A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND: Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS: A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS: We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS: IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

The reactions of euthyroid and hyperthyroid glands to radioactive iodine.

BACKGROUND: Researchers generally assume that the thyroid gland reacts more or less comparably to external irradiation and radioactive iodine. DESIGN: The thyroid glands from 20 euthyroid patients and 20 hyperthyroid patients, all of which had been treated with radioactive iodine, were studied. RESULTS: The two groups manifested different reactions. Almost all the euthyroid glands displayed a fibrotic atrophic pattern, whereas the glands from the Graves' disease patients showed more adenomatous and Hashimoto lesions than atrophy. CONCLUSION: Differences in the reactivity of normal and hyperplastic follicles may cause different reactions to treatment with radioactive iodine.

The practice of prophylactic mastectomy: a survey of Maryland surgeons.

OBJECTIVES: Bilateral prophylactic mastectomy is a drastic breast cancer preventive option for which indications are not standardized and efficacy has not been proven. To estimate the magnitude of this controversial practice, surgeons were surveyed on their recommendations about and performance of prophylactic mastectomy. METHODS: A cross-sectional survey was sent to general surgeons (n = 522), plastic surgeons (n = 80), and gynecologists (n = 801) licensed to practice in Maryland in 1992. Proportions responding were 41.9%, 66.3%, and 54.9%, respectively. In addition, there were 30 respondents who identified "other" as their specialty. The respondents were asked about the role of bilateral prophylactic mastectomy and the number of times they had recommended and performed it in a year. RESULTS: Seven hundred forty-two surgeons responded (51.8%). More plastic surgeons (84.6%) than general surgeons (47.0%) and gynecologists (38.3%) agreed that bilateral prophylactic mastectomy has a role in the care of high-risk women. Eighty-one percent of plastic surgeons had recommended the procedure, compared with 38.8% of general surgeons and 17.7% of gynecologists. CONCLUSIONS: Indications and practice patterns reveal heterogeneity of medical opinion and practice of prophylactic mastectomy. This study raises the need for better evaluation of the efficacy and appropriateness of prophylactic mastectomy.

Multiplanar CT evaluation of brachial plexopathy in breast cancer.

Standard axial CT supplemented by two-dimensional reconstruction in coronal, sagittal, and oblique planes was used to evaluate 35 patients with a history of breast cancer and clinical symptoms suggestive of brachial plexopathy. In five patients, definite tumor recurrence was seen either within the axilla or the neurovascular bundle or near the origin of the brachial plexus at the C5-C7 level. In six patients, there was thickening around the plexus compatible with fibrosis or scarring. In these patients, no mass was seen. In 24 patients, no evidence of abnormality was noted. Reformatted views can supplement transaxial CT and are particularly effective in defining the course of the brachial plexus and detection of tumor recurrence. The oblique views along with orthogonal planes provide optimal visualization of the brachial plexus and are helpful in the detection of tumor involvement.

Conservative treatment of distal rectal cancer by local excision.

From 1954 through 1982, 57 patients with invasive, distal rectal cancer had a full-thickness local excision with curative intent. Prognostic criteria and need for further treatment were based on the histopathologic results of the operative specimen. The overall 5-year survival rate was 83.4%. The rectal cancer-specific mortality rate was 10.5%. None of the 27 patients without adverse prognostic factors died from rectal cancer, and for this group local excision alone was sufficient treatment. The only single factors associated with an adverse outcome were mucinous characteristics and full-thickness invasion. Ulceration alone and penetration into the muscularis propria alone were not adverse factors. In the presence of multiple adverse prognostic factors, mucinous characteristics or full-thickness penetration, local excision was inadequate treatment and an abdominal perineal resection was necessary.

Intractable bladder hemorrhage requiring cystectomy after use of intravesical thiotepa.

A case of nearly exsanguinating bladder hemorrhage, occurring six months after intravesical thiotepa administration, is reported. The hemorrhage was not attributable to myelosuppression. This case also demonstrates the hazard of using formalin to control such hemorrhage.

Tuboovarian abscess presenting as sciatic pain: case report.

The authors report the successful conservative treatment of a tuboovarian abscess in a 25-year old woman who presented with low grade fever and severe right sciatic pain. Computed tomography and ultrasonography corroborated a clinical diagnosis of tuboovarian abscess after an initial diagnosis of epidural abscess had been made. This is the first report of a tuboovarian abscess presenting principally as sciatic pain. The diagnosis and treatment of this lesion are discussed.

The function of the primordial germ cell in extragonadal tissues.

