A new approach to the management of primary unresectable carcinoma of the breast: is radiation therapy necessary?

Nearly all patients with locally advanced, inoperable breast cancer have occult metastases. Although radiation therapy may in some cases control local disease, it has no effect on the metastases and thus does not improve survival. Twenty-five patients with locally advanced inoperable breast cancer have been treated at Kaiser Permanente Medical Center during the last 10 years. Review of these patients confirms the limited local control and poor survival of these patients when treated with radiation therapy. A therapeutic plan which both achieves local control and treats distant micrometastases by the combined use of chemotherapy (with or without hormonal manipulation) and surgery is presented. Preoperative response of the primary lesion to therapy has also allowed selection of the proper postoperative adjuvant therapy. An example of this type of therapy with its results is presented in detail. Although preliminary tests are hopeful, obviously a large, controlled clinical trial will be needed to test their validity.

Concepts of neck lift.

Traditional skin-tightening or neck-lifting has been and still is a satisfactory method for correcting an unsightly neck. In cases of fatty neck, prominent platysmal bands, or both, additional measures must be employed if the defects are to be corrected. Excellent techniques have been developed in the past several years to correct these defects but are not without their own problems. A more conservative approach to the platysma has been used satisfactorily, but in all cases the patient should be appraised of the anatomic problems and provide some input into the approaches used.

Direct alternatives for neck skin redundancy in males.

The problem of redundancy of tissue of the neck, often called "turkey gobbler neck," can be corrected satisfactorily without performing a traditional face--neck lift (Fig. 4). This can be achieved with a vertical excision of skin, resection of fat, Z-plasty to the medial platysmal edges, and skin closure in a Z fashion. This operation is limited to males who distinctly prefer not to have a face-neck lift and is done only after description of the resulting scar which, because of its direction and location, has not been obtrusive.

Recurrent basal cell carcinoma. A review concerning the incidence, behavior, and management of recurrent basal cell carcinoma, with emphasis on the incompletely excised lesion.

Although controversial among dermatologists and surgeons, the conclusion based on this review is that basal cell carcinomas, with marginal histologic involvement, should be reexcised. When the margins contain tumor with one high-power field (400X), it is reasonable, in view of the 12 percent recurrence risk, to carefully follow patients who are elderly or are experiencing other extenuating circumstances.