Tissue dielectric constant ratios as a method to characterize truncal lymphedema.

Truncal lymphedema is one possible complication of breast cancer treatment. It affects many women and is diagnosed based on symptoms and clinical assessment. Because changes occur late in the process, it is useful to have a quantitative assessment that is applied earlier to detect more subtle changes and quantitively assess treatment progress. Our goal was to describe a possible method to accomplish this via measurements of tissue dielectric constant (TDC). TDC was measured at lateral thorax, anterior forearm, and biceps in 120 women awaiting surgery for breast cancer. Inter-side TDC ratios were defined as values measured on the at-risk (cancer-side) lateral thorax divided by TDC values measured on contralateral thorax, forearm, and biceps. These ratios, designated as thorax-thorax, thorax-forearm, and thorax- biceps were (mean ± SD) 1.017 ± 0.121, 1.138 ± 0.223, and 1.263 ± 0.255 respectively. Corresponding truncal lymphedema thresholds were determined by adding 2.5SD to each mean yielding thresholds of 1.32, 1.70 and 1.90. For these thresholds, 99.4% of patients would have inter-side ratios less than the threshold value. Thus, from assessments in a non-lymphedematous patient-group a set of reference threshold-ratios are now available against which patients surgically treated for breast cancer may be prospectively compared.

Tissue Dielectric Constant (TDC) as an Index of Skin Water in Women With and Without Breast Cancer: Upper Limb Assessment Via a Self-Contained Compact Measurement Device.

Previous work showed tissue dielectric constant (TDC) measurements at 300 MHz useful to evaluate local skin water and then a hand-held compact version provided values similar to the original multi-probe system when assessed in healthy subjects. Our current goals were to use the compact portable device to determine: 1) its utility in assessing agerelated differences between younger healthy women vs. women with breast cancer (BC); 2) upper-arm site differences in women with BC and 3) its utility and limitations of a single measurement vs. averaging triplicate measurements. A total of 84 women were included; 42 were young (24.0 ± 2.4 years) self-described healthy women (group A) and 42 were older (65.5 ± 1.6 years) women with recently diagnosed BC who were awaiting surgery (group B). In both groups TDC values were assessed on the anterior forearm and in group B at the hand, forearm and biceps with all measurements bilateral and in triplicate Results showed the following. 1) Forearm TDC values are similar for younger and older groups with no significant differences (NSD) between groups or between dominant and nondominant sides or inter-arm ratios. 2) Hand TDC values are about 21% greater than forearm and biceps values but inter-arm ratios (at-risk/contralateral) are NSD among sites with values for hand, forearm and biceps of 1.027 ± 0.180, 0.997 ± 0.066 and 1.010 ± 0.075 respectively. 3) Based on limits of agreement analyses, single TDC measurements are adequate for most forearm and biceps evaluations but multiple measurements are likely needed for hand measurements. 4) Theoretical detection thresholds for nilateral lymphedema using a 3SD limit of inter-arm ratios are 1.57, 1.20 and 1.24 for and, forearm and biceps. These ratios indicate likely useful forearm and biceps thresholds but a less useful ratio at the hand due primarily to the large variance in hand TDC values among patients.

Tissue dielectric constant (TDC) as an index of localized arm skin water: differences between measuring probes and genders.

An easily measured, non-invasive, quantitative estimate of local skin tissue water is useful to assess local lymphedema and its change. One method uses skin tissue dielectric constant (TDC) values that at 300 MHz TDC depend on free and bound water within the measurement volume. In practice such measurements have been done with a research-type multi-probe, but recently a hand-held compact-probe has become available that may be more clinically convenient. Because most available published data is based on multiprobe measurements it is important to characterize possible differences between devices that unless known might lead to ambiguous quantitative comparisons between TDC values. Thus, our purpose was to evaluate potential differences in measured TDC values between multi-probe and compact-probe devices with respect to probe effective sampling depth, anatomical site, and gender and also to compare compact-probe TDC values measured on women with and without breast cancer (BC). TDC was measured bilaterally on forearms and biceps of 32 male and 32 female volunteers and on 12 female patients awaiting surgery for breast cancer. Results show that 1) TDC values at 2.5 mm depth were significantly less than at 1.5 mm; 2) Female TDC values were significantly less than male values; 3) TDC values were not different between females with and without BC; and 4) dominant/non-dominant arm TDC ratios were not significantly different for any probe among genders or arm anatomical site. These findings indicate that probe type differences in absolute TDC values are present and should be taken into account when TDC values are compared. However, comparisons based on inter-arm TDC ratios are not statistically different among probes with respect to gender or anatomical location.