The identity of the germ cell tumours of the pineal and the thymus with those of the testis and ovary suggests that the widely disseminated primordial germ cells might subserve some special function in these sanctuaries. It is proposed that thymic localization might be required for the conveyance of genetic haematological and immunological information and that the pineal-diencephalic localization could programme neuroophthalmic tissues prior to the development of the blood-brain barrier. The latter speculation was tested by producing allergic encephalomyelitis in thymectomized, bursectomized and thymobursectomized chickens. It was found that although thymectomy and, to a lesser extent, bursectomy decreased the severity of the experimental encephalomyelitis the combined procedure resulted in more severe inflammatory lesions. This may be due to release of suppressed intraneural immunological mechanisms in the somatically impaired bird.

Changing aspects of radiation enteropathy.

Fifty-two patients with radiation enteropathy secondary to radiation for abdominal or pelvic malignant neoplasms are described. This series (1977 to 1984) is compared with a series of 50 patients from the same institution over an earlier period (1961 to 1977). Intestinal obstruction was the principal complication in both series; 96% of the patients underwent either intestinal resection or anastomotic bypass of the affected segment. Changes that have occurred since the last report are as follows: changes in source of radiation energy (linear accelerator); less evidence of mucosal damage; increased serosal reaction ("serosal peel"); and increased use of elemental diets, parenteral nutrition, and long intestinal tubes in surgical management. Since postoperative radiation injury occurs most frequently in the pelvis, new developments for the exclusion of small bowel from the pelvis during radiation are reviewed. Changes in fractionation of radiation dosage should also be considered in patients with enteric symptoms during radiation therapy.

Primary metastasizing aortic endothelioma.

An instance of malignant endothelioma, primary in the aorta, metastasizing to intestine and bone, is reported. The aortic tumor was successfully resected. The unexpected finding of a large hepatic growth at autopsy raised the possibility that the aortic neoplasm was a metastasis. Histochemical, immunologic, and ultrastructural studies supported the diagnosis of an endothelial neoplasm. Although a number of malignant aortic and large vessel tumors have been reported, only four previous instances appear to be endotheliomatous.

Pseudosarcoid granulomas in Hodgkin's disease.

The sarcoid-like granulomas encountered in lymph nodes, spleens, and hepatic biopsy specimens removed from patients being "staged" in the course of Hodgkin's disease and, in lower incidence, in non-Hodgkin's lymphomas may, at least in part, be due to reactions to the oily radiographic contrast medium used in lymphangiography. They are seen more often following lymphangiography than when no contrast medium is used. The granulomas in patients who have not undergone lymphangiographic procedures are attributed to the many agents inciting pseudosarcoid lesions. It is speculated that the granulomas seen in Hodgkin's disease after lymphangiography may be the result of a combination of lipogranulomatous reaction and the effects of an immune adjuvant.

The modern enigma of radiation enteropathy: sequelae and solutions.

With the extended indications for abdominal and pelvic radiation therapy, administered at higher dosage levels, an increased incidence of radiation injury to the intestine can be anticipated. Increased efforts are urgently needed to develop innovative methods in the detection, prevention, and management of radiation-induced intestinal injury. Fifty cases of radiation enteropathy have been reviewed to highlight problems in management and to suggest preventive and therapeutic measures, both surgical and nonsurgical.

Metastatic hemangiopericytoma associated with microangiopathic hemolytic anemia: review and report of a case.

The hemangiopericytoma is an invasive tumor of vascular origin. No matter how benign the course and how circumscribed the mass, it must be considered a lesion with high malignant potential. In the case report here, a hemangiopericytoma of the pancreas with metastasis to the liver was associated with microangiopathic hemolytic anemia in a 78-year old woman. The anemia may have been present before the onset of metastasis. If so, it could have been a major factor in the breakdown of host response and could have initiated the malignant dissemination. Under these circumstances it could be an indicator of metastasis in patients with previously diagnosed tumors. However, there are many cases of metastatic malignancy associated with this anemia in which the opposite situation holds. The anemia is usually of extracorpuscular origin. Apparently intravascular coagula1ion caused by injury from tumor-cell aggregates in small vessels induces erythrocyte fragmentation in fibrin strands. A vicious cycle of cell fragmentation, vascular injury and fibrin strand formation completes the course. Analysis of the findings should be based upon more than a strictly pathologic approach; it should also be related to the new discoveries in cancer research.

The case against tylectomy for carcinoma of the breast. The factor of multicentricity.

Five hundred consecutive cases of breast carcinoma were studied to determine the incidence of multicentric lesions in the resected specimens. When residual tumor in juxtaposition to the primary tumor or biopsy cavity is excluded, 41.6 per cent of specimens exhibited multicentric foci of tumor; 31 per cent of such foci were in sectors or quadrants remote from the primary tumor. In more than half of these cases the lymph nodes were uninvolved and cure rate would have been maximal had these multicentric tumor foci been removed. These findings confirm previous similar studies and we consider tylectomy an inappropriate mode of therapy for breast cancer.