Variations in breast conservation surgery for women with axillary lymph node negative breast cancer in British Columbia.

A population-based study was conducted including all women diagnosed in British Columbia in 1991 with invasive node negative breast cancer (n = 942) in order to identify factors associated with variation in use of breast conserving surgery (BCS) and to determine if provincial practice guidelines were followed. Patient, disease, treatment and physician-specific information was abstracted from medical records and original source documents. 413 (44%) patients received BCS (51% and 23% in surgical candidates and non-candidates, respectively). Significant independent factors associated with BCS included patients' age, residence, family income, tumour size, tumour location, and extent of ductal carcinoma in-situ. Age and income had a significant interaction with stronger income effects in older women. A strong surgeon effect was observed which was not explained by measured surgeon attributes. Expansion of radiation treatment facilities may help address access issues. Further examination of the patient-physician relationship and of ways to assist patients in decision making is needed.

Linear dermatomyofibroma.

Dermatomyofibroma is a rare, plaque-like, cutaneous myofibroblastic proliferation that usually presents as a 1-2 cm, firm, dermal plaque, often with brown-red discoloration. We report an example of dermatomyofibroma presenting as a poorly defined, linear, indurated area, 8 cm in length, on the posterior aspect of the neck of a 20-year-old female. This lesion is the largest dermatomyofibroma reported to date and the first to demonstrate a linear distribution.

An evaluation of prognostic scoring systems in patients with follicular thyroid cancer.

BACKGROUND: Prognostic scoring systems for thyroid cancer have not been investigated in patients with pure follicular cancer; thus, the purpose of this study was to compare the following prognostic indices: the European Organization for Research and Treatment of Cancer (EORTC) method; the Age, Grade, Extent, Size (AGES) score; and the Age, Metastasis, Extent, Size (ALIES) score. PATIENTS AND METHODS: A retrospective study reviewing 122 patients actively treated between 1955 and 1990 was conducted. Scoring systems were calculated and survival analysis completed. AGES low-risk patients were analyzed with respect to known risk factors. RESULTS: The AGES scoring system significantly defined low- and high-risk groups (P = 0.0041); the ratio of deaths between high-versus low-risk groups was 1.9:1. EORTC scores distinguished four risk groups (P = 0.002). The AMES scoring system did not significantly assign risk. In multivariate analysis of low-risk AGES patients, age, perithyroidal tissue involvement, and positive frozen section reached statistical significance. CONCLUSIONS: The AGES and EORTC scoring systems best defined low- and high-risk groups of patients with pure follicular cancer, although the separation between groups was low.

Sarcoma and Cystosarcoma phyllodes tumors of the breast--a retrospective review of 58 cases.

A retrospective review of 58 rare breast neoplasms encountered at the British Columbia Cancer Agency between 1972 and 1992 was undertaken. There were 38 cystosarcoma phyllodes tumors, 6 carcinosarcomas, and 14 other sarcomas. Initial management involved total mastectomy in 37 cases, wide excision in 14, and excision biopsy in 7. Recurrence developed in 19 patients. Local recurrence developed in 7 patients following mastectomy, 2 incidences following wide excision, and 2 following excision biopsy. There was no significant difference in recurrence in relation to the surgical approach. Tumor grade was a significant predictor for metastatic recurrence but not for local recurrence. Adequate surgical excision remains the only curative therapy for these rare tumors. In selected cases, partial mastectomy is an acceptable treatment.

Blunt traumatic liver injury associated with clostridial infection of early onset.

Hepatic clostridial infections associated with blunt abdominal trauma are rare. Generally they occur from 2 weeks to 3 months after injury and are thought to result from the growth of normal enteric organisms, which are carried to the liver by the portal venous system and infect devitalized tissue. The authors describe two patients in whom the hepatic infection became established in less than 24 hours after injury and was due to Clostridium spp. The patients were successfully treated by hepatic resection and combination antimicrobial therapy. Hyperbaric oxygen was used as an adjunct in one case.

Impact of cervical lymph node metastases from squamous cell cancer of the lip.

The records of 123 patients with squamous cell cancer of the lip presenting to the Vancouver Clinic of the British Columbia Cancer Agency from 1984 and 1988 were reviewed, and 4 were excluded from the study for various reasons. Initial treatment was surgery in 40, radiotherapy in 61, and combined in 18 patients. The primary tumor was staged as TIS in 11, T1 in 57, T2 in 24, T3 in 15, T4 in 1, and undetermined in 11. Follow-up continued for a minimum of 2 years in all but five patients. Lymph node metastases developed in 19 patients, representing 18% of the 108 patients with invasive cancer. The size of the primary tumor correlated with the likelihood of metastases. The neck disease was controlled in only 8 of the 19 patients with metastases, whereas control of the primary tumor was achieved in all but 3 patients. It is concluded that the development of node metastases in patients with lip cancer is more frequent than commonly appreciated and is associated with a high mortality rate. Close follow-up is essential to allow early detection of neck involvement. Aggressive surgery is indicated when such involvement becomes evident.

