Role of axillary dissection in mammographically detected breast cancer.

The traditional rationale for axillary lymphadenectomy in patients with breast cancer was that the procedure was therapeutic, diagnostic, and needed to determine adjuvant therapy. Recent data have shown that there is little, if any, therapeutic value to this procedure and that the decision to use adjuvant chemotherapy or hormonal therapy may no longer be absolutely contingent on axillary node status. Increasingly, primary tumor factors are being used to establish the aggressiveness of cancers. Therefore, the widespread use of axillary lymphadenectomy especially in small, mammographically detected breast cancers is questioned.

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience.

BACKGROUND: Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation. METHODS: A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992. RESULTS: The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Academic medicine: as threatened as most would have us believe?

All academic health centers (AHCs) are threatened by the complexity of health care reform and by the speed with which it is occurring. We have been forced in all areas of our academic and clinical life to reassess the way in which we have traditionally operated. We must, in fact, do more than reassess. We must change fundamentally. This is true whether one considers medical education, biomedical research, or clinical services. Practically speaking, health care reform forced on us by the business community of America realistically means downsizing unless faculties are willing to change and pursue novel contemporary opportunities. It means less money and the need to do more with what we have. Educationally, we must emphasize the training of generalist physicians. On the research side, it means interdepartmental collaboration around core program project initiatives. It means a sharing of resources (including space) and the need to develop quality relationships with industry and philanthropic organizations. On the clinical side, we must develop a fully integrated, highly competitive, cost-efficient physician/hospital organization, and most AHCs must become part of a larger integrated delivery system to protect not only clinical but academic interests.

Paget's disease of the nipple-areola complex.

The histogenesis of Paget's disease has been hotly debated, and only recently has epidermotropic theory become widely accepted. With the evolution of our understanding of breast cancer, it became apparent that the prognosis of Paget's disease was more a reflection of that of the underlying carcinoma, be it intraductal or infiltrating. The standard treatment of Paget's disease remains mastectomy with or without axillary dissection. In this era of breast-conserving surgery, however, there is much evidence to suggest that conservative treatment of Paget's disease of the breast is possible. A breast-conserving algorithm for the treatment of Paget's disease of the breast is proposed. Further refinements or modifications to the algorithm should be made as data from ongoing trials redefine our understanding of breast pathology and treatment.

Evolving strategies for the management of non-palpable breast abnormalities.

Increased public and professional awareness has resulted in more women obtaining mammograms. As a result, the surgeon is often called on to diagnose and treat occult breast lesions. The development of new diagnostic modalities has changed the way such breast lesions are approached. Management decisions are made in the context of new pressures applied by the growing managed care imperative and increased mediocolegal exposure. In this review, we establish guidelines for the management of non-palpable breast abnormalities that place the welfare of the patient first.

Surgical residents in the 1990s. Issues and concerns for men and women.

OBJECTIVE: To survey the concerns of surgical residents in New England and to determine whether similarities or differences exist based on gender. DESIGN/SETTING: A survey was distributed to all 21 surgical residency programs. The survey consisted of six demographic questions and 23 items, which the residents coded on a Likert-type scale. PARTICIPANTS: Surgical residents enrolled in a general surgical residency or specialty residents completing general surgery requirements. INTERVENTION: Distribution and completion of the survey. MAIN OUTCOME MEASURE: Prominent concerns among residents during training years and gender differences based on these concerns. RESULTS: All programs responded. A completed survey was returned by 501 residents (73%), 378 (75%) of whom were male and 123 (25%) of whom were female. On a scale of 1 to 5 (from no concern to major concern), the five most important issues were work hours (mean, 3.4), personal finances (mean, 3.1), quantity and quality of formal education (mean, 3.0 each), and postponement of family plans (mean, 2.9). Six items surveyed were of more concern to women than men; availability of role models, mentors, or both; comfort in expressing emotions at work; initiating and maintaining personal relationships; having children during residency; and postponing family plans. CONCLUSIONS: Three of the highest-reported concerns for the entire group are issues that could conceivably be controlled by surgical chairpersons and program directors. In contrast, only one of the six concerns that differed for men and women is directly program related. The remaining five issues require changes in societal values for these differences to dissolve.

Reduction of skeletal muscle injury through stress conditioning using the heat-shock response.

