A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND: Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS: A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS: We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS: IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

Consensus guidelines from The American Society of Peritoneal Surface Malignancies on standardizing the delivery of hyperthermic intraperitoneal chemotherapy (HIPEC) in colorectal cancer patients in the United States.

BACKGROUND: The American Society of Peritoneal Surface Malignancies (ASPSM) is a consortium of cancer centers performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). This is a position paper from the ASPSM on the standardization of the delivery of HIPEC. METHODS: A survey was conducted of all cancer centers performing HIPEC in the United States. We attempted to obtain consensus by the modified method of Delphi on seven key HIPEC parameters: (1) method, (2) inflow temperature, (3) perfusate volume, (4) drug, (5) dosage, (6) timing of drug delivery, and (7) total perfusion time. Statistical analysis was performed using nonparametric tests. RESULTS: Response rates for ASPSM members (n = 45) and non-ASPSM members (n = 24) were 89 and 33 %, respectively. Of the responders from ASPSM members, 95 % agreed with implementing the proposal. Majority of the surgical oncologists favored the closed method of delivery with a standardized dual dose of mitomycin for a 90-min chemoperfusion for patients undergoing cytoreductive surgery for peritoneal carcinomatosis of colorectal origin. CONCLUSIONS: This recommendation on a standardized delivery of HIPEC in patients with colorectal cancer represents an important first step in enhancing research in this field. Studies directed at maximizing the efficacy of each of the seven key elements will need to follow.

Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study.

BACKGROUND: Evaluation of peritoneal metastases by computed tomography (CT) scans is challenging and has been reported to be inaccurate. METHODS: A multi-institutional prospective observational registry study of patients with peritoneal carcinomatosis from colorectal cancer was conducted and a subset analysis was performed to examine peritoneal cancer index (PCI) based on CT and intraoperative exploration. RESULTS: Fifty-two patients (mean age 52.6 ± 12.4 years) from 16 institutions were included in this study. Inaccuracies of CT-based assessment of lesion sizes were observed in the RUQ (P = 0.004), LLQ (P < 0.0005), RLQ (P = 0.003), distal jejunum (P = 0.004), and distal ileum (P < 0.0005). When CT-PCI was classified based on the extent of carcinomatosis, 17 cases (33%) were underestimations, of which, 11 cases (21%) were upstaged from low to moderate, 4 cases (8%) were upstaged from low to severe, and 2 cases (4%) were upstaged from moderate to severe. Relevant clinical discordance where an upstage occurred to severe carcinomatosis constituted a true inaccuracy and was observed in six cases (12%). CONCLUSIONS: The actual clinical impact of inaccuracies of CT-PCI was modest. CT-PCI will remain as a mandatory imaging tool and may be supplemented with other tools including positron emission tomography scan or diagnostic laparoscopy, in the patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Laparoscopic cholecystectomy for recurrent gallstone pancreatitis during pregnancy.

A pregnant patient with gallstone-induced pancreatitis initially responded to medical treatment, but the pancreatitis recurred. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy were done at 28 weeks' gestation. The remainder of the pregnancy was unremarkable. Although 20 cases of laparoscopic cholecystectomy have been reported for cholecystitis during pregnancy, this is the first report of laparoscopic management of recurrent gallstone pancreatitis in a pregnant patient.

Perforation of a Meckel's diverticulum caused by ingestion of a coin.

A 25-year-old woman ingested a quarter. Three days later, lower abdominal pain, fever, chills, and physical findings compatible with pelvic inflammatory disease developed. Radiographic examination showed the coin in the middle pelvis. Persistent abdominal complaints, abnormal physical examination, and failure of the coin to progress through the gastrointestinal tract despite conservative management led to surgical intervention. Exploration revealed an inflammatory process in the posterior uterine culde-sac with multiple omental, small bowel, and uterine adhesions due to perforation of a Meckel's diverticulum. Excision of the Meckel's diverticulum was done, and the patient recovered satisfactorily.

A matter of degree: job skills for human service administrators.

A small but important literature discusses which degrees and which skills are "best" for human service administrators. This research surveys current human service administrators to determine their views. The MSW administration degree, while seen as useful at the entry and middle levels of management, falls behind both the MBA and the MPA at top levels. Skills considered important are very similar at all levels of management, although managers of nonprofits had higher expectations for skill level in many areas than did managers at government agencies. Implications for schools of social work are discussed.

Training resident surgeons in combat: an experience during the Persian Gulf War.

