Total lobectomy and total thyroidectomy in the management of thyroid lesions.

OBJECTIVE: To study an unselected consecutive series of patients undergoing thyroidectomy for tumors to establish the complication rates of total lobectomy with isthmectomy and total thyroidectomy. DESIGN: Retrospective study. PATIENTS: Two hundred eight consecutive, unselected patients were operated on by one surgeon from 1980 to 1990. One hundred nineteen patients (57%) had a total lobectomy and isthmectomy and 85 patients (41%) had total thyroidectomy. Four patients (2%) had partial excision for technical reasons, two with anaplastic cancers and two with advanced thyroiditis. RESULTS: Forty-two malignant lesions (20%) were diagnosed with a mean follow-up of 5 years. Malignant lesions were diagnosed in 15 (31%) of 48 males and 27 (17%) of 160 women. Ten patients (5%) had parathyroid adenomas. Long-term follow-up revealed that there were no deaths, permanent hypocalcemia, or recurrent laryngeal nerve damage. One patient was returned to the operating room to control bleeding. CONCLUSION: This study suggests that total thyroid lobectomy with isthmectomy and total thyroidectomy are both safe procedures in the management of thyroid tumors.

Infiltrating syringomatous adenoma of the nipple.

Infiltrating syringomatous adenoma of the nipple is a distinct, benign clinical entity. It is similar histologically to a syringoma, a benign tumor originating in the ducts of the dermal sweat glands. When located in the nipple, this lesion has been mistaken for nipple duct adenoma or tubular carcinoma. Infiltrating syringomatous adenoma of the nipple is locally infiltrating but does not metastasize. Appropriate local management depends on an accurate diagnosis. Following is a case report, review of the literature, and therapeutic options for infiltrating syringomatous adenoma of the nipple.

Intravenous nitrogen mustard given immediately after mastectomy: possible effect on local recurrence.

A small group of patients with Stage I and II ductal breast carcinomas were treated with intravenous nitrogen mustard the day of mastectomy and the first two postoperative days. Long term follow-up revealed that only one patient developed isolated local recurrence, a rate much lower than usually reported. It is possible that early use of chemotherapy could reduce local recurrences in the recently traumatized tissue.

Parathyromatosis in hyperparathyroidism.

Recurrent hyperparathyroidism after parathyroidectomy may present a difficult diagnostic problem. A rare etiology is parathyromatosis (multiple nodules of hyperfunctioning parathyroid tissue scattered through the neck and mediastinum) due to spillage of otherwise benign parathyroid tissue during surgery. We present a case of recurrent hyperparathyroidism and parathyromatosis due to tissue spillage during surgical removal of probable double adenomas, a rare cause of primary hyperparathyroidism. Thus, parathyromatosis must be included in the differential diagnosis of recurrent or persistent hyperparathyroidism, distinguished from parathyroid carcinoma by histologic criteria. The surgeon must be careful of parathyroid spillage during surgery, even of benign tumors of the parathyroids.

Bilateral breast cancer.

The magnitude of the clinical problem of bilateral occurrence of breast cancer is controversial. In order to evaluate clinical and pathologic factors associated with increased risk for metachronous, contralateral breast cancer, we reviewed the records of 187 patients undergoing operative treatment for primary breast cancer by the same surgeon at a single institution. Variables analyzed included age, race, history of tuberculosis or cancer at other sites, family history of breast cancer or cancer at other sites, prior use of estrogens, tobacco, and alcohol, marital status, parity, age at first pregnancy, tumor size and location, histologic diagnosis, degree of cellular differentiation and involvement of axillary lymph nodes. The incidence of metachronous, contralateral breast cancer was 11.8 per cent. The only factor with a statistically significant association with bilateral cancer was histologic diagnosis characterized by multicentricity. Life table survival analysis revealed that the five-year survival following treatment for metachronous, contralateral cancer was 59 per cent. We conclude that bilateral breast cancer is a significant clinical problem, that histology characterized by multicentricity is associated with a higher incidence of bilateral breast cancer, and that favorable survival justifies an aggressive approach.

Histopathological and clinical correlations of cystosarcoma phyllodes.

We performed a detailed retrospective analysis of 25 patients treated primarily at Northwestern Memorial Hospital, Chicago, for cystosarcoma phyllodes. Histopathological evaluation correlated well with malignancy, but clinical suspicion did not. Pathological studies indicated that high-grade tumors, necrosis, infiltrating margin, and the presence of more than one mesenchymal element were often associated with aggressive behavior. Flow-cytometric analyses of DNA aneuploidy and proliferative index supported the grading system we used, since all four malignant cases examined showed high proliferative index, and three of the four cases showed aneuploidy. None of the low-grade cases, including the recurrent ones, showed increased proliferative index or aneuploidy. We believe that flow-cytometric analysis ought to be performed on cases in which there is doubt regarding the potential malignancy.

Prognostic indicators in cystosarcoma phylloides.

Cystosarcoma phylloides is a breast neoplasm that has a frequently unpredictable clinical course. We made a retrospective study of 25 patients with this disease in an attempt to evaluate the indicators of aggressive behavior. In our series, older patient age, nulliparity, rapid tumor growth, pain, and large size of tumors increased the suspicion of malignancy but were not always reliable indicators of malignancy. Skin ulceration, tumor necrosis, and infiltrating tumor margins were the most ominous characteristics. High-grade tumors, that is, those with increased cellularity, vascularity, mitotic figure, and pleomorphism, often indicated aggressive behavior. Mixed mesenchymal components were sometimes related to a malignant course. We found a 24 percent incidence of associated breast cancer. Carcinoma of the ipsilateral breast was found in four patients and later in the contralateral breast in two patients. Of our 25 patients, 10 (40 percent) had recurrence and 4 (16 percent) died from disease. Recurrences after treatment usually occurred within 3 years. Patients must be followed carefully for local recurrence or metastases, since the clinical course is not predictable. Forty percent of the lesions were diagnosed as being malignant. Local excision was associated with recurrence in six of eight patients and was clearly inadequate treatment. Quadrantectomy was effective for benign peripheral lesions when a generous margin could be obtained. From these data, we believe that mastectomy is indicated in all patients with malignant lesions and in those with large benign lesions.

