Surgery for early and minimally invasive breast cancer.

Limiting morbidity without sacrificing outcome remains paramount for patients with minimally invasive breast cancer, particularly regarding diagnosis, local disease control, limiting axillary dissection, and identifying the optimal timing for surgery. Stereotactic biopsy is evolving as a viable alternative to surgical biopsy, but it awaits confirmation in a randomized prospective study before its adoption on a routine basis. Breast-conserving therapy continues to offer local control rates similar to mastectomy, except for lesions with positive-excision margins, an extensive intraductal component, and perhaps in young patients and those with either lobular carcinoma or multifocal disease. Factors that provide prognostic information currently obtained by axillary dissection have not been identified, and hence axillary dissection remains a mainstay of treatment. Sentinel node biopsy requires further refinements and confirmation before its universal acceptance. Premenopausal patients undergoing surgery during the follicular phase of the menstrual cycle appear to fare poorly, thereby requiring further investigation.

Age correlates with increased frequency of high risk factors in elderly patients with thyroid cancer.

BACKGROUND: Age and certain pathologic features (ie, follicular histology, vascular invasion, and extracapsular extension) are reported to impact on prognosis in thyroid cancer, but the relationship between these two factors remains incompletely defined. PATIENTS AND METHODS: Clinical, pathologic, therapeutic, prognostic, and outcome data were retrospectively collected and compared among three groups of patients with thyroid cancer: group 1 (age 21 to 50), group 2 (age 51 to 70), and group 3 (age greater than 70). RESULTS: There was a statistically significant age-related decrement in survival: 10-year survival was 92% in group 1, 77% in group 2, and 48% in group 3. Follicular histology, vascular invasion, and extracapsular extension were more frequently observed in group 3 versus group 2 and in group 2 versus group 1 (all differences statistically significant except for vascular invasion). Although survival was significantly less for group 3 versus group 2 versus group 1, only vascular invasion and extracapsular extension independently predicted outcome by multivariate analysis. CONCLUSIONS: The prognostic importance of age in thyroid cancer may be due to the greater prevalence of pathologic risk factors in older patients.

Malignant potential in intestinal juvenile polyposis syndromes.

BACKGROUND: Unlike familial polyposis coli, where the premalignant nature of adenomatous polyps is well established, the cancer risk in juvenile polyposis has generally been considered not increased. METHODS: This study reviews all cases of juvenile polyposis reported in the English language to date to assess the occurrence and prognosis of carcinoma in the gastrointestinal tract. RESULTS: A total of 218 patients met the inclusion criteria. Mean age at diagnosis was 18.5 years (range: 9 months to 67 years). No gender preference was identified. The most common presenting symptom was chronic anemia, followed by acute gastrointestinal bleeding, rectal prolapse of polyp, protein-losing enteropathy, and intussusception. A family history of juvenile polyposis could be established in approximately 50% of patients, and associated congenital malformations were detected in 15%. Ninety-nine patients underwent 138 gastrointestinal operations: 121 colorectal, 12 gastric, and 5 small intestinal procedures. The development of a gastrointestinal carcinoma was reported in 36 cases (17%). Mean age at diagnosis of carcinoma was 35.5 years (range: 4-60 years). Most malignancies were located in the distal colon and rectum, with only one case of gastric and one case of duodenal carcinoma. Tumor stage at diagnosis was usually advanced, with poor survival figures. CONCLUSIONS: This study shows that juvenile polyposis syndromes carry a more significant risk of carcinoma than generally appreciated. Therefore, more intense endoscopic surveillance may be warranted, and definitive surgical options should often be considered in these syndromes.

Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient.

OBJECTIVE: To determine whether nonoperative management of splenic and hepatic injury in the multiply injured pediatric and adolescent patient is both safe and efficacious. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS: All patients younger than 19 years old who suffered trauma to the spleen or liver between February 1978 and December 1991 (n = 103) were retrospectively identified by a trauma registry. These patients were divided into three groups: the group as a whole, those suffering multiple injuries, and those suffering either head injury or injury remote from the abdomen that required operative repair. MAIN OUTCOME MEASURES: Injury severity and outcome within each group of patients were compared based on whether the splenic or hepatic injury was managed operatively or nonoperatively. RESULTS: Mean Injury Severity Scores among the multiply injured patients were not different depending on whether the splenic or hepatic injury was managed nonoperatively or operatively. Except for a higher incidence of transfusion requirement among patients who were treated operatively, measures of morbidity among the multiply injured patients did not differ based on treatment. The success rates of nonoperative treatment among all patients, those with multiple injuries, and those with either head injury or remote injury that required surgery were 94%, 90%, and 86%, respectively. CONCLUSION: Nonoperative management of splenic and hepatic injury in multiply injured pediatric and adolescent patients, including those with head injury and injury remote from the abdomen that requires surgical intervention, is successful and is not associated with a prohibitive morbidity.

Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula.

PURPOSE: The aim of this study was to compare patency and complication rates between basilic vein and polytetrafluoroethylene (PTFE) for brachial arteriovenous fistulas (AVF) for long-term hemodialysis. METHODS: All basilic vein and PTFE brachial AVF constructed between March 1988 and April 1993 were retrospectively reviewed. After construction of life-tables, log-rank testing was used to compare the primary patency rate of basilic vein AVF (n = 59) with the primary and secondary patency rates of PTFE AVF (n = 47). Complication rates were calculated for each type of fistula and compared by use of chi-squared testing. RESULTS: The primary patency rate for basilic vein AVF (90%) was superior to that of PTFE AVF (70%) at 1 year (p < 0.01), and at 2 years (86% vs 49%, p < 0.001). Complications occurred two and a half times more frequently in the PTFE group than in the basilic vein group (p < 0.05). CONCLUSIONS: Basilic vein AVF provided superior patency rates and lower complication rates compared with PTFE AVF. Prospective randomized trials comparing the two fistula types is required to firmly establish the basilic vein AVF as the alternative access procedure of choice after a failed or unconstructable radiocephalic fistula.

