Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism.

CONTEXT: We undertook this study to estimate the prevalence of the various androgen excess disorders using the new criteria suggested for the diagnosis of polycystic ovary syndrome (PCOS). SETTING: The study was performed at two endocrine departments at the University of Palermo (Palermo, Italy). PATIENTS: The records of all patients referred between 1980 and 2004 for evaluation of clinical hyperandrogenism were reevaluated. All past diagnoses were reviewed using the actual diagnostic criteria. To be included in this study, the records of the patients had to present the following available data: clinical evaluation of hyperandrogenism, body weight and height, testosterone (T), free T, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, progesterone, and pelvic sonography. A total of 1226 consecutive patients were seen during the study period, but only the scores of 950 patients satisfied all criteria and were reassessed for the diagnosis. RESULTS: The prevalence of androgen excess disorders was: PCOS, 72.1% (classic anovulatory patients, 56.6%; mild ovulatory patients, 15.5%), idiopathic hyperandrogenism, 15.8%; idiopathic hirsutism, 7.6%; 21-hydroxylase-deficient nonclassic adrenal hyperplasia, 4.3%; and androgen-secreting tumors, 0.2%. Compared with other androgen excess disorders, patients with PCOS had increased body weight whereas nonclassic adrenal hyperplasia patients were younger and more hirsute and had higher serum levels of T, free T, and 17-hydroxyprogesterone. CONCLUSIONS: Classic PCOS is the most common androgen excess disorder. However, mild androgen excess disorders (ovulatory PCOS and idiopathic hyperandrogenism) are also common and, in an endocrine setting, include about 30% of patients with clinical hyperandrogenism.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

[Hyperprolactinemia: from diagnosis to treatment]. / Le iperprolattinemie: dalla diagnosi al trattamento.

Hyperprolactinemia means the presence of abnormally high values of prolactin. It's the most common clinical hypothalamic-hypophysis disorder. Amenorrhea and anovulation are the most usual clinical findings but we can find milder alterations of gonadal function as oligomenorrhea or luteal phase alterations. Galattorrhea appears in approx 30% of patients, but its presence in women with ovulation disorders is highly suggestive of hyperprolactinemia. Subjects with primary amenorrhea and delayed puberty can present hyperprolactinemia. Male hyperprolactinemia can cause hypogonadism (decreased testosterone levels), libido decrease, infertility due oligospermia and gynecomastia while galactorrhea rarely occurs. Accurate anamnesis is very important for a correct diagnosis. It's necessary to exclude pregnancy and primary hypothyroidism. The use of many drugs can be associated with hyperprolactinemia but the most common causes are idiopathic hyperprolactinemia and hypophysis secreting adenoma. Diagnostic examinations are: PRL, FT3, FT4, TSH in case of hypothyroidism, testosterone in men, eventually sampling GH, IGF, ACTH, cortisol, free urinary cortisol. Dynamic tests are used just for idiopathic hyperprolactinemia, but today their meaning is widely discussed. CAT and MNR are necessary to observe hypotalamus, hypophysis and optic chiasm. Twenty years ago the sole option for prolactinoma patients was adenomectomy, today idiopathic hyperprolactinemia can be treated with drugs, while prolactinoma can be treated with a pharmacological, surgical or radiological therapy.

Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.

This report describes a 43-year-old patient presenting with an aneurysm located at the junction between the innominate artery and aorta, with spontaneous fistulization into the trachea. Emergency treatment of this unusually located lesion was undertaken to prevent intratracheal rupture. After ligation of the innominate artery, right common carotid artery, and right subclavian artery due to the risk of infection, the tracheal fistula was treated by direct closure and exclusion using an autologous pericardial flap. The procedure was performed under extracorporeal circulation and circulatory arrest with profound hypothermia.

Protracted survival after resection of metastatic uveal melanoma.

