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Established in 1957, the University of Florida Department of Surgery has a solid foundation on which current faculty are driven to build a stronger tomorrow. The department is focused on promoting patient-centered care, expanding its research portfolio to improve techniques and outcomes, and training the surgical leaders of tomorrow. It fosters an environment where faculty, residents, students, and staff challenge long-held traditions with the goal of improving the health of our patients, the quality of our care, and the vitality of our work environment.

The role of operation in patients with Multiple Endocrine Neoplasia Type 1 (MEN-1) and Zollinger-Ellison Syndrome (ZES) is controversial. Our institutional bias for this disease has, in general, been towards aggressive imaging and operative removal of localized gastrinomas. Few studies have reported long-term outcomes in patients with MEN-1 and ZES. A single institution retrospective review of all patients with MEN-1 and ZES from 1970 to present was performed. Twelve patients were identified (median age = 37 years at diagnosis). The median follow-up was 18 years from diagnosis of ZES. Common symptoms associated with gastrinoma in these patients were diarrhea (n = 6), abdominal pain (n = 4), and nausea/vomiting (n = 4). Most commonly identified sites of gastrinoma were: pancreas (n = 10), duodenum (n = 4), lymph nodes (n = 3), and liver (n = 1). Fifteen celiotomies were performed in total (median = 1; range 0-3). Operative procedures performed included: distal pancreatectomy (n = 4), acid reducing procedure (n = 4), enucleation of pancreatic gastrinoma (n = 3), duodenal resection (n = 3), pancreaticoduodenectomy (n = 1), and other (n = 7). One patient had a transient biochemical cure after operation lasting 3 years. Only one patient in this series had documented liver metastases of gastrinoma and no patients expired of metastatic gastrinoma. There was one postoperative patient death, secondary to respiratory arrest thought to be a result of aspiration or pulmonary embolus. Three patients died of nondisease related causes, and seven patients were alive at the time of last follow-up. Operations rarely result in biochemical cures in patients with MEN-1 and ZES. In our experience, resection of localized gastrinomas often did not require extended surgical resection and were associated with excellent long-term outcomes.

Nodular fasciitis (NF) typically presents as an enlarging soft tissue mass with imaging characteristics that may be suggestive of soft tissue sarcoma or desmoid tumor. This presentation can make a correct diagnosis and management of patients with NF a challenge. We report our recent experience with two cases of NF that were both referred with a diagnoses of "soft tissue sarcoma." Patient 1 was a 46-year-old woman who had undergone breast augmentation and was referred with a rapidly growing firm mass on the left chest wall beneath the breast implant. Computed tomography of the chest noted the mass to be 8 cm x 11 cm in size displacing the implant laterally with no radiological involvement of the bony structures of the chest. Core biopsy was suggestive of inflammation only. Given the clinical suspicion of malignancy, the patient underwent resection of the mass with implant removal. Final pathology showed NF. Patient 2 was a 65-year-old woman referred with an enlarging tender 3-cm infraclavicular mass and a clinical diagnosis of "soft tissue sarcoma." Preoperative biopsy suggested NF. The patient underwent complete excision, which confirmed the diagnosis. These cases highlight the clinical issues associated with management of patients with NF. Current approaches to evaluation, diagnosis, and treatment of NF are discussed.

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.

Idiopathic granulomatous mastitis, also known as idiopathic granulomatous lobular mastitis, is a benign breast lesion that represents both a diagnostic and therapeutic dilemma. We report two cases of granulomatous mastitis recently evaluated and managed at our institution. To better understand this rare disease, we analyzed treatment outcomes in reported cases of granulomatous mastitis. One hundred sixteen cases were subsequently analyzed. Primary management strategies included observation (n = 9), steroids (n = 29), partial mastectomy (n = 75), and mastectomy (n = 3). Success rates with each treatment were observation, 56 per cent; steroids, 42 per cent; partial mastectomy, 79 per cent; and mastectomy, 100 per cent. Based on this analysis, we propose a clinically useful algorithm for both workup and management of these challenging cases.

Apocrine adenocarcinoma is a rare malignancy with invasive potential. Its clinical behavior and histologic appearance are highly variable, making accurate diagnosis difficult. We report on a case of apocrine carcinoma presenting with lymph node infiltration and extensive extramammary Paget's disease. Wide local excision with lymph node dissection is the mainstay of treatment. The role of adjuvant therapy has yet to be established.

