refractive Surgery and Associate Editor of Ophthalmology, the journal of the American Academy of Ophthalmology.


OCMA Specialty Spotlight:The PRECICE Device

Dr. Samuel Rosenfeld, an orthopedic surgeon with the CHOC Children's Orthopaedic Institute, is the first on the West Coast to perform a limb lengthening procedure using the PRECICE™ Remote Control Device. Developed by Irvine-based Ellipse Technologies, in collaboration with Dr. Stuart Green of UC Irvine, and cleared for use in the United States by the FDA in July 2011, the PRECICE represents a new era for limb lengthening.

The device, considered by physicians to be precise and gentle, is implanted with minimal incision   surgery. A magnetic motor assembly in a rod is placed inside the patient's bone and responds to an external remote controller. The surgeon uses the external remote controller to gently and more accurately control the rate of lengthening, including the potential to reverse the lengthening. In addition to providing a less invasive procedure for limb lengthening, PRECICE has been recognized for significantly reducing the potential for complications, such as infections, during the healing process. Presently, the device is used for lengthening the femur and tibia bones.

Leg length discrepancies can be congenital (present at birth) or acquired as a result of an accident, a significant fracture that does not heal or disease, such as cancer. The conventional approach for leg lengthening has been the use of an adjustable external fixation device attached to the bone with pins and adjusted by the surgeon. The leg lengthens as the bone heals. The procedure has been associated with a high rate of complications, most commonly infections at the pin sites.

An alternative to external fixation devices, the first implantable device - called the intermedullary skeletal kinetic distractor (ISKD) - was approved by the FDA in 2001. A telescopic rod implanted in the marrow cavity of the bone and activated by movement, the ISKD makes it more challenging to control the rate of lengthening, potentially resulting in nerve damage, poor bone healing and muscle contractions. With the better control of the PRECICE system, some of these issues may be eliminated.

Named a "physician of excellence" from the Orange County Medical Association, Dr. Samuel Rosenfeld is a pediatric orthopedic surgeon with special interests in muscular dystrophy, spina bifida and spasticity.

He received his medical degree from Pennsylvania State University College of Medicine; his internship in general surgery at the University of California Irvine Medical Center, where he also completed his residency in orthopedic surgery; and a fellowship in pediatric orthopedics and rehabilitation at Rancho Los Amigos Hospital in Downey, California. He's part of the multidisciplinary team of experts at the CHOC Children's Orthopaedic Institute.

The CHOC Children's Orthopaedic Institute is the only program of its kind in the region offering a wide range of comprehensive subspecialty programs specializing in the diagnosis and treatment of complex orthopedic injury, illness and disorders in children and adolescents. At the CHOC Orthopaedic Institute, highly experienced pediatric orthopedic surgeons and specialists, along with a multidisciplinary team, provide a complete range of clinical, surgical and ancillary support services for their patients in one convenient setting.


Dr. Samuel Rosenfeld is a pediatric orthopedic surgeon with special interests in muscular dystrophy, spina bifida and spasticity. He received his medical degree from Pennsylvania State University College of Medicine; his internship in general surgery at the University of California Irvine Medical Center, where he also completed his residency in orthopedic surgery; and a fellowship in pediatric orthopedics and rehabilitation at Rancho Los Amigos hospital in Downey, California.

 


OCMA Specialty Spotlight: The Be Aware Foundation

Be Aware Foundation Releases Two New Videos that Empower Women to do Breast Self-Exam with Confidence

The Be Aware Foundation, a non-profit organization dedicated to raising awareness for early breast cancer detection, released two educational videos developed to empower women to perform breast self-exam (BSE) with confidence. The two videos can be viewed on the foundation's website (beawarefoundation.org) or on the foundation's YouTube channel (BeAwareFoundation).


Although mammography has been proven to be the best screening tool to detect breast cancer at an early stage, mammograms have some significant limitations. In women with dense breasts, mammograms miss approximately 30 percent of cancers. Some cancers show up as lumps between mammograms, and women under 40 years are not advised to do annual screening.

"Current guidelines for doing BSE are confusing," said Be Aware Foundation President Peggy Brooker. "The guidelines recommend that women should be aware of their breasts and report any changes to her doctor, but the guidelines also state that doing BSE should be a woman's choice." The next question is "how can a woman detect an early change if she is not doing regular breast self-examination?"

"My 40 years of treating women with breast problems has convinced me that women can be taught to do BSE with confidence," said Be Aware Foundation co-founder Dr. John West. "With the support of the Be Aware Foundation I have created two videos which spell out, step-by-step, what women must do to learn how to do BSE with confidence. These videos have the potential to save lives, save breasts and save money....and it's free for every woman to learn from."

 

Founded in 2004 by Tanja Cebula, a cancer survivor, and Dr. John West, the Be Aware Foundation is dedicated to saving lives by educating and inspiring women to follow early detection guidelines for breast cancer. Our volunteer RN's and breast cancer   survivors deliver a compelling educational program in a "lunch and learn" format to companies, agencies and other groups of women in Orange County. Women who attend our Pearls of Wisdom program are encouraged to fill out a Personal Plan of Action whereby they commit to following the early detection guidelines.

We send email reminders to perform monthly breast self exams and annual clinical exams and mammograms. These email reminders also offer important information about new developments in breast cancer prevention and treatment, as well as general women's health topics, and our Ask the Doctor topics. 


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