An update on prognosis in breast cancer patients with extensive axillary disease.

Lymph node (LN) status is the most important factor in predicting survival in breast cancer. Historically, patients with 10 or more positive LN have been thought to have a particularly poor prognosis, which has in the past been used to alter therapeutic recommendations. Studies conducted both prior to and after the use of anthracycline-based chemotherapy demonstrate poor survival. We hypothesized that the current survival rate is considerably higher. All patients with breast cancer treated at our institution between July 1991 and December 2005 with at least 10 positive axillary LN were identified. A multivariate Cox proportional hazards model was performed using age, number of positive nodes, and primary tumor characteristics. Of 55 patients identified, two were excluded for incomplete follow-up information. The median patient age was 53; median follow-up was 5-years. The overall 5-year survival rate was 71.9%. On univariate analysis estrogen receptor (ER) status (p = 0.0001), progesterone receptor status (p = 0.004), use of adjuvant chemotherapy (p = 0.01), T-stage (p = 0.03), and adjuvant hormonal therapy (p = 0.002) were statistically significant for survival. In the multivariate analysis, only ER status and the use of adjuvant chemotherapy remained significant for survival. ER negativity conferred a hazard ratio of 12.6 (95% confidence interval: 3.7-43.2) and the use of adjuvant chemotherapy had a hazard ratio of 0.14 (95% confidence interval: 0.04-0.46). In our study, patients with at least 10 positive axillary LN had a 5-year survival of 71.9% which may be due to the improvements in local and systemic therapy.

The prognostic significance of micrometastases in breast cancer: a SEER population-based analysis.

INTRODUCTION: The prognostic significance of lymph node micrometastases in breast cancer is controversial. We hypothesized that the survival of patients with solely micrometastatic disease (N1mi) would be intermediate to patients with 1-3 tumor-positive lymph nodes (N1) and those with no positive lymph nodes (N0). METHODS: We queried the surveillance, epidemiology and end results (SEER) database for all patients between 1992 and 2003 with invasive ductal or lobular breast cancer without distant metastases and < or = 3 axillary nodes with macroscopic disease. Patients were stratified by nodal involvement and compared using the Kaplan-Meier method. Cox proportional hazards regression was utilized to compare survival after adjusting for patient and tumor characteristics. RESULTS: Between 1992 and 2003, N1mi diagnoses increased from 2.3% to 7% among the 209,720 study patients (p < 0.001). In a T-stage stratified univariate analysis, N1mi patients had a worse prognosis in T2 lesions. On multivariate analysis, N1mi remained a significant prognostic indicator across all patients (p < 0.0001) with a hazard ratio of 1.35 compared to N0 disease and 0.82 compared to N1 disease. Other negative prognostic factors included male gender, estrogen-receptor negativity, progesterone-receptor negativity, lobular histology, higher grade, older age, higher T-stage, and diagnosis in an earlier time period. CONCLUSION: Nodal micrometastasis of breast cancer carries a prognosis intermediate to N0 and N1 disease, even after adjusting for tumor- and patient-related factors. Prospective study is warranted and the results of pending trials are highly anticipated. Until then adjuvant therapy trials should consider using N1mi as a stratification factor when determining nodal status.

Trends in breast cancer at a county hospital.

Breast cancer mortality has changed dramatically with improvements in screening techniques. Mammography is essential for early detection; however, its contribution to the survival benefit in young women is questionable. We report our experience in breast biopsies at a county teaching hospital with a traditionally younger patient population. Institutional review board approval was obtained prior to data collection. A total of 550 breast biopsies were conducted between 1995 and 2000. Data regarding age, method of breast biopsy, and pathology was reviewed. One hundred twenty of 550 patients (21.8%) had breast carcinoma detected on breast biopsies with the predominant histologic subtype being invasive ductal carcinoma. The mean age of patients with carcinoma was 52.8 years, whereas that of patients with benign breast disease was 43.6 years (P < 0.05). Forty-three per cent of all breast cancers occurred in women under the age of 50 years. During the study period, there was neither an increase in the number of breast biopsies performed per year nor a decrease in the average age of women with breast cancer. However, observing a significant percentage of breast cancer patients under 50 years old, our data suggest the importance of strict adherence to current screening recommendations including self-breast examination and yearly mammography.

Routine chest X-ray after percutaneous tracheostomy is unnecessary.

Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.

The quality of surgical resident interpretation of after-hour CT scans of the head and abdomen in trauma.

Computed tomography (CT) is an important diagnostic tool in the evaluation of trauma patients. Accurate interpretation of CT scans remains critical in decision-making and the resultant quality of care. In our study, the records of a consecutive cohort of trauma patients who underwent after-hour CT scans of the head and abdomen between January 23 and June 30, 2004, at Kern Medical Center were reviewed. Three hundred thirty-five CT studies were collected in 211 patients. The accuracy of resident interpretation was 92.8 per cent for abdominal and 97.5 per cent for head CT. Resident readings were 93.2 per cent sensitive and 95.4 per cent specific with a positive predictive value of 85.2 per cent and a negative predictive value of 98.0 per cent. There were 16 (4.8%) instances of interpretation discrepancy between the surgical resident and attending radiologist. Most differences occurred in the evaluation of abdominal CT. In no instance was management or outcome for these patients affected. This data demonstrates a low error rate in resident interpretation of after-hour CT scans of the head and abdomen in trauma, but there remains a need for the continued review of the quality of surgical resident radiologic interpretation in situations when an attending radiologist is not immediately available.

Laparoscopic versus open appendectomy: is the postoperative infectious complication rate different?

Despite the reported advantages of laparoscopic appendectomy (LA), there is debate about the postoperative infectious complication rate. Our study attempts to determine if the infectious complication rate between LA and open appendectomy (OA) is different. A retrospective review was conducted of all patients who underwent appendectomy at Kern Medical Center between 1999 and 2003. Age, sex, white blood cell count, temperature, pathology, and postoperative complications were identified. Fifty-seven patients underwent LA, and 159 patients underwent OA. The groups were well matched for demographics, white blood cell count, temperature, and percent perforated appendicitis. There was an overall 9.3 per cent complication rate. The infectious complication rate in OA versus LA group was statistically different (6.3% vs 17.6%, P = 0.04). The infectious complication rate in the LA group was significantly higher than in the OA group. Further large randomized trials are necessary to confirm our findings and to identify if LA is appropriate for a subset of appendicitis patients.

The efficacy of postoperative oral antibiotics in appendicitis: a randomized prospective double-blinded study.

The conventional treatment of acute appendicitis is appendectomy followed by intravenous (IV) antibiotics until intraabdominal infection has resolved. It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics. All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study. Perforated/gangrenous appendicitis was equally represented in the two study arms. After appendectomy, and when IV antibiotics were ready to be discontinued, patients were randomized to receive a 7-day outpatient course of either placebo (Group 1) or oral antibiotics (Group 2). Patients were monitored for infectious complications for a minimum of 3 months, and there was no statistical difference (11.5% in Group 1 vs 12.1% in Group 2, P = 0.61). The data suggest that adding a course of outpatient oral antibiotics, after completing a course of IV antibiotics, does not decrease postoperative infectious complications in appendicitis patients.