The heat-shock response refers to specific reversible changes in cellular metabolism that impart a protective effect on individual cells, as well as entire organisms, against subsequent noxious stimuli. Our objective was to quantify skeletal muscle injury following an ischemic event in a rat model by measuring levels of adenosine triphosphate and creatine phosphate. The animals were divided into two experimental groups. Animals in group 1 (n = 15) were subjected to limb ischemia alone, and animals in group 2 (n = 15) were treated with heat-shock conditioning prior to the onset of ischemia. Skeletal muscle specimens also were examined ultrastructurally by electron microscopy. Levels of creatine phosphate were higher in skeletal muscle obtained from animals in group 2. Mean levels of creatine phosphate +/- SEM for groups 1 and 2 were 1.12 +/- 0.06 mumol/gm and 1.95 +/- 0.11 mumol/gm, respectively (p < 0.0001). This represents 18.4 and 31.9 percent of baseline nonischemic levels for groups 1 and 2, respectively (p < 0.0001). Adenosine triphosphate levels were measured in skeletal muscle samples from a subset of animals in each experimental group, group 1 (n = 6) and group 2 (n = 5), and were not significantly different. Electron microscopy demonstrated mitochondrial changes consistent with ischemic injury in group 1, but only nonspecific changes were noted in specimens from group 2. The presence of the primary 72-kDa heat-shock protein (HSP 72) was confirmed only in those animals treated by heat-shock conditioning. We conclude that prior stress conditioning using the heat-shock response confers significant biochemical and ultrastructural protection against ischemic injury in rat skeletal muscle.

Regional deep hypothermia of the spinal cord protects against ischemic injury during thoracic aortic cross-clamping.

We tested in pigs the hypothesis that regional deep hypothermia of the spinal cord achieved by cerebrospinal fluid cooling will protect against ischemic injury during thoracic aortic cross-clamping. Eight control animals underwent aortic cross-clamping at the distal aortic arch and just above the diaphragm for 30 minutes. Eight experimental animals had placement of two subarachnoid perfusion catheters through laminectomies at T4 and the lower lumbar region. The subarachnoid space was perfused with normal saline solution at 6 degrees C delivered by gravity infusion, with infusion rates adjusted to maintain cord temperatures at less than 20 degrees C. After 30 minutes of aortic cross-clamping, the infusion was stopped and the cord allowed to warm to body temperature. Hind limb neurologic function was graded by Tarlov's scale. All of the animals in the control group had complete hind limb paraplegia (Tarlov grade 0) postoperatively. Seven of the 8 animals in the experimental group had preservation of hind limb motor function (Tarlov grade 2), and 1 animal had complete hind limb paraplegia (Tarlov grade 0) (p = 0.002, Fisher's exact test). We conclude that regional deep hypothermia of the spinal cord in pigs does provide some protection from ischemic injury during thoracic aortic cross-clamping. Clinically this may be a useful adjunct for prevention of paraplegia during thoracic aortic operations.

Changing role of splenectomy for hematologic disease.

In the past decade the development of accurate imaging and the evolution of the medical management of hematologic diseases has led to changes in the indications for splenectomy for these disorders. To assess the impact of these developments, a multi-institutional, retrospective review was undertaken. One hundred fifty-six splenectomies were performed for hematologic disorders between July 1, 1979 and June 30, 1991. Patients were divided into 2 groups: those undergoing splenectomy from 1979-1985 (Period I), and those undergoing splenectomy from 1986-1991 (Period II). Diseases were classified into 3 groups: cytopenic/anemic conditions, symptomatic splenomegaly, and Hodgkin's disease. Data was compared between the two periods using chi-square analysis. More splenectomies were performed for hematologic disorders during Period II than Period I (P < .005). This increase is secondary to a rise in the number of splenectomies performed for cytopenia/anemia during Period II. In contrast, splenectomies for splenomegaly and Hodgkin's disease decreased during Period II (P < .005 and < .05). More Hodgkin's patients were upstaged on the basis of positive laparotomy findings in Period II, compared to Period I (40% versus 10%, P = .01). Surgeons are now performing more splenectomies for cytopenic/anemic diseases, and fewer for splenomegaly and Hodgkin's disease. These results are consistent with recent trends: (1) earlier splenectomy in patients with cytopenia/anemia; (2) earlier medical intervention in infiltrative splenic disorders; and (3) more reliance on radiologic staging in Hodgkin's disease and widespread use of combination chemotherapy, leaving surgical staging for those cases in which treatment would be changed by laparotomy findings.

Preliminary assessment of a scientific curriculum in a surgical residency program.

