Axillary node metastases in relation to size and location of breast cancers: analysis of 147 patients.

This prospective study of 147 patients undergoing axillary lymphadenectomy for treatment of breast cancer over a 3 1/2-year period relates frequency and number of involved lymph nodes to the size and location of the tumor within the breast. A total of 35.3 per cent of patients in the entire series had axillary metastases. Of 29 patients with cancers 0-10 mm, five had axillary metastases (17.2%). All five cancers were located at the upper outer quadrant (UOQ) of the breast. Thirteen of 58 patients with cancers 11-20 mm had positive nodes. Eight of the 13 cancers were at the UOQ. Only one of 13 patients with cancer at the lower inner quadrant had nodal metastases. A total of 25.8 per cent of cancers 0-20 mm located at the upper half of the breast were associated with positive nodes, in contrast with 11.1 per cent of those located in the center and 7.1 per cent of those located in the lower half of the breast; likewise, 28 per cent of cancers 0-20 mm located at the lateral aspect of the breast had axillary nodes involved, and 11.5 per cent when cancer was located in the median half. Using such an analysis, 25 per cent of all lymphadenectomies could have been omitted, as could 37.9 per cent of those performed for T1 cancers (0-20 mm) without compromising systemic adjuvant therapy.

Major abdominal operations on Jehovah's Witnesses.

Thirteen major operations have been successfully performed on 11 Jehovah's Witnesses, without complications. After detailed preadmission assessment, all patients received pretreatment assurances that their religious beliefs would be respected, regardless of the circumstances in the operating room. There were no untoward effects of this policy. Whereas the religious and legal aspects of the issue may be confusing and unacceptable to some surgeons, those undertaking to treat such patients must use ancillary means, technical variations, and alternatives to standard procedures in order to minimize risks and achieve acceptable results. Preoperative agreement should be viewed as binding by the surgeon and should be adhered to regardless of events developing during and after operation. Such an approach constitutes the best preoperative preparation, orients the patients positively toward their surgical treatment, and diverts the surgeon's attention from the legal and philosophical considerations to the surgical and technical ones, thus, allowing him to perform optimally and serve his patient's best interests. The recovery phase in this small series of electively performed operations occurred at anticipated rates and no postoperative complications developed.

Localization of residual medullary thyroid cancer by thallium/technetium scintigraphy.

Whole-body thallium/technetium subtraction scintiscans, with thallium 201 chloride and technetium 99m pertechnetate, were obtained on 10 patients with medullary thyroid cancer with postoperative elevations of serum calcitonin values. Seven patients had the hereditary variant of medullary thyroid cancer (the multiple endocrine neoplasia, type II syndrome) while three patients had the sporadic form. Negative scans were obtained on five patients with basal calcitonin levels less than 3 ng/ml (normal less than 0.35 ng/ml). Five other patients with elevated calcitonin levels (range 3.6 to 69.2 ng/ml; mean 28.3 ng/ml) had positive scans that have guided further surgical approaches. Serum calcitonin appears to remain the most sensitive indicator of residual medullary thyroid cancer while localization of this residual tumor tissue frequently can be obtained through thallium/technetium subtraction imaging in both the hereditary and sporadic forms of the disease.

The role of fine needle aspiration cytology in the management of solid breast tumors.

The value of fine needle aspiration cytology in patients with breast masses has found limited acceptance in the United States. When employed consistently, however, it has been reliable and has facilitated patient management. A positive cytological diagnosis of cancer has always been confirmed by histology, while "atypical," "suspicious," and "abnormal" categories represent cancer in varying degrees of frequency and open biopsy is usually necessary. The method is quick, easy, and causes no morbidity. The critical aspects for its success are those of interested surgeons and cytopathologists, and appropriate sampling and processing technique. In our experience with fine needle aspiration cytology in 38 patients with breast tumors, all 23 patients with cytological diagnosis of cancer, three of four with suspicious, and one of three with atypical smears proved to have cancer. Two of four patients with unsatisfactory smears had carcinoma on biopsy, both of the infiltrating lobular variety. Based on this limited experience, as well as on information in the available literature, fine needle aspiration cytology is strongly recommended in the evaluation and management of patients with breast tumors.

Work in progress: radioisotopic evaluation of gastroplasty patients.

Radioisotopic gastric emptying studies, using technetium-99m-sulfur-colloid-labeled egg, were performed in 14 patients who had undergone gastroplasty. The radioisotopic method was found to be a good quantitative indicator of the amount of solids that empty from the stomach and a useful tool in the longterm follow-up of gastroplasty patients. It was particularly helpful in evaluating the efficacy of surgery in patients with poor postsurgical weight reduction.

Vaginal evisceration. A case report and brief review of the literature.

A 70-year-old woman was successfully treated for spontaneous vaginal evisceration, with extensive infarction of small intestine, by an abdominal and vaginal approach. Vaginal evisceration is a rare condition. It usually occurs in postmenopausal women after one or more vaginal operations and in the presence of an enterocele or other local abnormalities that contribute to tissue weakness. Prompt recognition and surgical treatment, combining abdominal and vaginal approaches as indicated, and use of ancillary antibiotics and anticoagulant regimens is associated with successful outcome in most instances.

Review of 555 cholecystectomies without drainage.

During a 10-year period, 555 cholecystectomies were performed without drainage of the gallbladder bed or subhepatic space. Six per cent of the patients had acute cholecystitis or hydrops of the gallbaldder and 11% had common duct exploration. Only in those patients with frank infection, spillage of obviously infected bile or in whom satisfactory closure of the gallbladder bed could not be accomplished was a drain used. Meticulous closure of the gallbladder bed was performed to minimize leakage of bile. The series was critically studied to evaluate complications, morbidity, mortality and hospital stay. It was concluded that drainage following cholecystectomy or choledochotomy can safely be omitted except for the indications mentioned.

Ileal loop ureteroileostomy in patients with neurogenic bladder. Personal experience with 54 patients.

(1) In a six year experience with ileal loops in patients with neurogenic bladder, 49% of the patients were paralyzed, 30% had multiple sclerosis, and 91% had recurrent or persistent urinary tract infection. Reflux, incontinence, retention, and bladder calculi were additional indications for supravesical urinary diversions. (2) All loops were performed in a similar manner, most of them placed retroperitoneally, and a vigorous program of postoperative care was followed. There were no postoperative deaths, and a moderate number of complications occurred in 51.8% of the patients. (3) The participation of the enterostomal therapist is the preparation of the patient and in the immediate and long-term stomal care has been invaluable and is strongly recommended.