The Persian Gulf War necessitated the activation of many Army Reserve and National Guard physicians, including a number in residency training. No prototype existed for the continued training of resident surgeons in a combat setting. The 159th Mobile Army Surgical Hospital (MASH) deployed in support of the Allied invasion of Iraq. A structured training program for two general surgery residents attached to the 159th MASH was developed and implemented. This program combined supervised operating room experience, perioperative management, morbidity and mortality conferences, and orthopedic grand rounds, all with careful professional documentation. A planned reading program could not be realized, due to the physical setting of wartime. Residents and attending staff interacted positively and the residents were able to continue their formal training as an integral part of the hospital. The model developed by the 159th MASH is a practical method of continuing structured resident training in a combat setting.

Preliminary experience with the Hutson-Russell loop cutaneous choledochojejunostomy.

In 1984, the use of a choledochojejunocutaneous fistula was described to allow balloon dilation of benign biliary strictures. Later, the use of the technique to obtain repeated access to the biliary tree in a larger series of patients was reported. The experience provided a foundation for the application of the technique in nine patients at Wilford Hall United States Air Force Medical Center. Represented were a variety of benign and malignant disorders. Six patient reports are offered from this preliminary experience to demonstrate the range of problems lending themselves to the use of the Hutson-Russell loop. Suggestions for present and future applications of the versatile choledochojejunocutaneous loop are included.

Splenectomy for hematologic disorders: a 20 year experience.

A retrospective chart analysis was conducted for all patients undergoing splenectomy for hematologic disorders at the Baptist Hospitals of Louisville between 1970 and 1989. Fifty-nine charts comprise the basis of this review. Variables considered included disease entities treated by splenectomy, indications for splenectomy, and morbidity and mortality associated with the surgery. Additional variables evaluated were splenic weight, estimated blood loss at surgery, technique of splenectomy, and drainage of the splenic bed. The authors found a high correlation of splenic weight to the hematologic disorder treated. Larger spleens were associated with greater blood loss at surgery. Preliminary splenic artery ligation did not reduce the operative blood loss in patients with massive spleens. Drainage of the splenic bed was not associated with postoperative bleeding or intra-abdominal abscess. The low morbidity (22%) and mortality (3.4%) compares favorably to other published studies, demonstrating that splenectomy for hematologic disorders may be safely performed in the community hospital setting.

Major hepatic resection in a residency training program.

Records of 30 major hepatic resections performed at David Grant USAF Medical Center and Wilford Hall USAF Medical Center were analyzed to assess the feasibility, safety, and resources required for such procedures in a general surgery residency training program. The mean intraoperative blood loss during surgery was 2022 mL and the mean intraoperative transfusion volume was 4.2 units of packed red blood cells. Patients spent an average of 2.7 days in the intensive care unit, with a mean overall postoperative stay of 15 days. One death occurred within 30 days of operation due to a postoperative myocardial infarction, and another death during the hospital stay was due to hepatic insufficiency and Candida endocarditis. Overall, five major postoperative complications occurred (17%), one requiring reoperation. All but one procedure was done by a closely supervised surgical resident. This experience compares favorably with others in the literature and supports the practice of hepatic resection as part of surgical training.

Wound complications following modified radical mastectomy: an analysis of perioperative factors.

To assess the effect of perioperative factors on the incidence of postoperative wound complications, the authors retrospectively analyzed 101 patients who had undergone modified radical mastectomy. These factors included age, body weight, operative techniques, estimated blood loss, wound-catheter drainage, extent of axillary dissection, nodal involvement, and length of hospital stay. Complications included seroma (10.9%), wound infection (8.9%), wound necrosis (5%), hematoma (3%), lymphedema (2%), and pneumothorax (1%). The logistic regression method was used to analyze the data. When electrocautery was used to create the skin flaps, the probability of a wound complication was .462, a 44% increase over that calculated for the cold-knife technique (P = .05). A prolonged hospitalization accompanied the occurrence of a wound complication. No other factors reached statistical significance.

Endometriosis arising in abdominal incisions.

The differential diagnosis of an incisional mass arising in a female includes endometriosis. The occurrence of abdominal scar endometriosis following hysterotomy is uncommon, being reported in less than 0.5% of patients undergoing cesarean section. Three cases of this unusual problem are reported, the experience at David Grant USAF Medical Center evaluated, and pertinent literature reviewed. The principles of surgical management include obtaining an accurate diagnosis and adequate excision.

HLA-DR and differentiated thyroid cancer. Lack of association with the nonmedullary types and possible association with the medullary type.

