Enhancing the clinical pathway for patients undergoing axillary lymph node dissection.

BACKGROUND: Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers. METHODS: Consecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates. RESULTS: From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education. CONCLUSION: ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.

Initial experiences with a multidisciplinary approach to decreasing the length of hospital stay for patients undergoing unilateral mastectomy.

BACKGROUND: We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety. MATERIALS AND METHODS: As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days. RESULTS: Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented. CONCLUSIONS: This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.

Magnetic resonance imaging detects unsuspected disease in patients with invasive lobular cancer.

BACKGROUND: Predicting the extent of disease in the breasts of patients with invasive lobular cancer (ILC) can be difficult because of the limits of physical examination and standard imaging. We determined the utility of magnetic resonance imaging (MRI) in finding otherwise unsuspected cancer in the ipsilateral or contralateral breast of patients with ILC. METHODS: Through database review of all breast MRIs performed between January 1, 1999, and December 30, 2002, we identified patients with newly diagnosed ILC who underwent an MRI for extent-of-disease evaluation or contralateral screening. MRI findings separate from the primary tumor were biopsied and correlated with pathology by using MRI-guided biopsy. RESULTS: Sixty-two patients were identified. In all, 59 ipsilateral and 57 contralateral studies were performed. Suspicious lesions separate from the primary tumor were found by MRI in 38 (61%) of 62 patients. Eight patients were excluded from further analysis (seven elected mastectomy without biopsy; one had an unguided excision). Nineteen of 51 patients with an ipsilateral finding underwent MRI-guided biopsy, which revealed cancer in 11, or 22% of those imaged. Twenty of 53 patients with a contralateral finding underwent MRI-guided biopsy, which revealed cancer in 5, or 9% of those imaged. CONCLUSIONS: MRI of the breast identifies unsuspected multicentric or contralateral cancer in patients with ILC. These findings support the use of MRI in selected patients with ILC, particularly in the ipsilateral breast.

Contrast-enhanced breast MRI for cancer detection using a commercially available system--a perspective.

The diagnosis and treatment of breast cancer are dependent upon early detection of the disease by physical examination and mammography. Although mammography is a relatively good and cost-effective method of early breast cancer detection, there are some inherent weaknesses associated with this imaging modality that limit its sensitivity and specificity. Contrast-enhanced MRI of the breasts provides the additional capability to answer questions raised or unanswered with conventional imaging methods. This paper reviews contrast-enhanced breast MRI interpretation guidelines and patient preselection criteria for diagnostic problem cases. Technical aspects using a commercially available three-dimensional (3D) spoiled gradient-echo technique are discussed.

Comparison of transcutaneous oximetry and laser Doppler flowmetry as noninvasive predictors of wound healing after excision of extremity soft-tissue sarcomas.

BACKGROUND: We wished to determine whether transcutaneous oximetry or laser Doppler flowmetry (LDF) could identify patients at risk for wound failure after conservative, limb-sparing surgery for extremity sarcomas. METHODS: Studies were performed on postoperative days (PODs) 1, 4/5, 7, and 9. Measurements of transcutaneous oxygen pressure (tcPO2) were taken at breathing room air (BL) and 100% oxygen (rate tcPO2). LDF measurements were taken at multiple sites along the wound, and a perfusion index was calculated. RESULTS: Twenty-four patients were studied. Four (17%) had nonhealing wounds. There was no difference in tcPO2 (BL) values between healed and nonhealing wounds. Measurement of rate tcPO2 on POD 1 was significantly lower in the nonhealing wounds than in those with normal healing (28.5 +/- 12.1 mm Hg vs 14.3 +/- 16.2 mm Hg, mean +/- SD, p = 0.03). Rate tcPO2 values increased significantly in healing wounds from POD 1 to PODs 7 and 9 (p = 0.006, p = 0.009). This increase was absent in nonhealing wounds. A clear separation was noted in rate tcPO2 values between groups, with a minimum rate tcPO2 value recorded in a healed wound of 9 mm Hg/min, compared with the maximum value in a nonhealing wound of 7 mm Hg/min. The LDF perfusion index failed to predict wound healing at any of the measured time points. CONCLUSIONS: This study showed that measurement of tcPO2 during oxygen inhalation can accurately predict wound healing in patients after excision of an extremity sarcoma.

Role of contralateral breast biopsy in infiltrating lobular cancer.

BACKGROUND: Although infiltrating lobular carcinoma (ILC) is known to be associated with higher rates of bilaterality, contralateral breast biopsies are not routinely performed in such patients. METHODS: The pathology reports of all patients with ILC admitted to Memorial Sloan-Kettering Cancer Center between 1970 and 1980 were retrospectively reviewed. The incidence of contralateral biopsies, random and directed, was determined. The findings on contralateral biopsy were evaluated with respect to age of the patient, nodal status of the ipsilateral cancer, and multicentricity of the primary lesion. RESULTS: Of the 275 patients undergoing mastectomy for ILC, 130 (47%) had contralateral biopsies. Twenty-two were directed biopsies and 108 were random biopsies. On random biopsy 11 (10%) patients were found to have infiltrating carcinomas and seven (6%) were found to have intraductal cancer. Multicentric invasive disease in the ipsilateral breast was found to be predictive of a positive contralateral biopsy (p = 0.01). CONCLUSIONS: Despite the current trend toward less extensive surgery for breast cancer, random contralateral breast biopsy is indicated in patients with ILC.