Efficacy of 131I ablation following thyroidectomy in patients with invasive follicular thyroid cancer.

The role of thyroid ablation following thyroidectomy for invasive follicular cancer remains controversial. The use of iodine 131 (131I) ablation as adjuvant therapy may facilitate follow-up of patients in whom serum thyroglobulin levels and 131I total body scans are used to detect metastatic disease. It is uncertain if 131I ablation improves survival of patients with follicular thyroid cancer. Thus, the purpose of this study was to determine if survival is enhanced following ablation, with particular reference to those patients with minimally invasive cancer. Between the years 1955 to 1988, 142 patients with invasive thyroid follicular cancer were treated at the British Columbia Cancer Agency, of whom 71 had minimal invasion and no extrathyroidal extension of tumor. In this group of patients, 46 underwent hormone suppression only, 17 had ablation, and 8 had neither. The average follow-up was 9 years and extended beyond 15 years in many patients. Data were entered in a mainframe computer, and Kaplan-Meier survival analysis was used, comparing crude survival, disease-specific survival, and disease-free survival. There was no significant difference between groups. In patients with follicular thyroid cancer and capsular invasion only, 131I ablation does not improve survival compared with patients treated with thyroid hormone suppression only.

Clinical parameters predictive of malignancy of thyroid follicular neoplasms.

Needle aspiration biopsy is commonly employed in the evaluation of thyroid nodules. Unfortunately, the cytologic finding of a "follicular neoplasm" does not distinguish between a thyroid adenoma and a follicular cancer. The purpose of this study was to identify clinical parameters that characterize patients with an increased risk of having a thyroid follicular cancer who preoperatively have a "follicular neoplasm" identified by needle aspiration biopsy. A total of 395 patients initially treated at Vancouver General Hospital and the British Columbia Cancer Agency between the years of 1965 and 1985 were identified and their data were entered into a computer database. Patients with thyroid adenomas were compared to patients with follicular cancer using the chi-square test and Student's t-test. Statistically significant parameters that distinguished patients at risk of having a thyroid cancer (p less than 0.05) included age greater than 50 years, nodule size greater than 3 cm, and a history of neck irradiation. Sex, family history of goiter or neoplasm, alcohol and tobacco use, and use of exogenous estrogen were not significant parameters. Patients can be identified preoperatively to be at an increased risk of having a follicular cancer and accordingly appropriate surgical resection can be planned.

Acute graft-versus-host disease of the intestine. A surgical perspective.

The general surgeon may be involved in assessment and treatment of intestinal complications in patients who have undergone bone marrow transplantation. It is important to recognize the major causes of intestinal morbidity in these patients and to be aware of the cause and natural progression of the entity of acute graft-versus-host disease. Of 89 patients who underwent allogeneic bone marrow transplantation over a 6 year period, acute intestinal graft versus host disease developed in 29 (33 percent). Although surgical consultation for abdominal pain and peritonism was requested for 15 of these patients, intestinal perforation did not occur, and only two patients underwent laparotomy, both for obstruction (and hemorrhage in one case). Patients who require operation tend to be in the end stages of the disease, and the chance for salvage appears to be remote.

Lymph node metastases from well-differentiated thyroid cancer. A clinical review.

The records of 77 patients with well-differentiated thyroid cancer and proved lymph node metastases have been reviewed. The control of regional metastases was satisfactory in those with only a few nodes involved when limited dissections were utilized initially. In those patients with more extensive nodal involvement, the ultimate rate of failure to control disease in the neck was unacceptably high among those who initially underwent conservative localized neck dissection. Although regional control will not influence mortality, a more aggressive modified neck dissection is recommended for patients presenting with significant nodal involvement.

Squamous cell carcinoma of the tongue and lower oral cavity in patients under 40 years of age.

Squamous cell carcinoma of the tongue and lower oral cavity is uncommon in patients under the age of 40 years. The site distribution and male to female ratio of patients differed markedly from those of the overall squamous cell carcinoma group. The tongue was by far the most common site, and the majority of patients were women. There were no apparent etiologic or biologic factors noted. Lymph node metastases occurred in 38 percent of our patients and were present in six of seven tumor-related deaths. Those patients who died usually had a poor response to initial treatment, and most were dead within less than 2 years after diagnosis. The overall cure rate in our study patients was much better than that for the overall group of patients, and this was especially so in patients with tongue cancer (80 percent absolute cure rate). Aggressive treatment and careful follow-up for recurrence or metastases are necessary.

Carcinoma of the parotid gland.

Sixty-nine patients with parotid gland cancer were studied at the Cancer Control Agency of British Columbia; half were treated successfully. Localized cancers should be treated by total parotidectomy with facial nerve preservation. Facial nerve sacrifice and radical neck dissection for metastatic lymph nodes may be required. If adequate surgery has been done, the histologic type of the tumor significantly determines the outcome. Postoperative radiation to the parotid bed in the more malignant types of tumor is advocated and appears to improve the results of treatment.