A structured, basic science curriculum was instituted for surgical residents of the University of Connecticut (Farmington) Integrated Residency Program during the 1990-1991 academic year in concordance with American Board of Surgery guidelines. The impact of the new program was measured by comparing performance on monthly basic science examinations, the in-training examination, and "mock" oral examinations for the 1990-1991 academic year with that of the preceding academic year. While monthly examination scores improved for the entire group of residents (67.7 vs 64.6), in-training and oral examination scores did not change significantly. Categorical residents generally demonstrated superior performance and greater improvement than did preliminary residents. Data analysis suggested that the new curriculum was an effective educational device and that university-designed monthly examinations were valid testing instruments, but there was an apparent incongruity between the goals of the curriculum and the American Board of Surgery In-Training Examination.

Intrarectal sonography. A new technique for the assessment of rectal tumors.

Preoperative staging of rectal tumors provides a selective therapeutic approach. Twenty-three patients were evaluated with prospective intrarectal sonography. Endosonography identified all 21 rectal lesions. Two patients with previous rectal carcinoma had no evidence of recurrence. Thirteen of 17 patients (76%) with rectal carcinoma were correctly staged by endosonography. A submucosal leiomyosarcoma and pararectal arachnoid cyst were correctly identified. Preoperative assessment of lymph node status was accurate in five of ten patients (50%). Results of preoperative digital rectal examination predicting rectal wall involvement correlated with pathologic findings in 11 of 15 patients (73%). Intrarectal sonography is an important staging technique for preoperative evaluation of rectal wall invasion and guides appropriate surgical intervention.

Survey of residents' attitudes toward reform of work hours.

Traditional work schedules of surgical residents have been cited as a factor that negatively influences residency education and the quality of patient care. As an adjunct to the formulation of recommendations for the development of the environment for general surgery training, the New England Association of Program Directors in Surgery set out to sample the attitudes of surgical residents in New England relative to their perceived need to reform work hours. Seventy-two percent of the residents thought there was a need for some level of resident work schedule change. The major variable that correlated with this opinion was the reported amount of sleep that a resident needed before returning to work after a 24-hour shift. The ultimate effect on education, patient care, and fiscal resources of these potentially sensitive changes remains to be determined.

Clinical and pathologic prognostic variables in oropharyngeal squamous cell carcinoma.

Eighty-five patients with squamous cell carcinoma of the oropharynx were studied to assess the value of histopathologic parameters related to their survival. The overall survival was 58 percent at 3 years and 51 percent at 5 years. Stepwise logistic regression analysis was used to determine the prognostic value of each of the histopathologic features. The extent of in situ carcinoma and presence of multifocality were positive predictors of survival, and perineural invasion and nodal involvement on clinical examination were negative predictors. None of the other parameters used in this study attained statistical significance. We conclude that the histologic grade traditionally used to predict clinical behavior may not be useful. Clinical stage, particularly nodal status; perineural invasion; and the multifocal or in situ disease, should be considered in pathologic reports to provide better prognostic profile in oropharyngeal carcinoma.

Comparative pharmacokinetics of cefotetan and cefoxitin in patients undergoing hysterectomies and colorectal operations.

Forty patients undergoing hysterectomy and 16 patients undergoing colorectal surgery were given intravenous 2 g doses of cefotetan (20 in the hysterectomy group and 8 in the colorectal group) or cefoxitin (20 in the hysterectomy and 8 in the colorectal group) before surgery. Serum samples were obtained simultaneously with tissue samples. Concentrations of each drug in serum and tissue were measured by high-pressure liquid chromatography. In both experiments, the composite drug concentration profile as a function of time in serum was consistent with that observed in nonsurgical patients; that is, a half-life of approximately 3.5 hours and 0.8 hours for cefotetan and cefoxitin, respectively. This also was true of tissue kinetics, in that tissue profiles appeared parallel to, but somewhat lower than, serum. At 20 minutes after administration, the peak myometrium concentration was 158 micrograms/g for cefotetan, and the corresponding serum concentration was 298 micrograms/ml. For cefoxitin, the corresponding values were 66 micrograms/g and 101 micrograms/ml. At 47 minutes, the cefotetan tissue and serum concentrations were 29 micrograms/g and 235 micrograms/ml respectively, and the corresponding values for cefoxitin were 15 micrograms/g and 43 micrograms/ml. Similar relationships were observed with these drugs in colorectal tissue. Although both antibiotics provide good concentrations during the early phase of surgery, cefotetan's concentrations persisted longer, which may be relevant in the prevention of infection in prolonged surgical procedures.