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Superior herniation of mediastinal thymus as a neck mass in children during valsalva maneuver
Letters to the Editor
799
Superior herniation of mediastinal thymus as a neck mass in children during valsalva maneuver To the Editor: We read with great interest the article written by Jianhong et al1 in the September 2006 issue of American Journal of Surgery describing the surgical treatment of jugular vein phlebectasia in children. In the article, jugular vein phlebectasia and laryngocele are mentioned as the two conditions in which neck mass is apparent or aggravated during valsalva maneuver and disappeared or decreased at rest. We would like to take this opportunity to recall an unusual clinical entity called “superior herniation of mediastinal thymus,” which presents as an anterior neck mass during valsalva maneuver and disappears during rest or normal breathing. This entity was defined by Mandell et al2 as intermittent migration of the broadest part of the “normal” thymus out of the thorax into the suprasternal region during valsalva maneuver along with increased intrathoracic pressure. It is important for surgeons and radiologists to be aware of this entity, in addition to the conditions mentioned in the article, especially to avoid unnecessary biopsy or surgery and their potential risk of altering immune function because the tissue present may be the only normal thymic tissue.
Saliha Senel, M.D. Nilgun Erkek, M.D. Candemir Karacan, M.D. Department of Pediatrics Dr Sami Ulus Children’s Hospital Ankara, Turkey Emrah Senel, M.D. Department of Pediatric Surgery Diskapi Children’s Hospital Ankara, Turkey doi:10.1016/j.amjsurg.2007.12.029
References 1. Jianhong Li, Xuewu J, Tingze H. Surgical treatment of jugular vein phlebectasia in children. Am J Surg 2206;192:286 –90. 2. Mandell GA, Bellah RD, Boulden MEC, et al. Cervical trachea: dynamics in response to herniation of the normal thymus. Radiology 1993;186:383– 6.
Scoring systems for the prediction of non–sentinel node metastasis in breast cancer patients To the Editor: In a recent issue of American Journal of Surgery, Ponzone et al1 contributed to the debate concerning the validation of two scoring systems predicting non–sentinel node (non-SN) metastasis in breast cancer patients having a metastatic sentinel node (SN). We read this article with interest; however, it invites several comments. SN biopsy is now accepted as the standard of care for axillary-node staging in patients with early-stage, clinically node-negative breast cancer. If the SN contains metastasis, it is currently recommended to perform axillary lymph node dissection (ALND). However, in 40% to 70% of patients, the SLN is the only involved axillary node, implying that these patients undergo unnecessary ALND. The future stake for our daily practice is to be able to select from patients having SN involvement those who have the weak risk of non-SLN involvement to avoid subjecting them to unnecessary ALND. A scoring system algorithm seems to be the best tool to select the patients for whom ALND would be pointless. Score or nomogram should be simple to use and have excellent negative predictive value.
Several studies have attempted to identify predictors of non-SN metastases in patients having a tumor-involved SN. Histologic primary tumor size, size of the SN metastasis, number of tumor-involved SNs, proportion of involved SNs among all removed SNs, and extracapsular extension of the SN metastasis have each been identified as independent predictors of non-SN tumor involvement in breast cancer patients having SN metastasis. Unfortunately, neither of these characteristics has been demonstrated to be a strong enough predictor of non-SN tumor involvement to identify a subset of patient who can safely forgo ALND. Several scoring system algorithms, including our scoring system (Tenon score),2 have been described to identify the individual patient’s risk of having non-SN metastases to predict non-SN status in breast cancer patients with SN metastasis. In the study by Ponzone et al,1 the authors concluded that the Memorial Sloan-Kettering nomogram3 was more accurate than the M. D. Anderson score,4 with the Memorial Sloan-Kettering nomogram having an ROC curve of 0.71. We are not totally in agreement with the explanation of Ponzole et al.1 The authors argued that the M. D. Anderson
799
Superior herniation of mediastinal thymus as a neck mass in children during valsalva maneuver To the Editor: We read with great interest the article written by Jianhong et al1 in the September 2006 issue of American Journal of Surgery describing the surgical treatment of jugular vein phlebectasia in children. In the article, jugular vein phlebectasia and laryngocele are mentioned as the two conditions in which neck mass is apparent or aggravated during valsalva maneuver and disappeared or decreased at rest. We would like to take this opportunity to recall an unusual clinical entity called “superior herniation of mediastinal thymus,” which presents as an anterior neck mass during valsalva maneuver and disappears during rest or normal breathing. This entity was defined by Mandell et al2 as intermittent migration of the broadest part of the “normal” thymus out of the thorax into the suprasternal region during valsalva maneuver along with increased intrathoracic pressure. It is important for surgeons and radiologists to be aware of this entity, in addition to the conditions mentioned in the article, especially to avoid unnecessary biopsy or surgery and their potential risk of altering immune function because the tissue present may be the only normal thymic tissue.
Saliha Senel, M.D. Nilgun Erkek, M.D. Candemir Karacan, M.D. Department of Pediatrics Dr Sami Ulus Children’s Hospital Ankara, Turkey Emrah Senel, M.D. Department of Pediatric Surgery Diskapi Children’s Hospital Ankara, Turkey doi:10.1016/j.amjsurg.2007.12.029
References 1. Jianhong Li, Xuewu J, Tingze H. Surgical treatment of jugular vein phlebectasia in children. Am J Surg 2206;192:286 –90. 2. Mandell GA, Bellah RD, Boulden MEC, et al. Cervical trachea: dynamics in response to herniation of the normal thymus. Radiology 1993;186:383– 6.
Scoring systems for the prediction of non–sentinel node metastasis in breast cancer patients To the Editor: In a recent issue of American Journal of Surgery, Ponzone et al1 contributed to the debate concerning the validation of two scoring systems predicting non–sentinel node (non-SN) metastasis in breast cancer patients having a metastatic sentinel node (SN). We read this article with interest; however, it invites several comments. SN biopsy is now accepted as the standard of care for axillary-node staging in patients with early-stage, clinically node-negative breast cancer. If the SN contains metastasis, it is currently recommended to perform axillary lymph node dissection (ALND). However, in 40% to 70% of patients, the SLN is the only involved axillary node, implying that these patients undergo unnecessary ALND. The future stake for our daily practice is to be able to select from patients having SN involvement those who have the weak risk of non-SLN involvement to avoid subjecting them to unnecessary ALND. A scoring system algorithm seems to be the best tool to select the patients for whom ALND would be pointless. Score or nomogram should be simple to use and have excellent negative predictive value.
Several studies have attempted to identify predictors of non-SN metastases in patients having a tumor-involved SN. Histologic primary tumor size, size of the SN metastasis, number of tumor-involved SNs, proportion of involved SNs among all removed SNs, and extracapsular extension of the SN metastasis have each been identified as independent predictors of non-SN tumor involvement in breast cancer patients having SN metastasis. Unfortunately, neither of these characteristics has been demonstrated to be a strong enough predictor of non-SN tumor involvement to identify a subset of patient who can safely forgo ALND. Several scoring system algorithms, including our scoring system (Tenon score),2 have been described to identify the individual patient’s risk of having non-SN metastases to predict non-SN status in breast cancer patients with SN metastasis. In the study by Ponzone et al,1 the authors concluded that the Memorial Sloan-Kettering nomogram3 was more accurate than the M. D. Anderson score,4 with the Memorial Sloan-Kettering nomogram having an ROC curve of 0.71. We are not totally in agreement with the explanation of Ponzole et al.1 The authors argued that the M. D. Anderson