BACKGROUND: The objective of this study was to evaluate the usefulness of resection of metastatic uveal melanoma and to analyze the characteristics of patients who may benefit from surgical intervention. PATIENTS AND METHODS Twelve patients underwent surgical removal of metastasis between 1976 and 1998. Data regarding primary uveal melanoma, systemic metastasis, surgical procedures, and outcomes were reviewed retrospectively. RESULTS: There were seven patients with liver metastases, two with lung metastases, one with brain metastasis, and two patients with metastases in the liver and other organs. Median time to systemic metastasis was 8 years. Seven of 12 patients were asymptomatic when they were found to have metastasis. Ten patients underwent complete resection of metastasis. No significant surgical complications were experienced. Median recurrence free and overall survival periods after complete resection were 19 months (range, 6-78 months) and greater than 27 months (range, 11-86 months), respectively. Recurrence free and overall 5-year survival rates of those patients were 15.6% and 53.3%, respectively. Three of these patients had no further systemic recurrence. All patients whose time to systemic metastasis was within 5 years developed further systemic recurrence within 2 years after surgery. In contrast, in 8 patients whose time to systemic metastases was greater than 5 years, 4 patients either were recurrence free or developed second metastasis more than 4 years after surgery. CONCLUSIONS: Complete surgical removal of metastatic uveal melanoma provided unexpectedly long survival without significant morbidity for the selected patients. These results are encouraging and justify a trial in which patients eligible for resection are randomized between standard treatment and surgery.

Localization of the sentinel lymph node in breast cancer by combined lymphoscintigraphy, blue dye and intraoperative gamma probe.

Axillary lymph node status represents the most important prognostic factor in patients with operable breast cancer. A severe limitation of this technique is the relatively high rate of false negative sentinel lymph nodes (>5%). We studied 284 patients suffering from breast cancer; 264 had T1 tumors (16 T1a, 37 T1b and 211 T1c), while 20 had T2 tumors. All patients underwent lymphoscintigraphy 18-h before surgery. At surgery, 0.5 mL of patent blue violet was injected subdermally, and the sentinel lymph node (SN) was searched by gamma probe and by the dye method. The surgically isolated SN was processed for intraoperative and delayed examinations. The SN was successfully identified by the combined radioisotopic procedure and patent blue dye technique in 278/284 cases (97.9%). Analysis of the predictive value of the SN in relation to the status of the axillary lymph nodes was limited to 191 patients undergoing standard axillary dissection irrespective of the SN status. Overall, 63/191 (33%) identified SNs were metastatic, the SN alone being involved in 37/63 (58.7%) patients; a positive axillary status with negative SN was found in 10/73 (13.7%) patients with metastatic involvement. In T1a-T1b patients the SN turned out to be metastatic in 9/53 patients (17.0%). In 7/9 patients the SN was the only site of metastasis, while in 2/9 patients other axillary lymph nodes were found to be metastatic in addition to the SN. None of the 44 patients in whom the SN proved to be non-metastatic showed any metastatic involvement of other axillary lymph nodes. Our results demonstrate a good predictive value of SN biopsy in patients with breast cancer; the predictive value was excellent in those subjects with nodules smaller than 1 cm.

Sentinel lymph node mapping in early-stage breast cancer: technical issues and results with vital blue dye mapping and radioguided surgery.

BACKGROUND AND OBJECTIVES: Axillary lymph node status is the most important prognostic factor in patients with operable breast cancer. Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. Sentinel lymph node identification proved feasible by either peritumoral dye injection (Patent Blue-V) or radiodetection, with identification rates of 65-97% and 92-98%, respectively. However, some important issues need further definition, namely (a) optimization of the technique for intraoperative detection of the sN, (b) predictive value of the sN with regard to axillary lymph node status, and (c) reliability of intraoperative histology of the sN. We reviewed our experience in sN detection in patients with stage I-II breast cancer to assess the feasibility and accuracy of lymphatic mapping, by vital blue dye or radioguided surgery, and sN histology as a predictor of axillary lymph node status. METHODS: Two groups of patients (55 and 48) were recruited between May 1996 and May 1997 and between October 1997 and February 1998; the patients of the first series underwent vital blue dye lymphatic mapping only, whereas those of the second series had a combined approach with both vital blue dye mapping and radioguided detection of the sN. RESULTS: In the first set of patients, the sN was identified in 36/55 patients (65.4%); sN histology predicted axillary lymph node status with a 77% sensitivity (10/13), a 100% specificity (23/23), an 88.5% negative predictive value (23/26), and an overall 91.5% accuracy (33/36). The sN was the quasi-elective site of lymph node metastases because in clinically N0 patients nodal involvement was 20-fold more likely at histology in sN than in non-sN (30% and 1.5%, respectively). In the second set of patients, 49 lymphadenectomies were performed because 1 patient had bilateral breast cancer; the sN was identified in 45/49 lymphadenectomies (92%). The sN was intraoperatively negative at frozen-section examination in 33 cases, and final histology confirmed the absence of metastases in 31/33 cases (94%), whereas in 2 cases (6%) micrometastases only were detected. Final histology of the sN predicted axillary lymph node status with an 87.5% sensitivity (14/16), a 100% specificity (29/29), a 93.5% negative predictive value (29/31), and an overall 95.5% accuracy (43/45). CONCLUSIONS: Sentinel lymphadenectomy can be better accomplished when both mapping techniques (vital blue dye and radioguided surgery) are used. In this group of patients, agreement of intraoperative histology of the sN with the final diagnosis was 94%, and sN histology accurately predicted axillary lymph node status in 43/45 lymphadenectomy specimens (95.5%) in which an sN was identified.