Breast carcinoma presenting as chondrosternal thickening: a long-standing masquerade.

The internal mammary lymphatics are the second most common site of regional metastasis in breast carcinoma. However, because of their retrosternal location, they rarely become clinically evident. This report describes a patient with a parasternal breast carcinoma metastasis arising from internal mammary lymphatics. The metastasis caused symptoms for more than 3 years before the primary tumor was discovered. The pathologic elements underlying this unusual presentation along with the treatment options and the surgical management with extended mastectomy are discussed in detail.

Management of the high-risk patient.

While breast cancer is affecting American women at an epidemic rate, certain patients are identified as being at particularly high risk because of environmental, endocrine, genetic, and pathologic risk factors. Risk assessment, dietary, and psychological counseling, as well as breast cancer screening, are the function of a high-risk breast cancer program. Our own program is discussed.

The malignant nature of papillary and cystic neoplasm of the pancreas.

Two new cases of papillary and cystic neoplasm of the pancreas are reported. One patient was a 20-year-old woman with massive unresectable liver metastases, and the other was a 15-year-old boy. To study the natural history and malignant potential of this tumor, the English literature was reviewed to obtain an additional 56 cases. Clinical characteristics include pain and a mass in most patients, although many are found incidentally. Jaundice, hemoperitoneum, nausea, and vomiting are unusual findings. Most patients are treated by wide resection with good results. These tumors appear to be indolent. However, 16% of patients had major organ or blood vessel invasion, and 7% had liver metastases at some time during the course of their disease, illustrating the malignant nature of this tumor. Long-term follow-up is necessary to evaluate the efficacy of treatment, especially in the case of locally advanced and metastatic disease.

Extraadrenal retroperitoneal paragangliomas: natural history and response to treatment.

Extraadrenal retroperitoneal paragangliomas (RP) are uncommon tumors. Because of their rarity, little is known of their natural history or response to treatment. We reviewed 22 patients with RP who were seen at our center between 1949 and 1990. The distribution of male and female patients was nearly equal, and the mean age was 42. Most patients were admitted with pain or a mass, and eight of 22 tumors were functional. No significant difference was noted in duration of symptoms, size of the tumor, or survival between functional and nonfunctional tumors. Eleven of 22 (50%) RP metastasized and were therefore classified as malignant. Five-year and 10-year disease free survival rates were 19% and 19% for tumors not resected and 75% and 45% for those completely resected. Once metastases occurred, the 5-year survival rate was 36%, but no patient survived beyond 76 months. Predictors of survival included complete resection of the tumor but not size or functional status. Although some patients who received chemotherapy or radiotherapy had clinical responses, a survival benefit could not be shown. RP have a high rate of malignant behavior and should be treated aggressively with operation. Late metastases are not uncommon, and prolonged follow-up is necessary. Once metastases have occurred, some patients may have prolonged survival.

Evaluation of 24-second cyanide-containing and cyanide-free methods for whole blood hemoglobin on the Technicon H*1TM analyzer with normal and abnormal blood samples.

Automated methods, with and without cyanide (+CN and -CN), for whole blood hemoglobin (Hb) determination were evaluated on the Technicon H*1TM System. Both automated Hb methods were linear over the range 0-250 g/L (0-25 g/dL) and correlated well with the International Committee for Standardization of Hematology (ICSH) reference method and with the Coulter S+II. Both methods quantitatively converted whole blood containing up to 100% carboxyhemoglobin in less than 24 seconds to their respective end products. With respect to abnormal samples (sickle cell anemia, multiple myeloma, and hyperlipemia), both H*1 methods gave Hb results that were equivalent to the (postfiltration) ICSH method. For samples with white blood cell (WBC) counts less than 36 X 10(9)/L, the +CN method was equivalent to the (postfiltration) ICSH method, whereas for WBC counts greater than 20 X 10(9)/L, the -CN method showed acceptable recovery of the mean but unacceptable imprecision. For WBC counts of 36-164 X 10(9)/L, the +CN method yielded acceptable Hb recovery with unacceptable imprecision. Hyperlipemia, resulting from addition of Intralipid directly to the blood samples, caused large errors in both H*1 methods.

Reliability of the Derifield-Thompson test for leg length inequality, and use of the test to demonstrate cervical adjusting efficacy.

