Mammographic wire localization in diagnosis and treatment of occult carcinoma of breast.

The use of screening mammography has increased dramatically, leading to the discovery of suspicious, nonpalpable mammary lesions. Mammographic wire localization (MWL) is currently being used to facilitate the biopsy of these lesions. We reviewed 104 patients undergoing 106 biopsies after MWL during a 14 month period to determine the usefulness of MWL. The average age of the patients was 58 +/- 14 years, with a range of 38 to 83 years. Abnormal mammographic findings consisted of microcalcifications (48 per cent) or mass and density (43 per cent), or both (9 per cent). Lesions of the right side (55 per cent) and upper and outer quadrant (49 per cent) were predominant. An average of 1.4 (range of one to four) specimens taken at biopsy per patient were required to remove the lesion. The mean duration of the biopsy was 34 minutes, with a range of ten to 75 minutes, and the mean total time in the operating room was 63 (range 31 to 115) minutes. The average cost of the procedure did not differ significantly between local and general anesthesia ($1,030 versus $1,142, respectively). Pathologic findings included fibrocystic disease (77 per cent), carcinoma (12 per cent) and fibroadenoma (7 per cent). Normal mammary tissue was found in 4 per cent of the biopsies. Five of the 13 carcinomas were in situ and seven were either in situ (five) or microinvasive only (two); only six lesions were frankly invasive. Ten patients were treated with modified radical mastectomy while three had segmental resection. All patients had in situ or Stage I carcinoma. MWL effectively localized nonpalpable mammary lesions and allowed accurate diagnosis and treatment of early stage carcinoma of the breast.

Congenital foramen of Bochdalek's hernia in an infant with obstructive jaundice.

A case of infantile obstructive jaundice caused by a right-sided foramen of Bochdalek's diaphragmatic hernia is reported. This association has not previously been reported in an infant. At operation, extrahepatic biliary obstruction was relieved by reduction of the contents of the hernia. This unusual presentation of a right-sided congenital diaphragmatic hernia underscores the usual diagnostic delay seen with such lesions.

Revascularization after thrombolytic therapy for acute myocardial infarction: an analysis of 573 patients.

From October, 1981, to January, 1987, at our center, 891 patients received streptokinase within 6 hours of acute myocardial infarction. A total of 318 patients were treated medically, while 388 patients (43.5%) underwent coronary artery bypass grafting (CABG) alone and 185 (20.7%) were treated with percutaneous coronary angioplasty (PTCA). Subsequent CABG was performed in 37 of 185 PTCA patients after unsuccessful angioplasty. Group characteristics were similar. However, multiple-vessel coronary artery disease was present in 70.3% of CABG patients compared with 24.1% in the PTCA groups. Procedure mortality was 3.6% for CABG alone, 5.4% for PTCA alone, and 13.5% for the combined angioplasty and operation group (p less than 0.05 compared with CABG). All deaths in the PTCA group with subsequent CABG occurred in those patients taken emergently to CABG (5 of 20 patients). We conclude that with proper patient selection both forms of revascularization are safe and effective. However, emergency coronary bypass surgery in the event of failed angioplasty has a high risk.

Early and late results of operation after thrombolytic therapy for acute myocardial infarction.

Recent reports have established the efficacy of thrombolytic therapy in limiting myocardial infarction. Between September 1981 and September 1984, 355 patients were treated with intracoronary (87) or intravenous (268) streptokinase within 6 hours of acute myocardial infarction. Thrombolysis was successful in 63% of patients receiving intracoronary streptokinase and 81% of those receiving intravenous streptokinase. Because residual critical stenosis is usually present and predisposes the patient to reinfarction, revascularization procedures were investigated as an extension of thrombolytic therapy. One hundred ninety-one patients aged 56 +/- 10 (25 to 77) years underwent early surgical revascularization 4.1 +/- 3.6 days after intracoronary or intravenous streptokinase for acute myocardial infarction. Results of this treatment were successful in 89% (170/191) of the patients. Thirteen patients (6.8%) underwent emergency coronary artery bypass grafting for failed percutaneous angioplasty. There were 3.2 +/- 1.4 grafts per patient and 3.8 +/- 2.9 units of blood were administered in the perioperative period. Operative mortality was 4.2% (8/191) with a 15.4% mortality (2/13) in the group in which angioplasty failed. Mean hospitalization time after operation was 10.9 +/- 6.8 days. Follow-up was 27 +/- 8 (12 to 48) months and was obtained on all patients. Late cardiac mortality was 1.0% (2/183). Ninety percent of the follow-up group was without angina and only 1.7% showed no improvement after operation. Reinfarction occurred in four patients (2.2%), with graft failure documented by coronary arteriography in two of these patients. This experience indicates that early revascularization after thrombolytic therapy may be performed with low operative mortality and morbidity and is associated with excellent late results.