Objective assessment of axillary morbidity in breast cancer treatment.

Historically, axillary lymph node dissection (ALND) was a critical aspect of the operative management of breast cancer. Recently, the role of ALND has been questioned, with postoperative morbidity possibly overshadowing patient benefit. Our objective was to quantitatively assess the long-term morbidity of ALND in patients with breast cancer. We conducted a cross-sectional study of patients being followed by the Breast Surgery Clinic at a university-affiliated urban hospital. Ninety-five patients with unilateral breast cancer who had undergone ALND were evaluated at routine follow-up visits in the latter half of 1998. A questionnaire was used to quantify the degree of subjective findings, including arm swelling, chest wall pain, decreased mobility, and weakness. Upper extremity strength, active range of motion, and circumference were measured. Overall, 70 per cent of patients had at least one complaint, with 18 per cent having moderate to severe symptoms. Twenty-one per cent had notable decrements in strength or range of motion, 9.3 per cent of patients required chronic compression garments for lymphedema, and 6.4 per cent changed their vocational status because of surgical morbidity. We conclude that adverse effects from ALND occur commonly. Objective findings are less common, perhaps causing clinicians to underappreciate postoperative morbidity. A significant subset of patients had enduring disability.

Status of scintimammography and its relationship to other detection methods for breast cancer.

Breast cancer is the most important malignancy for women of the world's industrialized nations. It is second only to lung cancer in cancer-related mortality. Early detection is the best means of improving survival; the cornerstone of early diagnosis is mammography. Given the endemic nature of breast cancer, screening mammography has secured a routine place in health maintenance for women, although it is less than perfect. To aid in the diagnosis of malignant breast disease, other imaging modalities have evolved: ultrasound, magnetic resonance imaging (MRI), positron emission tomography (PET), and SMM. Scintimammography (SMM) is rapidly with a variety of applications for the management of breast disease. This technology has become a complementary modality to other conventional methods of breast imaging. This review will focus on the science behind SMM and how it is currently used in the management of breast lesions.

Scintimammographic analysis of nonpalpable breast lesions previously identified by conventional mammography.

BACKGROUND: In randomized trials, screening mammography has led to decreased mortality from breast cancer. However, the low positive predictive value of mammography (i.e., the proportion of patients with a positive test result who actually have breast cancer) results in a large number of unnecessary biopsies. We determined whether scintimammography with technetium-99m-sestamibi is a useful supplemental diagnostic tool for women with nonpalpable breast abnormalities identified by conventional mammography. METHODS: Scintimammography was performed preoperatively on 70 women who were 31-66 years of age (mean age and median age = 51 years). These women had nonpalpable breast abnormalities identified by conventional mammography; subsequently, a needle-localization excisional biopsy of each suspicious lesion was performed. Scintimammographic images were interpreted independently by two nuclear medicine physicians who were blinded to all clinical and pathologic data, and an interobserver variation analysis was performed. RESULTS: Interobserver variation analysis of the scintimammographic findings showed an agreement for breast diagnosis of 97% and a kappa coefficient of 0.90. Comparison of scintimammographic findings and histopathologic results revealed that the sensitivity (proportion of patients with breast cancer who had a positive test result), the specificity (proportion of patients without breast cancer who had a negative test result), the positive predictive value and the negative predictive value (proportion of patients with a negative test result who actually did not have breast cancer) of scintimammography were 56% (95% confidence interval [CI] = 23%-85%), 87% (95% CI = 75%-94%), 38% (95% CI = 15%-68%), and 93% (95% CI = 82%-98%), respectively. Four of nine breast cancers were not detected by scintimammography. CONCLUSION: Because of excellent interobserver agreement, scintimammography provides an objective way of detecting primary breast carcinoma. In view of its low sensitivity and positive predictive value, however, scintimammography is not currently recommended as a screening test in patients with nonpalpable positive mammographic findings.

Detection of axillary lymph node metastasis of breast carcinoma with technetium-99m sestamibi scintimammography.