Role of surgery in stage IE non-Hodgkin's lymphoma of the thyroid.

BACKGROUND: Controversy persists regarding the role of surgery in the treatment of stage IE non-Hodgkin's lymphoma of the thyroid. Treatment options vary from complete surgical resection only to needle biopsy as the only invasive procedure required. METHODS: During a 29-year period 15 patients with stage IE non-Hodgkin's lymphoma were treated, with complete follow-up available in all patients. All patients had surgical exploration, followed in most cases by radiation therapy and/or chemotherapy. RESULTS: After operation six patients exhibited no gross residual tumor, all with intrathyroid disease, and all remained disease free; five of nine patients with residual disease, all with extrathyroid lesions, had persistent or recurrent disease (p < 0.04). Among patients with residual disease after operation five of six receiving postoperative radiation therapy exclusively have died of or had recurrence of disease, whereas no further persistent or recurrent disease occurred in the three patients who received adjuvant chemotherapy (p < 0.02). CONCLUSIONS: Surgery permitted the distinction between intrathyroid tumor, which may be treatable by local therapy alone, and extrathyroid lesions, which appear to require systemic chemotherapy. Surgery provides not only the same diagnostic ability as needle biopsy but also important therapeutic implications regarding adjuvant therapy.

In vitro immune responsiveness of rats lacking active dipeptidylpeptidase IV.

DPPIV (CD26) is a cell surface serine exoprotease recently described as a T cell activation molecule. A substrain of German Fischer 344 rats expressing a truncated, inactive form of DPPIV were used to determine whether the absence of enzymatic activity affected the overall immunological competence of these rats as compared to American Fischer 344 rats that express normal levels of DPPIV activity. The proliferative responses of splenic leukocytes obtained from both strains of rats were assessed in vitro following stimulation by T cell (Con A), B cell (LPS), and T and B cell (PWM) mitogens. In addition, proliferation was determined in the presence and absence of N-MMA, an inhibitor of nitric oxide production which is known to be a potent regulator of lymphocyte proliferation in vitro. Finally, the ability of these rats to produce a secondary response to KLH-primed lymphocytes was compared. No significant differences were found between the magnitude of either the mitogen or antigen-driven responses of immune cells obtained from American and German rats. The response to restimulation by KLH resulted in equivalent levels of KLH-specific immunoglobulin and IFN-gamma production as well. Taken together, these findings demonstrate that the proteolytic activity of DPPIV may not be necessary for the generation of immune competence or that in the absence of functional DPPIV, German Fischer rats have developed a compensatory proteolytic mechanism.

Factors affecting prognosis and management of carcinoma of the colon and rectum in patients more than eighty years of age.

BACKGROUND: The safety and efficacy of operations for gastrointestinal diseases in very elderly patients has been a matter of debate in recent years. STUDY DESIGN: One hundred seventy-seven instances of carcinoma of the colon and rectum in patients more than 80 years of age who wee surgically treated between 1961 and 1987 were reviewed. They were compared with 623 similar instances in patients younger than 80 years of age who were treated during the same time period. RESULTS: Octogenarians and nonagenarians significantly more often displayed obstruction or perforation, elevated preoperative carcinoembryonic antigen, right-sided lesions, and solitary hepatic metastases, when present. Patients more than 80 years of age received adjuvant chemotherapy or radiotherapy less often. Carcinoma recurrence in very elderly patients implied a very poor prognosis, with only a 4 percent salvage rate. The actuarial five year survival rate was 32 percent for the older patients and 48 percent in the younger group (p < 0.05). There was no significant difference in operative mortality between the two groups. CONCLUSIONS: In general, age alone should not alter treatment strategy in patients with carcinoma of the colon and rectum.

Prognostic factors and management considerations in patients with cervical metastases of thyroid cancer.

Included among the controversies involving thyroid cancer are the risk factors and treatment decisions in patients with nodal metastases. We have reviewed selected clinical, pathologic, and therapeutic parameters in patients who present with cervical node metastases and related these parameters to disease outcome. There were 108 patients (68 women, 40 men), who had a mean age of 54 years. Univariate analysis showed a significantly increased risk of recurrence to be associated with the presence of primary tumor invasion (vascular, lymphatic, nerve, or muscle), the age and sex of the patient, the presence of mediastinal nodes, and adjuvant treatment with iodine 131. The presence of tumor invasion, the age and sex of the patient, and the presence of mediastinal nodes were significantly associated with higher rates of recurrence when tested by multivariate analysis. The 5- and 10-year disease-free survival rates were 76% and 72%, respectively, with a mean follow-up of 86 months. A comparison of recurrence and survival rates in thyroid cancer patients who were either node positive or node negative during the same 10-year period (152 patients) showed no statistically significant differences. However, node-positive patients with the risk factors of tumor invasion, age over 45 years, and positive mediastinal nodes had more aggressive disease. Although thyroid cancer patients with nodal metastases generally have a good prognosis, high-risk subgroups have been identified who may benefit from a more aggressive therapeutic and follow-up approach.