Pattern of lymphatic drainage to the sentinel lymph node in breast cancer patients.

BACKGROUND AND OBJECTIVE: We performed a pilot study on 30 consecutive patients undergoing sentinel node (sN) biopsy by radioguided surgery and vital blue dye mapping to determine whether there is a single sN for each breast independent of tumor site or an sN specifically related to the site of the breast neoplasm. METHODS: There were 6 groups of 5 patients; each patient had a subdermal injection of radiotracer on the tumor site plus a second injection of radiotracer that was changed in every subset of patients to test whether modifying the site or the route of injection could have impaired the proper detection of the sN. RESULTS: "False" sN were detected only in patients who had a second injection of radiotracer away from the tumor site; this occurred in 2 of 5 patients (40%) in group I, in 3 of 5 patients (60%) in group II, in all patients in group III, and in 3 of 5 patients (60%) in group IV. The different route of injection (peritumoral or subdermal) always on the tumor site that was tested in groups V and VI did not impair the proper detection of the sN. CONCLUSIONS: Our findings support the hypothesis of a precise topographic correspondence between the primary tumor and its specific sN more than the existence of a first sN in the axillary basin, which indiscriminately drains all quadrants of the breast, like "a neck of a bottle." This should be considered for the proper selection of the injection site of either vital blue dye or radiopharmaceuticals.

Fhit expression in gastric adenocarcinoma: correlation with disease stage and survival.

BACKGROUND: The FHIT gene is inactivated by deletion in a large fraction of human tumors, including gastric carcinomas, and the Fhit protein has been proposed to act as a tumor suppressor in multiple tumor types. A large fraction of gastric adenocarcinomas have lost expression of the candidate tumor suppressor protein, Fhit, whereas normal gastric epithelial cells are strongly positive and Fhit loss has been found to correlate with alterations of the FHIT locus. Because the majority of gastric tumors in the current study were found to be entirely negative for Fhit protein, it is possible that alteration of the carcinogen-susceptible fragile region within the FHIT gene is an early event in gastric carcinoma, as it is in lung carcinoma. METHODS: To determine whether the absence of Fhit protein correlates with expression of tumor markers or with clinical parameters, such as grade, stage, and survival time, the authors assessed Fhit expression using immunohistochemistry in a well characterized set of 55 gastric adenocarcinomas resected over several years, with longitudinal follow-up of patients for outcome. RESULTS: In this set of 55 gastric cancers, the absence of Fhit protein correlated with higher tumor stage (P = 0.003) and higher histologic grade (P = 0.007). In addition, patients whose tumors had lost expression of Fhit died of disease significantly earlier than those with Fhit positive tumors (P = 0.017). The absence of Fhit expression did not correlate with the expression of any tumor markers. CONCLUSIONS: Larger studies will be required to elucidate further the relation between tumor stage, grade, and Fhit loss and to determine whether inclusion of Fhit antiserum in immunophenotyping of gastric adenocarcinomas will be a useful indicator of post-diagnosis prognosis.

Five risk factors identify patients with gastroesophageal intussusception.