Superior mesenteric artery syndrome. Diagnostic criteria and therapeutic approaches.

The hospital records and radiographs of 44 patients diagnosed as having superior mesenteric artery syndrome were reviewed using strict clinical and radiographic criteria. Only six (14.6 percent) of the patients fulfilled these criteria, suggesting over-diagnosis of the disorder. An acute change in clinical status, such as an operation or complication of a medical disease, appeared to precipitate the superior mesenteric artery syndrome in these patients, all of whom had chronic debilitating diseases. In four of the six patients conservative therapy failed, and they required surgical decompression.

Hyperparathyroidism: problems in surgical management.

A retrospective study of 210 patients who had 225 operations for hyperparathyroidism over a 20 year period has been reported. These patients were operated on by 20 staff surgeons, 12 of whom performed such an operation less than five times for this disease during the study period. There was a significant operative and postoperative morbidity of about 8 percent. There was one postoperative death, and two patients died later of related problems. The recurrence rate was 1 percent. The total rate of untoward results was about 18 percent. The success rate of primary operations was 95 percent (71 percent for reoperations). These findings were similar to those in many published reports, but were less than satisfactory. It is possible that results could be improved by putting such patients in the care of experienced surgeons. Careful identification of all of the parathyroid glands is essential to obtain satisfactory results. There was an unusually large incidence of this disease in patients with thyroid disease, immobilization, and thiazide intake. There was a correlation between the preoperative serum calcium levels and the size of the parathyroid tumors that were removed. An interesting "rebound" postoperative hypercalcemia has been described.

Intraoperative angiography in intestinal angiodysplasia.

Intraoperative angiography is quite useful in locating the site of bleeding in patients with angiodysplasia of the small intestine. We recommend the placement preoperatively of an angiographic catheter in these patients. We have described a technique that complements this procedure with metallic clip labeling to locate precisely the area of bleeding. This method of treatment is illustrated in the present study by reports of patients bleeding from vascular malformations of the ileum, duodenum and the head of the pancreas.

Experience with lobular carcinoma of the breast. Emphasis on recent aspects of management.

A total of 105 patients with lobular carcinoma of the breast were seen at two hospitals between 1966 and 1978. Mammography was found to be of limited value in the preoperative assessment of these patients. As reported by others, there was a high incidence of bilateral lobular neoplasia. In the patients with lobular carcinoma in situ for whom follow-up data were available, all were alive and well. In contrast to this, infiltrating lobular carcinoma was found to be as malignant a lesion as any other infiltrating breast cancer regardless of the operative procedure performed. These latter tumors were found to bind substantial levels of estrogen receptor proteins. From the information gained, it is suggested that early hormonal manipulation and/or chemotherapy may be advantageous in the patient with recurrent infiltrating lobular carcinoma in particular.

Intracellular hyperthermia. A biophysical approach to cancer treatment via intracellular temperature and biophysical alterations.

This paper introduces a new multi-disciplinary "intracellular" biophysical treatment of cancer. The basic concept uses locally induced heat energy after tumor phagocytosis of submicron particles whose composition permits magnetic excitation. The key to this process is the utilization of the cancer cell membrane to contain the energy within the cancer cell. Any magnetic or electric dipole contained within or introduced into the cell, or that is capable of being produced by an external field, can be used. Submicron particles are colloidally suspended, injected intravenously and are phagocytized by cancer cells. Application of an external high frequency or pulsed electromagnetic field then raises the particles' temperature thus generating intracellular heat in precise increments. This results in selective thermal destruction of cancer cells with little effect on normal cells. Experimental evidence is presented showing tumor cell destruction in spontaneous mammary tumors in Sprague Dawley rats. In addition, we suggest that certain biophysical properties are altered within the cancer cells and could be used to enhance this effect. Specific radioisotopes or tumor specific antibodies bound to particles or chemotherapeutic microspheres increase cancer cell sensitivity and affinity for these particles. This "intracellular" treatment of cancer has a wide potential range of applications.

Colostomy and colostomy closure.

A series of 181 adult patients subjected to colostomy was studied, almost all of whom had disease rather than injury. The complication rate was 28 per cent. One hundred of these patients had a subsequent colostomy closure with a complication rate of 17 per cent. Of the patients who had both procedures, 35 (35 per cent) had one or more significant complications. The causes and prevention of these complications are described.

Phytobezoar: a recurring abdominal problem.

Phytobezoars often follow gastric surgery for peptic ulcer disease. Billroth I resections have a high incidence of gastric bezoars, especially if accompanied by vagotomy. The larger opening of a Billroth II resection may result in intestinal bezoars with obstruction in the narrow terminal ileum. Gastric bezoars can be treated with enzymes or can be broken up by endoscopy; only rarely is operative removal required. Intestinal bezoars can be treated by long-tube and enzyme instillation but usually require laparotomy. If possible, the bolus should be milked into the cecum, but enterotomy or even resection may be required. Prevention is the best treatment and can be carried out by instructing patients who have had gastric surgery to avoid the fibrous portion of oranges and grapefruit and to avoid persimmons.