Several investigators have advocated management of breast cancer patients without axillary dissection, obviating the morbidity associated with this procedure. Approximately 30-40 per cent of all patients with breast carcinoma will have lymph node metastasis. Axillary dissection offers no therapeutic benefit to node-negative patients, and it may lead to unnecessary morbidity. It is apparent that a noninvasive test to determine the presence of axillary metastases may obviate the need for axillary dissection. The aim of this study was to determine the role of scintimammography (SMM) with technetium-99m sestamibi in the detection of axillary node metastasis in breast carcinoma. Thirty-one women with the diagnosis of breast carcinoma who had SMM and axillary lymphadenectomy were included. SMM was done following an intravenous injection of 20 mCi of Tc-99m sestamibi. Planar scintigraphic imaging was acquired in a lateral prone and an anterior view of the breasts for the evaluation of the axilla. SMM scans were interpreted by two nuclear medicine physicians blinded to the clinical presentation and histologic results. The correlation of SMM with histologic assessment showed a sensitivity of 75 per cent, specificity of 82 per cent, positive predictive value of 88 per cent, and negative predictive value of 64 per cent. The interobserver correlation of SMM interpretation between the two nuclear medicine physicians showed good agreement, with kappa = 0.49. Consistency in the interpretation of Tc-99m SMM was obtained when two independent radiologists reviewed the studies. Based on these data, we are unable to show that SMM is a reliable test for the detection of axillary metastases in patients with breast cancer. However, a high positive value of 88 per cent is encouraging and deserves further study.

Use of intraperitoneal 5-fluorouracil and chlorhexidine for prevention of recurrence of perforated colorectal carcinoma in a rat model.

PURPOSE: Colorectal cancer is a prevalent and mortal disease, resulting in nearly 55,000 deaths in the United States annually. Preoperative or intraoperative spillage of tumor cells because of perforation occurs in up to 10 percent of cases. When this spillage occurs, the chance of recurrence and death is dramatically increased. METHODS: In an effort to reduce the chance of recurrence and death, we used a rat model to evaluate the efficacies of intraperitoneal 5-fluorouracil and chlorhexidine in reducing the incidence of recurrence. Rats were injected with 10 mg/kg azoxymethane subcutaneously weekly for 12 weeks to induce colorectal cancers. At 20 weeks, subtotal colectomies were performed on rats with colorectal tumors and without peritoneal implants or liver metastases. At the time of surgery, a cut portion of the tumor was placed in the abdomen for 30 minutes; the rats then randomly received peritoneal irrigation with 5-fluorouracil, chlorhexidine, or sterile water (control). Eight weeks postoperatively a necropsy was performed. At that time, obvious and suspected recurrences and the anastomotic area were sampled for histologic evaluation. RESULTS: Significant differences were seen with chlorhexidine vs. water for gross tumor (P = 0.05) and microscopic tumor (P < 0.05). 5-Fluorouracil showed a greater rate of abscess formation vs. both control and chlorhexidine (P > 0.05). CONCLUSIONS: Use of chlorhexidine intraperitoneal therapy at the time of the operation for perforated colorectal cancer significantly decreases the frequency of gross tumor recurrence but not total recurrences. Intraperitoneal 5-fluorouracil does not significantly decrease recurrence and may increase the risk of abscess when used intraoperatively.

Effect of interleukin-2 on microvascular liquid and protein transport in the rat small intestine.

Interleukin-2 (IL-2), a glycoprotein lymphokine derived from activated T-lymphocytes displays potent anti-cancer properties but its therapeutic use has been limited by generalized tissue swelling. To shed light on the mechanism underlying this potentially life-threatening edematogenic syndrome, recombinant IL-2 or an equal volume of control solution (excipient or 5% dextrose) was administered to 88 adult, male Sprague-Dawley rats. Initially, rats were injected with 50,000 Cetus units (equal to 300,000 I.U.) of IL-2 intraperitoneally, either one-time ("acute" rats) or every eight hours for two or seven days ("chronic" rats). Thereafter, under pentobarbital anesthesia, the main mesenteric lymph duct was isolated, incised, and measurements made of intestinal lymph flow (JV) and the total protein content and protein fractions in lymph (L) and plasma (P) (refractometry and agarose gel electrophoresis, respectively). Final measurements were also carried out after superior mesenteric vein constriction to assess filtration-independent L/P total protein "washdown." After IL-2, JV and protein clearance (JV x L/P) were increased (p less than 0.001) while lymph and plasma total protein content and protein fractionation were unchanged. Protein washdown was also maintained. These data are not only inconsistent with bulk "plasma leak" from damaged capillaries, but in conjunction with previously demonstrated increased cardiac output and reduced systemic vascular resistance after IL-2 administration, the findings favor augmented microvascular surface exchange area from increased capillary perfusion as the primary mechanism underlying increased transcapillary liquid and protein flux. This conclusion conforms to the rapid reversal of edema in patients after cessation of IL-2 therapy.