HYPOTHESIS: Risk factors in patients with gastroesophageal intussusception who have noncardiac chest pain need to be identified and analyzed. DESIGN: Prospective consecutive series of 43 patients with gastroesophageal intussusception. SETTING: Outpatient gastrointestinal endoscopy suite for 42 patients; 1 patient sustained gastroesophageal intussusception during labor and delivery and underwent an emergency laparotomy. INTERVENTION: Upper gastrointestinal tract endoscopy under intravenous sedation with appropriate monitoring of vital signs and photographic documentation in most patients. RESULTS: Gastroesophageal intussusception was documented endoscopically in 42 of 43 patients and was found to occur equally in men and women. Five risk factors have been identified: eating disorders or alcohol abuse, sudden sustained exertion, small-bowel obstruction, acid bile peptic disease, and pregnancy. Fifteen (70%) of 22 men were younger than 35 years; precipitating factors included sustained athletic effort and binge eating and drinking episodes. Fifteen (70%) of the 21 women were older than 35 years and had binge eating, peptic disease, and complications of pregnancy as risk factors. CONCLUSIONS: Five risk factors identify patients with severe vomiting or retching who are most likely to develop gastroesophageal intussusception, the precursor of a Mallory-Weiss tear. Upper gastrointestinal tract endoscopy with photographic documentation is the most accurate method of diagnosis. For most patients, medical management can reverse the cause of the vomiting. If vomiting is caused by mechanical obstruction or massive hemorrhage, surgical intervention may be necessary.

The consequences of a major bile duct injury during laparoscopic cholecystectomy.

Bile duct injury is perhaps the most feared complication of laparoscopic cholecystectomy. The focus of this study was on the immediate and short-term outcome of patients who have undergone repair of major bile duct injuries with respect to hospital stay, perioperative interventions, and reoperations. The records of patients who underwent surgery at three academic hospitals in Philadelphia (Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Graduate Hospital) from 1990 to 1995 for repair of a major biliary injury following laparoscopic cholecystectomy were reviewed. A major biliary injury was defined as any disruption (including ligation, avulsion, or resection) of the extrahepatic biliary system. Small biliary leaks not requiring surgery were excluded. Thirty-two patients sustained major bile duct injuries. The injury was recognized immediately in 10 patients. The remaining 22 patients had pain (59%), jaundice (50%), and/or fever (32%) as the symptom heralding the injury. Bismuth classification was as follows: 13% of patients were class I, 63% were class II, 7% were class III, 7% were class IV, and 10% were class V. Biliary reconstruction included a Roux-en-Y hepaticojejunostomy in 30 patients and two were primary repairs. There was one postoperative death from multiorgan system failure. The mean length of hospital stay after repair was 17 +/- 8 days. Over a mean follow-up period of 11.5 +/- 10.5 months, 11 patients (38%) required 19 emergency readmissions, most commonly for cholangitis. Five patients (17%) required postoperative balloon dilatation for biliary stricture. At follow-up 18 patients (62.0%) remain asymptomatic with normal liver function, eight (28%) are experiencing episodic cholangitis, and three (10%) are asymptomatic with persistently elevated liver function values. The consequences of a major biliary tract injury following laparoscopic cholecystectomy include a complex operative repair resulting in a lengthy postoperative stay with an increased risk of death, an excessive number of perioperative diagnostic and therapeutic studies, frequent readmissions (often as emergencies), and a lifelong risk of restricture. The "cost" to these patients remains enormous.

Intraoperative radiotherapy in the combined-modality management of pancreatic cancer.

The purpose of this study is to assess the feasibility, clinical tolerance, local control, and survival rates using a combined-modality treatment program of intraoperative radiation, chemotherapy, and external beam radiation for the management of patients with pancreatic cancer. One hundred eighty patients with biopsy-proven adenocarcinoma of the pancreas have been treated by a single surgical practice between 1979 and 1992. Of these, 105 had locally advanced but unresectable primary tumors (stages 2 and 3). All patients were treated with a program of multimodality therapy, including surgery, chemotherapy, and radiation therapy. Three groups were identified. Group I (33 patients) received intraoperative radiation therapy (IORT) as part of their treatment. Group II (43 patients) received intraoperative radiation in the form of iodine-125 (I-125) implantation. Group III (29 patients) received no intraoperative radiation. All three groups were comparably similar with respect to age at presentation, amount of preoperative weight loss, preoperative symptoms, and tumor location. Overall perioperative mortality was 4.8 per cent (five patients), with no difference between groups noted. Perioperative complications occurred in 32 (30.4%) of the 105 patients. Complications occurred in only 18.1 per cent of patients in Group I (IORT), compared with 39.5 per cent of Group II (I-125) patients (P < 0.01). Group III patients (no intraoperative radiation) experienced complications in 31.0 per cent of cases (P = 0.09 vs Group I). Actuarial survival was 18 months for Group I (IORT) versus 15 months for Group II (I-125). One- and 2-year actuarial survival rates were 60 and 17 per cent for patients in Group I (IORT) and 56 and 19 per cent for Group II (I-125). Actuarial local control rates for patients receiving IORT (Group I) was 70 per cent at 2 years. Patients with pancreatic cancer historically have poor survival and local control rates despite aggressive chemotherapy and radiation. The addition of intraoperative radiation to the combined modality management of pancreatic cancer offers markedly improved survival rates and local control with minimal morbidity for patients with unresectable disease. Intraoperative radiation in the form of IORT can be delivered with a significantly fewer complications than I-125 seed implantation.

