Decade-long experience with surgical therapy of myasthenia gravis: early complications of 324 transsternal thymectomies.

BACKGROUND: We studied the incidences and evaluated the management of early postoperative complications after thymectomy for myasthenia gravis. METHODS: During the period between 1987 and 1996, 324 thymectomies were performed through median sternotomy access under general anesthesia. Postoperative management was administered according to a standardized protocol of anticholinesterase medication, which was withdrawn for the 48 hours of obligatory postoperative mechanical ventilation. The mean age of patients was 34 years (range, 8 to 71 years). RESULTS: One hundred forty-nine patients made an uneventful recovery; 104 patients had only minor complications, whereas 71 patients had major complications. The mortality rate was 0.6% (2 patients). The major surgical complications were recorded as sternal bleeding (1 patient) and sternal disruption (1 patient). The major general complications were recorded as tracheal stenosis (1 patient), pneumonia (3 patients), heart failure (1 patient), gastric hemorrhage (1 patient), and respiratory insufficiency (71 patients). Forty-six reintubations were performed on 40 patients and 19 tracheostomies (6%) were performed postoperatively. CONCLUSIONS: The excessive incidence of respiratory insufficiency and airway-associated morbidity was potentially related, at least partially, to prolonged mechanical ventilation and withdrawal of anticholinesterase medication. Earlier weaning of patients with revision of 48-hour withdrawal of anticholinesterase medication is necessary.

[Paraesophageal hiatal hernia complicated with stomach cancer]. / Paraoesophagealis hiatus hernia és gyomorrák együttes elófordulása.

The authors present the history of a 79 years old female patient who had to be operated on with paraesophageal hiatal hernia causing cahexia, hematemesis, dysphagia and pain. They found an upside down stomach with cancer inside. They emphasize that endoscopy is very important in the diagnostic process and that cancer can develop even if the stomach is located in the chest.

[Surgery for lung metastases]. / A tüdömetasztázisok sebészete.

Authors analyse the cases of lung metastasectomy collected during fourteen years in eleven thoracic surgical departments in Hungary. 668 operations were carried out on 620 patients. The primary tumor originated mainly from kidney, testis and colo-rectum. Most of the interventions were performed through median sternotomy. The tumors were removed by tissue sparing lung resections (wedge resection). The prognosis depends basically on tumor free interval, however the number and the size of the metastases and the histology of the primary tumor have also impact on it. When lung lesions appear in a cancer patient, thoracic surgeon should be consulted to consider operability. In certain cases metastasectomies can result in longer survival and better quality of life.

An analysis of breast cancer in Hungary: experience of the National Institute of Oncology, Budapest.

Breast cancer is the most common type of cancer in women throughout the world (18%), with a yearly morbidity that is already over half a million. Its incidence in Hungary is increasing in each age group, and the mortality is strikingly high. This study was conducted to assess the effectiveness of breast-conserving surgery in comparison to more radical surgery on a large group of patients. During the 15 years between 1980 and 1994, a total of 6,358 patients with primary breast cancer underwent surgery at the National Institute of Oncology in Budapest, Hungary, as breast-conserving surgery in 2,026 patients (31.8%). Breast-conserving surgery is being performed in an ever-increasing number of patients, followed by adjuvant radiochemotherapy in premenopausal patients, or radiohormone therapy in menopausal patients. During follow-up, recurrence was found in only 5.9% of the patients who underwent breast-conserving treatment. Thus, according to our experience, breast conservation therapy for the management of breast cancer offers favourable results, provided that the preconditions to this treatment are adequately met.

[Malignant cystosarcoma phyllodes: clinico-pathological conference in connection with two cases]. / Malignus cystosarcoma phyllodes: kliniko-patológiai áttekintés két eset kapcsán.

Clinical and morphological characteristics of two malignant cystosarcoma phyllodes mammae were reported with the review of recent literature. One of the patients went to see her doctor 2 years after she had noticed the tumour because of "problems in her family". In the removed giant fibroadenoma osteo-chondrosarcomatous transformation was found. The other patient tried "to mobilise her inner energies against the growth" for 3 years. The removed tumour weighed 2100 grams and there were metastases in the axillary lymph nodes. Histological examination showed malignant cystosarcoma phyllodes with vasoformative tendency. Electron microscopical studies confirmed in both cases that the tumors with varying structures originated from immature mesenchymal cells. Authors agree on wide extirpation of the tumour. According to the literature adjuvant chemo- or radiotherapy do not improve patients survival. In case of early radical operation the malignant transformation is less probable.

[Clinical significance of steroid receptors in breast cancer]. / Az emlörák szteroid receptorainak klinikai jelentösége.

The steroid receptor determination (first of all estrogen receptor--ER--) of the breast cancer tissue has become an important factor for prognostication and treatment. Authors from the Surgical Department of the National Institute of Oncology provide a biostatistical survey of their 727 breast cancer patients. Following factors proved to have significant impact on the prognosis: positivity of ER, the quantitative value of ER, ER vs. lymph node status, ER vs. DFI, ER and the site of metastases and the hormone therapy. The progesterone receptor (PR) provides indication in case only for DFI for metastases. However, in this very respect it has a more significant value than that of ER. Multidimensional analysis has shown that the most important prognostic factors are the lymph node status, patient's age, size of the tumour and the ER value.