The Derifield-Thompson test for leg length inequality (LLI) is commonly used by chiropractors to assess a need for adjustment and to evaluate the results of adjustment. The two previous studies testing the reliability of the technique reported conflicting results. This study had two objectives: to demonstrate inter- and intraobserver reliability in detecting a LLI as little as 3 mm; and to document what effect Pierce-Stillwagon cervical adjusting has on a functional LLI. Twenty-six subjects walked into five successive examining rooms where a Derifield leg check was performed, including an estimate of the millimeters of difference in leg lengths. The subjects then entered a treatment room where they were randomly given no treatment, cervical adjusting, or gluteal massage. This process continued for 5 cycles. This study demonstrated that clinicians could reliably measure a LLI to less than 3 mm (both inter- and intraobserver), and also detect a change in LLI when the head was rotated. Neither cervical adjustment nor gluteal massage produced a significant change in observed LLI.

Pathway of oxidation of pyruvic oxime by a heterotrophic nitrifier of the genus Alcaligenes: evidence against nitroethane as an intermediate.

The role of nitroethane as an intermediate in the oxidation of pyruvic oxime to nitrate by an Alcaligenes sp. was examined. Unlike pyruvic oxime, which serves as a sole source of C and N for the bacterium, nitroethane was incapable of supporting the growth of the microbe. Nitroethane was metabolized and diauxic growth did occur, however, if the nitroethane medium was amended with yeast extract. Alcaligenes sp. resting cells and cell-free extracts were prepared from nitroethane-yeast extract grown cultures and the maximum rate of nitrite synthesis when nitroethane was the substrate was 6.8 nmol min-1 mg cell protein-1, a 10-fold lower rate than that previously noted for pyruvic oxime oxidation. These cell-free extracts were unable to metabolize pyruvic oxime. Resting cells and cell-free extracts prepared from Alcaligenes sp. cells grown in a pyruvic oxime medium were, conversely, incapable of metabolizing nitroethane. Collectively, these results indicate that nitroethane is not an intermediate in the pathway of pyruvic oxime oxidation and that two separate enzyme systems exist in the Alcaligenes sp. for the metabolism of pyruvic oxime and nitroethane.

Protective effect of vitamin E in rats with acute liver injury.

We have previously shown that supplemental vitamin E has a cytoprotective effect in the liver of rats with chronic CCL4-induced liver cirrhosis. In this study, we hypothesized that vitamin E would have a protective effect in acute liver injury induced by D-galactosamine. D-Galactosamine-induced injury has been thought to be due to a synergistic direct toxic effect and presence of intestinal bacteria and/or endotoxins. D-Galactosamine was used to induce acute "hepatitis" (1.5-2.0 g/Kg body weight, ip). Rats were placed on either standard chow or the same chow supplemented with vitamin E (300 mg DL-alpha-tocopherol/Kg diet) and 6 days later were given D-galactosamine. There was significantly improved early (5-day) survival and late (14-day) survival in the vitamin E-supplemented group. The vitamin E beneficial effect was manifested also by decreased liver fat and collagen content and decreased SGPT level. Because bacterial endotoxins have been implicated as playing a role in the pathogenesis of D-galactosamine hepatitis, the same experiment was carried out using germ-free and conventional rats. There was significantly improved survival in both the germ-free and conventional vitamin E-supplemented groups both at 5 and 14 days. There was no significant difference between conventional and germ-free rats with or without vitamin E supplementation. In summary (a) vitamin E improves the early fat and collagen accumulation in the liver, decreases SGPT level, and improves survival in the D-galactosamine experimental model of acute liver injury in both conventional and germ-free rats; and (b) D-galactosamine toxicity is probably not mediated through intestinal bacteria and/or endotoxins.

Determination of hematocrit based on diffusion of an inert molecular probe from agarose gels into whole blood.

Whole blood hematocrit was determined by an approach which depends on the diffusion of an inert probe, to which red blood cells are impermeable, from a small agarose gel into a stirred, much larger blood sample. Blood cells influence the diffusion rate of the probe by, on the average, physically blocking a fraction of the gel surface. The blocking effect increases with the hematocrit. Cyanocobalamin (B-12) was found to be a suitable probe because it did not penetrate, bind to, or lyse blood cells and was not bound by plasma solutes. The loss of B-12 from gels in contact with blood was monitored by determination of the absorbance change at 540 nm of gels which had been quickly rinsed. The visible spectrum of B-12 in agarose gels was identical to the spectrum in water. Beer's Law was obeyed in 1-mm thick agarose gels over a concentration range of 0.1-0.8 mM. Based on the results from 48 blood samples covering the hematocrit range 25-69, a least-squares line was generated with a slope, -3.46 X 10(-3) delta A/hematocrit unit, a Y intercept of 0.295, and a correlation coefficient of 0.971. The precision of the technique was +/- 9.7%. The assay was insensitive to mean corpuscular volume and sample volume as long as the latter was 50-fold larger than the gel volume. The diffusion coefficient for B-12 in 1% agarose gels was found to be 1.4 +/- 0.2 X 10(-6) cm2 sec-1.