Retrospective analysis of the clinical performance of anterior mediastinotomy.

BACKGROUND: Accurate staging of patients with lung cancer is imperative in generating an appropriate treatment strategy. This study examined the clinical performance of anterior mediastinotomy in staging patients with suspected left upper lobe non-small cell lung cancer. METHODS: This study was designed as a retrospective cohort. All patients with suspected left upper lobe cancer and otherwise normal computed tomography scan results were eligible. Patients with clinically unresectable disease (advanced disease or not fit for surgery) were excluded. After exclusions, 151 patients were stratified into two groups: 117 patients had cervical and anterior mediastinotomy as part of preoperative staging, and 34 had cervical mediastinoscopy only. The primary outcome was rate of preventable thoracotomy defined as thoracotomy during which either metastases to aortopulmonary or paraaortic lymph nodes, or mediastinal invasion was identified. RESULTS: The rate of preventable thoracotomy for the anterior mediastinotomy arm was 4 (3.4%) of 117, compared with 1 (2.9%) of 34 for cervical mediastinoscopy-only arm (p = 0.99). The rate of morbidity in the anterior mediastinotomy arm was 8 (6.8%) of 117, compared with 2 (5.8%) of 34 for the cervical mediastinoscopy-only arm (p = 0.99). Anterior mediastinotomy patients stayed in hospital 1 day longer (p = 0.008). Anterior mediastinotomy was successful at harvesting one or more lymph nodes in 67% of patients. Five patients (4.3%) who underwent anterior mediastinotomy were spared a thoracotomy by identification of metastases to aortopulmonary lymph nodes. CONCLUSIONS: In patients with suspected left upper lobe lung cancer and otherwise normal computed tomography scan results, anterior mediastinotomy does not significantly reduce the rate of preventable thoracotomy.

Reassessing the role of axillary lymph-node dissection in patients with early-stage breast cancer.

INTRODUCTION: There is considerable controversy regarding the value of axillary lymph-node dissection in the adjuvant systemic therapy of patients with early-stage breast cancer. Our objective was to assess the impact of nodal status in assigning adjuvant chemotherapy to these patients. METHODS: We carried out a review of all patients with stage I or II breast cancer treated at 3 university-affiliated hospitals in Saskatoon between Jan. 1, 1998, and Dec. 31, 2000. Data collected included: patient age, sex, tumour size, hormone receptor status, nuclear grade and presence of lymphovascular invasion. Patients were categorized as being at low, high or intermediate risk for recurrence based on Canadian consensus guidelines and at low or high risk according to criteria established by the United States National Institutes of Health (NIH). The influence of nodal status on subsequent treatment was determined assuming that all patients younger than 70 years at high risk of recurrence would receive chemotherapy. RESULTS: We identified 327 women with stage I or II breast cancer in whom all prognostic factors were available for analysis. Applying the Canadian criteria to determine the need for adjuvant chemotherapy, 68% of women would receive chemotherapy regardless of lymph-node status. Applying the NIH criteria, 82.5% of women younger than 70 years would receive adjuvant chemotherapy regardless of nodal status. CONCLUSIONS: Nodal status has little influence on subsequent management. Adoption of a selective approach to axillary lymph-node dissection could avoid the potential morbidities of this procedure in many patients with early-stage breast cancer.

Gastrocolic fistulae as a consequence of benign gastric ulcer disease.

Gastrocolic fistulae are a rare entity, occurring most commonly in the context of a malignant process or less frequently as a complication of a benign gastric ulcer. Presenting symptoms tend to be nonspecific, but the diagnosis can be confirmed with near certainty by barium enema examination or an upper gastrointestinal series. Although the management of gastrocolic fistulae has historically been surgical, medical management has recently been recommended as the first line of treatment when an underlying malignancy can be excluded.