The technique of identifying the sentinel lymph node (SLN) varies from each individual institution. Generally, the highest isotope count in a lymph node is considered the SLN, whereas other radioactive nodes might also be removed. The purpose of our study was to determine if the hottest node was always the tumor-containing node. Two hundred forty-seven breast cancer patients underwent SLN biopsy from April 1998 to April 2002. Lymphatic mapping involved a radiocolloid injection and lymphoscintigraphy followed by intraoperative assessment with a hand-held gamma probe. All SLN(s) with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN were removed. The SLN were sliced at 2-mm intervals with 4-microm step-sections (92-microm spacing) and evaluated by microscopy and immunohistochemistry. One hundred twenty (49%) of the 247 patients had 2 or more nodes resected. Of these 120 patients, 33 (28%) had a tumor-bearing node. In 25 (74%) cases, the tumor-bearing node was the most radioactive; however, in 8 (26%) cases, the positive node was a lesser reactive node. Although the most radioactive node in a draining basin is considered the SLN, this is often not the metastatic node. Therefore, all nodes with significant radioactive counts must be removed to ensure accurate staging.

Upregulation of nuclear factor (NF)-kappaB is found in many forms of cancer. Activation of NF-kappaB in cancer cells by chemotherapy or radiation can blunt the ability of this therapy to induce cell death. Proteasome inhibitors stimulate apoptosis in part via prevention of NF-kappaB activation. We sought to determine whether constitutive NF-kappaB activity is present in human colon cancer. In addition we studied whether alterations of NF-kappaB activity with a proteasome inhibitor would prevent colon cancer cell growth and induce apoptosis. We demonstrated constitutive transcriptional activation of NF-kappaB in SW48 and SW116 colon cancer cells by luciferase and electromobility shift assays. This was confirmed by p65 immunostaining. This activity was further induced in the presence of chemotherapy. In colon cancer specimens constitutive activation of NF-kappaB was observed in the majority of tumors. Treatment with the proteasome inhibitor (MG-132) inhibited growth and also stimulated apoptosis of colon cancer cells. We conclude that inhibition of NF-kappaB activation may be a logical therapy for certain cancers. This can be done via specific approaches on molecules necessary for keeping NF-kappaB inactivated in the cytoplasm. Other potentially useful ways to promote apoptosis in cancer cells include the utilization of proteasome inhibitors. Such inhibitors are currently being evaluated in clinical trials.

Although sentinel lymph node (SLN) biopsy is rapidly becoming the standard of care for small breast cancers the optimal radiocolloid injection technique remains controversial. We report our experience with sequential dermal-peritumoral radiocolloid injection that takes advantage of both techniques. One hundred eighteen patients with clinical stage T(is), T1, T2 and N0 breast cancer underwent SLN biopsy at the University of Florida. Twelve to 18 hours before surgery patients received either an injection of 0.5 to 1.0 mCi 50:50 filtered:unfiltered technetium sulfur colloid into the dermis overlying the tumor and/or a peritumoral injection of a 3 to 4-mCi of radiocolloid 30 minutes later. Dynamic lymphoscintigraphy was performed and the topographical location of all imaged lymph nodes was marked on the skin. The next morning the surgeon utilized a hand-held gamma probe to remove all SLN(s) defined as any lymph node with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN [internal mammary (IM) nodes were not removed]. The SLN identification rate was 98.5 per cent (3 IM nodes) for dermal injection (d.), 83.3 per cent (1 IM node) for peritumoral injection (p.), and 100 per cent (14 IM nodes) for sequential dermal-peritumoral injection (d.p.) (p < 0.05 DP versus D). Sequential d.p. 50:50 filtered:unfiltered technetium sulfur colloid injection results in a rapid, high SLN identification rate that persists until surgery the next morning. Delineation of nonaxillary SLNs may lead to more accurate breast cancer staging and may also influence the delivery of IM node radiation.