Sentinel lymph node mapping opens a new perspective in the surgical management of early-stage breast cancer: a combined approach with vital blue dye lymphatic mapping and radioguided surgery.

Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. However, some important issues need further definition: (1) optimization of the technique for intraoperative detection of the sN; (2) predictive value of the sN as regards axillary lymph node status, and (3) reliability of intraoperative histology of the sN. We report our experience in sN mapping in patients with Stage I-II breast cancer, with the aim of assessing: (1) the feasibility of lymphatic mapping with a combined approach (vital blue dye lymphatic mapping and radioguided surgery); (2) the agreement of the intraoperative histologic examination of the sN, by means of hematoxylin and eosin staining with final histology, and (3) the accuracy of sN histology as a predictor of axillary lymph node status.

Perfusion MRI in normal and abnormal pituitary gland. A preliminary study.

Perfusion MRI (magnetic resonance imaging) of the pituitary gland was performed in 20 healthy volunteers and 63 patients with various lesions involving the pituitary gland. All patients underwent sequential contrast-enhanced MRI using spoiled gradient recalled sequences with high temporal resolution (7 seconds). Four pituitary areas (pituitary stalk, posterior lobe, postero-superior, and antero-inferior adenohypophysis) were tested with a selected region of interest. Maximal contrast percentual variation was calculated. The timing of enhancement in normal patients matched perfectly with normal pituitary vascularization. Abnormal timing in pathological condition was investigated.

Pancreatic resection combined with intraoperative radiation therapy for pancreatic cancer.

OBJECTIVE: The objective of the study was to analyze a single center's experience in the treatment of pancreatic carcinoma with a combination of pancreatic resection and intraoperative radiation therapy (IORT). SUMMARY BACKGROUND DATA: Pancreatic cancer is the most lethal form of gastrointestinal malignancy. Historically, it carries a 20% 1-year survival and a 5-year survival of 3% to 5%. Since 1987, patients at Thomas Jefferson University Hospital have been offered IORT in an attempt to improve their survival. METHODS: The authors reviewed all patients treated at Thomas Jefferson University Hospital with pancreatic adenocarcinoma from 1987 to 1994. From this population, 14 patients were identified who received IORT in conjunction with curative surgery. Duration of hospital stay, perioperative complications, duration of postoperative ileus, and survival were assessed by retrospective review. RESULTS: Of the 14 patients, 6 were male and 8 were female. Patient median age was 61. Six patients had stage I disease, 2 had stage II, 6 had stage III. Two patients had total pancreatectomy, 2 had distal pancreatectomy, and the remaining had pancreaticoduodenectomy (Whipple resection). Median survival was 16 months with a 15.5% 5-year survival. Postoperative complications, duration of hospital stay, and duration of postoperative ileus were not adversely affected by the addition of IORT when compared to in-house control subjects. CONCLUSIONS: Intraoperative radiation therapy is a useful adjunct to surgical resection as treatment of pancreatic cancer. The authors' data suggested it can prolong median survival and long-term survival without adding significant morbidity.

Improved staging of liver tumors using laparoscopic intraoperative ultrasound.

BACKGROUND: Intraoperative ultrasound has been shown to provide significant assistance in operative staging and management of patients with liver tumors during open surgery. The availability of the 5.0-7.5 Mhz semiflexible ultrasound transducer with gray-scale, color and spectral Doppler capabilities can provide similar information laparoscopically. METHODS: Twenty-four consecutive patients with liver tumors (18 metastatic and six primary), in technically resectable locations determined by a variety of conventional imaging studies, were brought to the operating room. There was no known extrahepatic disease, and there was no recurrence at the primary site in the metastatic subgroup. These patients were evaluated intraoperatively with laparoscopy and intraoperative laparoscopic ultrasound to assess resectability prior to performing a major laparotomy. Laparoscopy was successful in 23 of the patients and in 19 of 23, laparoscopic ultrasound was also employed, using the 5.0-7.5 MHz semiflexible transducer. The use of the open entry technique, selection of alternate entry sites, coupled with expertise in laparoscopic lysis of adhesions, has allowed safe laparoscopic tumor staging. RESULTS: The laparoscopic evaluation was aborted only once due to dense adhesions, despite the fact that 67% of the patients had undergone previous abdominal surgery. There was only one complication: bleeding from a liver biopsy in an unresectable cirrhotic patient, necessitating laparotomy. Laparoscopy and ultrasound together predicted nonresectability in six of eight unresectable patients, all of whom were spared an unnecessary laparotomy. CONCLUSIONS: Laparoscopic ultrasonographic evaluation for the staging of liver tumors should be a prerequisite to definitive laparotomy, with the objective of avoiding unnecessary surgery.

