Breast-conserving surgery and definitive radiation: a comparison between quadrantectomy and local excision with special focus on local-regional control and cosmesis.

PURPOSE: Breast-conserving surgery and definitive radiation as an alternative to mastectomy is a well-accepted practice. However, there is limited information addressing the extent of surgical resection. The purpose of this study is to compare the outcome of patients treated with local excision or quadrantectomy, followed by definitive radiation with particular emphasis on local-regional control and cosmetic results. METHODS AND MATERIALS: Between 1978 and 1989, 425 patients with Stage I and II breast cancer underwent conservative surgery followed by definitive radiation. Fifty-four patients had a local excision and 371 had a quadrantectomy. Median follow-up was 42 months. Axillary dissection (levels I/II) was performed in 317 patients, and of these 126 patients had positive axillary lymph nodes. Radiation consisted of 4500-5000 cGy to the breast with Co60 or 4 MV photons, plus a boost to the tumor site (356/425 patients) for a total dose of 6000-6500 cGy. Treatment of the regional lymph nodes was given to patients with undissected or inadequately dissected axillas and usually to patients with multiple positive lymph nodes. Of the patients with positive lymph nodes, 46% received systemic chemotherapy. RESULTS: The 5-year actuarial freedom from local-regional recurrence rates for patients treated with local excision and quadrantectomy followed by definitive radiation were 92% and 93%, respectively (p = 0.7). The 5-year actuarial survival rates for local excision and quadrantectomy were as follows: overall (83% and 82%; p = 0.7), cause-specific disease-free (74% and 71%; p = 0.9), and distant disease-free (82% and 76%, p = 0.4). Estimated 10-year results are also presented. Cosmetic analysis required a minimum follow-up of 5 years. In the local excision, 77% of the patients had excellent-good result, compared to 53% following quadrantectomy (p = 0.03). Excluding patients who received chemotherapy, the excellent-good scores were 76% and 57%, respectively (p = 0.1). The most unfavorable cosmetic results were associated with quadrantectomy followed by radiation with boost dose and chemotherapy, excellent-good in 22%. CONCLUSION: Conservative surgery consisting of local excision or quadrantectomy resulted in comparable local-regional control, overall, disease-free and distant disease-free survival, although cosmetic results were superior in the local excision group.

Polyarteritis manifesting as calf myositis and fever.

A patient presented with fever of undetermined cause for two months. On physical examination, bilateral calf tenderness was elicited, prompting a diagnostic muscle biopsy for polyarteritis. This limited form of polyarteritis is reviewed in the context of this case and previously reported cases. Polyarteritis limited to muscle seems to have a good prognosis and responds readily to steroids alone.

Erythema nodosum heralding recurrent Hodgkin's disease.

The association of erythema nodosum with Hodgkin's disease is acknowledged, although not well-documented in the literature. Two patients with long remissions of their Hodgkin's disease manifested persistent erythema nodosum beginning 7 and 6 months, respectively, before relapse was clinically evident. The skin lesions in both patients partially responded to treatment with indomethacin, but did not resolve completely until chemotherapy was instituted. Erythema nodosum probably reflects an important change in the balance of biologic forces between the host and the neoplasm, the nature of which can only be speculated upon at this time. Erythema nodosum should be considered a warning signal of impending relapse in a patient with a history of Hodgkin's disease.