This is a retrospective analysis of 50 patients with a minimum 2-year follow-up who had clinical signs and/or histologic evidence of inflammatory breast cancer and were treated with curative intent between October 1964 and March 1989. The 5-year relapse-free, absolute, and cause-specific survival rates for the overall group of 50 patients were 36, 39, and 45 per cent, respectively. Patients who received treatment with radiotherapy, chemotherapy, and surgery (n = 33) had a 5-year relapse-free survival rate of 50 per cent, compared with 7 per cent for those patients (n = 17) who received less treatment (P = 0.0002). The only clinical factor with a negative impact on relapse-free survival was mass size > 5 cm (P = 0.07). No advantage could be demonstrated for preoperative chemotherapy over postoperative chemotherapy or for doxorubicin-containing regimens over cyclophosphamide, methotrexate, and 5-fluorouracil. There was no difference in the incidence of distant metastases for patients receiving preoperative rather than postoperative chemotherapy, but there were more local recurrences in patients in whom local-regional treatment was delayed. A higher rate of arm edema was associated with more extensive surgery.

Forty-two patients with initially unresectable rectal adenocarcinoma were treated with preoperative irradiation and surgery between March 1970 and March 1986 at the University of Florida (Gainesville, FL). No patient received adjuvant chemotherapy. All patients had follow-up for at least 5 years; 23 (55%) had follow-up for 10 years or more. Five patients (12%) underwent an exploratory laparotomy before irradiation; the remaining 37 patients were clinically thought to have unresectable disease. Eighteen patients had tumor fixation to one structure, and 24 patients (57%) had fixation to two or more structures. Lesions that exhibited impaired mobility but not complete fixation were considered to be clinically resectable and are not included in this series. The dose of preoperative irradiation ranged from 3,500 to 6,000 cGy at 180 cGy per fraction; 30 of 42 patients received 4,500 to 5,000 cGy and only 4 patients received less than 4,000 cGy. Forty-one patients were operated on 1 to 11 (mean 4.6) weeks after the completion of radiotherapy; 1 patient died of aspiration pneumonia after completing irradiation but before the planned resection. Resection of the rectal cancer was accomplished in 37 patients. Four patients were found to have extensive unresectable disease at laparotomy. Twenty-one patients had a complete resection: 11 were stage B2, and 10 were stage C2. Twenty patients had incomplete resection due to positive margins (8 patients), distant metastases with or without positive margins (8 patients), or no resection due to extensive disease (4 patients). Two patients died after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

The current emphasis on early detection of breast carcinoma prompted an analysis of all breast biopsies performed at an urban teaching hospital between January 1, 1983, and December 31, 1987. There were 1,342 biopsies during this interval in 933 patients with an overall mean age of 45.3 years. Malignancy was diagnosed in 197 patients (14.7%) with a mean age of 57.5 years, while the remaining patients with a benign diagnosis had a mean age of 43.2 years. There were 178 nonpalpable lesions (13.3%) and 22 malignancies were detected in this group (12.4%). Most (91%) of the nonpalpable malignancies were "early" (in situ and stage I), while 71 per cent of the palpable malignancies were "advanced" (stages II and III). Although the yearly number of biopsies remained constant, upward trends were demonstrated in the number of nonpalpable lesions biopsied, the proportion of malignancies detected among all biopsies, and in the yield of proliferative benign forms of breast disease, specifically those with atypia. These trends correlated with a sixfold increase in the yearly number of mammograms performed over the same time interval. These results suggest that a commitment to an expanded use of mammography and to an aggressive approach to breast biopsy can increase the detection of both early forms of breast carcinoma and those benign breast lesions that are known pathologic risk determinants for breast carcinoma. Such a commitment may influence the future survival of this population.

The treatment of early rectal (T1) adenocarcinoma is controversial. Between 1974 and 1985, nine patients underwent local excision of rectal cancer followed by radiation therapy (RT) at the University of Florida. All cancers were exophytic and less than or equal to 3 cm in diameter. Pathologically, all tumors were adenocarcinomas, Broder Grade I or II. Surgical margins were free of tumor in eight of nine (89%) specimens. Eight of nine (89%) cancers were confined to the submucosa and one cancer invaded the muscularis propria. All patients received a minimum 4500 rad with or without a boost of an additional 1000 to 1500 rad. There were no operative deaths and the morbidity was minimal. Follow-up ranged from 24 to 127 months (mean 64). Twelve months following treatment one patient died of pneumonia, with no evidence of disease (NED). Eight patients remain NED (mean 67 months) at the time of this study.