Alternative therapy for elderly patients with breast cancer.

Breast cancer treatment has undergone significant changes in concept, concurrent with alterations in our understanding of cancer biology and natural history. Within the last 10 years, oncologists have brought into question the traditional Halstedian concepts of the natural history of breast cancer and its appropriate management. The goal of treatment, once a primary cancer is detected in the breast, is to prevent metastasis and subsequent death of the patient. One hundred forty-two female patients over the age of 65 with histologically confirmed breast cancer were treated at Lankenau Hospital from 1982 to 1990. We treated 32 women over the age of 65 with quadrantectomy and tamoxifen as the sole form of therapy. No radiation, standard chemotherapy, nor axillary dissection was utilized. A cohort of 110 women of similar age, treated for breast cancer with "standard therapy" (total mastectomy or "segmental resection" and radiation with axillary nodal dissection) during the same time period, were also analyzed retrospectively. All segmental resections were followed by standard radiation doses to the ipsilateral breast and draining nodal basins with a local boost. Twenty-nine of 32 patients in the quad + tam group were available for follow-up 1 to 8 years following treatment (mean 52 months). The cumulative overall survival was 67 per cent and disease-free survival 92 per cent. No patient developed local recurrence. Follow-up analysis of the 110 women treated in "standard fashion" was complete in 88 patients 1 to 8 years post-treatment (mean 56 months). Cumulative overall survival was 82 per cent and disease-free survival 83 per cent. Local recurrence was noted in five per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute acalculous cholecystitis following open heart surgery.

We undertook a retrospective study designed to ascertain the frequency of acute acalculous cholecystitis (AAC) following open heart surgery. In the study period 1982-1990, 22 of 6393 patients following open heart surgery were recognized to have developed AAC, an incidence of 0.34%. The majority of patients (16/22) presented within the first postoperative week. Vague right upper quadrant physical findings, nonspecific changes in the liver function chemistries and unexplained sepsis frequently led to radiologic evaluations. Ultrasonography was the most valuable radiologic study, with a diagnosis sensitivity of 82%. Technetium cholescintography can serve as a useful adjunct when interpreted in the context of other clinical findings. Cholecystectomy was performed in 20 patients and cholecystostomy in two. Nine (41%) patients had gangrenous gallbladders with frank perforation in two. A specific preoperative diagnosis was made in 19 patients (86%). Fifteen patients survived for a mortality rate of 32%. In 12 of 15 survivors (80%), the diagnosis of AAC was established and laparotomy performed within 48 hours of first clinical suspicion. Gangrene and perforation were seen in 87% of patients in whom surgery was delayed. AAC is a life-threatening condition especially in critically ill patients. Experience suggests that early diagnosis and operative intervention are the key elements of treatment. Delay of operative management on the grounds of recent cardiac surgery is not justified.

Cutaneous angiosarcoma of the breast after segmental mastectomy and radiation therapy.

Angiosarcoma of the breast is an uncommon entity, and the development of cutaneous angiosarcoma of the breast after segmental mastectomy and irradiation therapy is even less common. We report a case of cutaneous angiosarcoma that developed 4 1/2 years after segmental mastectomy (lumpectomy) with axillary dissection and irradiation therapy for infiltrating ductal carcinoma of the breast.

Diagnostic laparoscopy.

Laparoscopy is a unique procedure which can be used in diagnostic or therapeutic situations involving intra-abdominal pathology. Until recently, open laparotomy has been the preferred method for such evaluations. The following cases indicate the increased sensitivity, specificity, safety, and cost effectiveness of laparoscopy in diagnostic situations.