Laparoscopic liver sonography: preliminary experience in liver metastases compared with CT portography.

This study evaluated the ability of laparoscopic ultrasonography to detect, localize, and characterize focal liver masses. Laparoscopic ultrasonography and CT portography of the liver were performed in 13 patients with known or suspected malignancy. Laparoscopic ultrasonography directly influenced surgical management in four (31%) cases; three by detection of small focal masses and one by exclusion of masses suspected on CT portography. Laparoscopic ultrasonography provided guidance for biopsy or added important anatomic information in three cases. Laparoscopic ultrasonography was complementary to CT portography but added no additional information in three cases, and it failed to provide any information in two cases. Laparoscopic ultrasonography was falsely negative in one case. In this preliminary series, laparoscopic ultrasonography assisted surgeons in critical decision-making by either providing important new information, clarifying questionable areas, or complementing CT portography.

Combined intraoperative radiation and perioperative chemotherapy for unresectable cancers of the pancreas.

PURPOSE: To evaluate the effectiveness of combined intraoperative radiation therapy (IORT) and perioperative chemotherapy in the management of unresectable pancreatic cancer. MATERIALS AND METHODS: Forty-nine patients with localized unresectable adenocarcinoma of the pancreas were treated in a multimodality program of initial IORT and perioperative chemotherapy (fluorouracil [5-FU]/leucovorin) followed by combined external-beam radiation (40 to 55 Gy) and continued chemotherapy. Patients were evaluated for toxicity, pattern of failure, and survival. The follow-up times of these patients range from a minimum of 12 months to a maximum of 62 months, with a median of 28 months. RESULTS: The incidence of perioperative mortality was 0%. Early postsurgical morbidity (grade 3/4) was observed in seven of 49 patients (14%) and late treatment-related morbidity (grade 3/4) in eight of 43 patients (19%) alive beyond 6 months. Morbidity was primarily gastrointestinal (GI), with no hematologic toxicities observed. The median survival time in the total group of patients is 16 months, with a 2-year survival rate of 22% and a 4-year survival rate of 7%. Freedom from local progression of disease was achieved in 71% of patients. CONCLUSION: The patients who undergo IORT with electrons and treated with perioperative chemotherapy (5-FU leucovorin) followed by additional external-beam radiation and chemotherapy appear to have improved survival, with few early or late complications. Dose escalation of external-beam radiation and chemotherapy may further improve local control of disease and survival of patients.

Ten-year results in 1070 patients with stages I and II breast cancer treated by conservative surgery and radiation therapy.

BACKGROUND: One thousand seventy patients treated conservatively for Stages I and II breast cancer between the years 1982 and 1994 were reviewed. The median follow-up was 40 months with a maximum follow-up of 152 months. METHODS: All patients had a wide local excision and lower lymph axillary node dissection followed by radiation therapy. The entire breast received an external beam dose of 4500 cGy at 180 cGy/5 days/week. An additional boost dose of 2000 cGy to the tumor bed was given at the time of lumpectomy (perioperative) with an Ir-192 implant or with electron beam therapy after the external beam therapy. RESULTS: The 5- and 10-year disease specific survival results were 97 and 90%, respectively for Stage I and 87 and 69% for patients with Stage II disease. The 5- and 10-year local control rates were 93 and 85% for Stage I and 92 and 87% for Stage II, respectively. The risk factors for local failure were premenopausal status and estrogen receptor-negative status at the univariate level but at the multivariate level the premenopausal and margins status were significant. CONCLUSION: These 10-year results were at least equivalent to reported series of similarly staged patients treated by mastectomy. This should encourage more surgeons to offer conservative treatment as an alternative to mastectomy to patients with Stage I and II breast cancer.