Role of surgery in the management of postmastectomy extremity angiosarcoma (Stewart-Treves syndrome).

Stewart-Treves syndrome (STS) is the rare occurrence of angiosarcoma in a setting of postmastectomy upper extremity lymphedema. A collective comparison of outcomes following various initial treatment options in STS has not previously been reported. We reviewed 160 cases of STS reported in the literature since 1966. We analyzed the relationship between initial treatment and survival in all 92 of these patients for whom detailed treatment and outcome data had been reported. There was no significant difference in survival comparing those initially treated with wide excision (n = 16) and those treated with amputation (n = 45) (P = 0.40). Even in the setting of initial surgical treatment, overall long-term survival was poor (<40%). There have been even fewer long-term survivors among those treated initially with regional chemotherapy (n = 7) or radiation therapy (n = 24). An update on STS and a discussion of recent advances in the understanding of its molecular pathogenesis that may result in future treatment improvements are presented.

Barium peritonitis.

Perforation of the gastrointestinal tract during the course of barium contrast examination represents a lethal circumstance if untreated. The reported mortality of barium peritonitis in collected series is approximately 50 per cent. The authors' personal experiences with seven cases of barium peritonitis are presented for review and analysis. Aggressive fluid resuscitation, broad-spectrum antibiotics, early operative intervention, and lavage are important factors in increasing patient survival. Depending upon the operative findings, appropriate surgical procedures may include closure, resection, or exteriorization of the site of perforation. Adequate nutritional support must be maintained. Selected cases may require or permit only supportive, nonoperative therapy. Following these principles of management, survival was achieved in six of the authors' seven patients. Of paramount concern in any discussion of this entity is its prevention. Predisposing procedures and conditions are detailed. Careful attention to the particulars of the technical features of barium contrast studies may obviate some occurrences. Barium enemas through a colostomy require particular care. The use of a water-soluble contrast medium, rather than barium, may be appropriate in certain clinical settings.