Occult breast cancer presenting with axillary metastasis.

The literature of occult breast cancer is reviewed and the management of our 43 patients is discussed. In 20 patients mastectomy and axillary block dissection, in nine upper-outer quadrant resection of the breast with axillary block dissection, and in two axillary biopsy were carried out. The primary tumour was found only in 11 patients during the first operation, either by macroscopic or microscopic examination. In 12 patients the primary breast tumour became detectable only later. Out of the 20 mastectomy specimens two primary tumours could not be identified even with the most thorough examination. In four patients of the breast conservation group the primary tumour remained occult until recently, and in the axillary block dissection group (12 patients) the site of the primary cancer could be identified only in two patients. The difficulties of the diagnosis and the dilemmas of the surgical indications and treatment are dealt with.

[Breast-preserving operations in surgically treatable breast cancer]. / Szervmegtartásos mütétek operábilis emlörákban.

Since 1980, based on international experience, breast conserving operations have been introduced at the Surgical Department, in the National Oncological Institute, Budapest. In 12 years, out of 4622 primary breast cancer operations, 1055 breast preserving interventions were carried out. For all patients adjuvant radiotherapy was indicated. In lymph node positive premenopausal cases chemo-radio-chemotherapy, for postmenopausal patients radiotherapy with tamoxifen has been provided. The first 604 patients (10 years) have been evaluated and 489 of them could be followed. The mean follow-up time was 49 months. During this period of time metastases have developed in 61 patients (12.5%); 26 (5.3%) of them died with the disease. Local recurrences occurred in 29 patients (5.9%). For small recurrences reexcision, for the others mastectomy or/and radiotherapy was carried out. Critical evaluation of the local recurrences was done.

[Occult breast cancer causing axillary metastasis]. / Hónalji nyirokcsomó áttétet adó okkult emlörák.

Authors review 43 cases of occult breast cancer selected from 6396 patients operated on for breast cancer in the National Institute of Oncology, Budapest over a 20-year period (1972-1991). In 20 patients mastectomy and axillary block dissection, in 9 upper-outer quadrant resection of the breast with axillary block dissection, in 12 only axillary block dissection, and in 2 axillary biopsy were carried out. The primary tumor was localized only in 11 patients during the first operation either by macroscopic or by microscopic examination. In 12 patients' breast the primary tumor became detectable only later. Out of the 20 mastectomy specimens, 2 primary tumors could not be identified even with the most thoroughful examination. Out of the breast conservation group in 4 patients, the primary tumor remained occult until recently, and in the axillary block dissection group (12 patients) the site of the primary cancer could be identified only in 2 patients. The authors deal with diagnostic difficulties and the dilemmas of the surgical indications and treatment.

Adult Wilms' tumour. A case report with immunohistochemical studies.

The case of a 27-year-old female patient presenting with a Wilms' tumour is reported. The tumour was dominantly of blastemal type showing minor epithelial (tubular) areas and anaplastic portions. Thorough immunohistochemical examinations were performed to solve differential diagnostic problems. Keratin positivity was found to be of differential diagnostic value in the distinction of this tumour from the so called small round cell tumours. Prognostic aspects of Wilms' tumour are also discussed.

Treatment of breast cancer in women older than 70 years.

Do age, associated diseases, general state, or the stage of tumor determine the operability of breast cancer in the elderly? Risk factors are studied on the basis of data on 465 patients over 70 years of age who had breast cancer surgery between 1977 and 1986. Operative mortality of patients is analyzed, and according to the results, the outcome of the surgery is mainly influenced by patients' performance status (Karnofsky/Zubrod index) and stage of disease and not by the associated diseases or patient age.

Radiotherapy alone or in combination with surgery in the management of stage III breast cancer.

239 women with stage III carcinoma of the breast were treated by primary radiation therapy from 1977 to 1985. Of them 212 had an objective response and 27 showed no response to irradiation. From the objective responders, 105 patients were subjected to mastectomy and axillary dissection and in 107 cases the radiotherapy was not followed by surgery. Patients of operated group had a 71% and the RT alone group had a 61% local-regional tumor control at 5 years. The analysis of local-regional recurrences revealed that none of the operated patients had axillary recurrence but 8 had in the RT alone group. Postirradiation surgery is recommended for patients who have residual disease especially in the axillary region. The 5-year survival rate of operated patients was significantly better, 58% vs. 35%. However, these results are not comparable since the incidence of less favourable cases was higher in the RT alone group. Chemotherapy was initiated for the 27 patients who failed to respond to RT, but results were unsatisfactory. None of them survived three years. Further studies are needed to explore the role of chemotherapy in this stage of breast cancer.

Gastric carcinoma associated with other malignant tumours.

Authors report on 25 patients treated for gastric cancers associated, synchronously or metachronously, with other malignant tumour. Hypotheses for the development of multiple malignant tumours are reviewed. They state that the prognosis of the second tumour is worse for its late detection and stress the importance of follow-up that also considers the possible development of a new tumour.