One hundred twenty-seven white European patients with differentiated thyroid cancer were typed for human lymphocyte antigen (HLA) DR specificities. There was no significant deviation from the HLA-DR distribution observed in 160 normal patient controls, neither in the entire group nor in the patient groups with nonmedullary types of thyroid cancer (61 with papillary and 44 with follicular, all nonradiation associated). Also, subdivision of patients with nonmedullary thyroid cancer according to age at diagnosis, presence of metastases, and presence of thyroglobulin antibodies in serum showed no significant deviation from the HLA-DR distribution. For the patients with medullary thyroid cancer (only sporadic [n = 20] or inherited isolated [n = 2] forms, no multiple endocrine neoplasias), there was a significant increase of HLA-DR2 (11 of 22 cases [50%]) in comparison with control patients (22%; P corrected to 0.02; relative risk, 3.6). These data suggest, in contrast to previous reports, that there is no genetic influence on the development of nonmedullary types of differentiated thyroid cancer. Medullary thyroid cancer without multiple endocrine neoplasia, however, may be associated with HLA-DR2.

Needle-localized biopsy of occult breast lesions.

Over a 3 1/2-year period, we did 121 needle-localized breast biopsies for nonpalpable, mammographically suggestive lesions. The presence of a mass lesion on mammography with or without microcalcifications was associated with malignancy more frequently than microcalcifications alone. In 15 cases (12.4%), biopsy showed malignancy; 13 patients had modified radical mastectomy, with 11 (85%) having no histologic evidence of axillary metastases. Evaluation of risk factors associated with breast cancer in those patients with positive biopsy results showed that advanced age and a past history of a breast cancer were present in a significant number of patients. Four patients (3.5%) had complications; a hematoma developed in one (0.8%), and three (2.7%) required a second biopsy to remove the suggestive mammographic lesion. We conclude that needle-localized breast biopsy is a reliable tool in detecting early breast carcinoma. The procedure causes only minimal morbidity and we believe it should be done in all patients with mammographically suggestive, nonpalpable breast lesions.

Surgical manifestations of eosinophilic gastroenteritis in the pediatric patient.

Eosinophilic gastroenteritis, an inflammatory bowel disease of unknown etiology, occurs in one of 10,000 admissions to this Children's Hospital. We had added 4 cases to the 11 retrieved from a literature review. The inflammation is characterized by mature eosinophils predominating a transmural process which may produce pain, obstruction, perforation, bleeding, or fistulae. All levels of the gastrointestinal tract are involved, but stomach (25.9%) and small bowel (66.7%) lesions are most common. Eosinophilia occurs in 61% of children and allergy in 13%. X-rays may demonstrate a diffuse or localized process. Operative intervention may be necessary to exclude tumors or regional enteritis, and at times to extirpate complications of local disease, but conservative therapy is the treatment of choice for this exacerbating-remitting disease.

Labial and palatal blood flow measurement before and after maxillary operations.

In order to quantify the blood flow conditions of the mobilized anterior maxillary fragment after an operation to correct severe maxillary prognathism, maxillary blood flow measurements were carried out using the washout of the inert, radioactive tracer. Xenon-133. It shows that post-operative blood flow is not decreased.

Laser surgery in exsanguinating liver injury.

Thirty-two conditioned 15-18 kg dogs underwent laparotomy, heparinization, left lateral hepatic lobe injury and subsequent partial left lateral hepatic lobectomy. The hemostatic capabilities of the surgical scalpel combined with suture ligatures and stay sutures, the Bovie, and the CO2 laser were compared. The CO2 laser proved significantly more effective in achieving hemostasis both in comparison to the Bovine and the surgical scalpel combined with classical methods. The postoperative mortality utilizing the Bovie was 11%, the scalpel 30% and the laser 23%. Two of the three laser deaths were related to a bulky laser delivery system which can be redesigned. Postoperative laboratory evaluation revealed that SGOT, LDH, alkaline phosphatase, total protein, albumin and hemoglobin levels were altered in the postoperative period but returned to normal levels in uniform fashion in all groups. There was no statistical difference between various surgical modalities with regard to these parameters. The white blood count was significantly lower in laser dogs when compared to the other two groups. Other laboratory parameters were unchanged. Damage to liver tissue may be less extensive when the laser is utilized as opposed to the Bovie or stay suture methods of hemostasis and healing is equally good. The CO-2 laser is considered a valuable ancillary tool in hepatic resection and clinical evaluation is warranted.