Tissue dielectric constant (TDC) measurements as a means of characterizing localized tissue water in arms of women with and without breast cancer treatment related lymphedema.

Quantitative measurements to detect lymphedema early in persons at-risk for breast cancer (BC) treatment-related lymphedema (BCRL) can aid clinical evaluations. Since BCRL may be initially manifest in skin and subcutis, the earliest changes might best be detected via local tissue water (LTW) measurements that are specifically sensitive to such changes. Tissue dielectric constant (TDC) measurements, which are sensitive to skin-to-fat tissue water, may be useful for this purpose. TDC differences between lymphedematous and non-lymphedematous tissue has not been fully characterized. Thus we measured TDC values (2.5 mm depth) in forearms of three groups of women (N = 80/group): 1) healthy with no BC (NOBC), 2) with BC but prior to surgery, and 3) with unilateral lymphedema (LE). TDC values for all arms except LE affected arms were not significantly different ranging between 24.8 ± 3.3 to 26.8 ± 4.9 and were significantly less (p < 0.001) as compared to 42.9 ± 8.2 for LE affected arms. Arm TDC ratios, dominant/non-dominant for NOBC, were 1.001 ± 0.050 and at-risk/ contralateral for BC were 0.998 ± 0.082 with both significantly less (p < 0.001) than LE group affected/control arm ratios (1.663 ± 0.321). These results show that BC per se does not significantly change arm LTW and that the presence of BCRL does not significantly change LTW of non-affected arms. Further, based on 3 standard deviations of measured arm ratios, our data demonstrates that an at-risk arm/contralateral arm TDC ratio of 1.2 and above could be a possible threshold to detect pre-clinical lymphedema. Further prospective measurement trial are needed to confirm this value.

Complications after laryngectomy.

The charts of 100 consecutive patients who underwent laryngectomy at Memorial Hospital were reviewed to assess those factors that contribute to postoperative complications. Laryngectomy was performed for epidermoid carcinoma in 94 patients and for laryngeal incompetence in 6. Total laryngectomy was performed in 48 patients and partial and circumferential pharyngectomies in addition to laryngectomy in 40 and 12 patients, respectively. Significant complications, which delayed discharge, occurred in 13 patients (27 percent) who had simple laryngectomy, including the formation of two fistulas (4 percent). After laryngopharyngectomy, the complication rate was 77 percent (40 of 52 patients) with pharyngocutaneous fistulas in 19 patients (37 percent). The fistula rate of formation was not increased in irradiated patients; however, the duration of time to closure of a pharyngocutaneous fistula, if it occurred, was longer. Planned pharyngostomy or staged deltopectoral flap reconstruction after extended laryngopharyngectomy was associated with excessive morbidity. Newer techniques of reconstruction utilizing flaps or gastric transposition offer the prospect of reduced morbidity after laryngopharyngectomy.

Primary lymphomas of the gastrointestinal tract. Analysis of prognostic factors with emphasis on histological type.

We have analyzed the clinicopathological factors affecting survival in 60 primary gastrointestinal lymphomas seen at Memorial Hospital between 1949 and 1978. Patients with generalized lymphoma (Stages III and IV) at the time of diagnosis and those without follow-up information or adequate histological material were excluded from this study. Lymphomas were classified according to the Lukes-Collins, Kiel, and Rappaport schemes and the patients were staged retrospectively by a modified Ann Arbor system. The patients were treated by surgical resection, radiotherapy, or both. Survival was influenced by histological type (P = 0.0116), stage of the disease (P less than 0.0001), and size of the primary tumor (P = 0.0007). Low-grade lymphoplasmacytoid lymphomas, recognized in 26.6% of the cases, had a low rate of extra-abdominal recurrence; 74% of these patients were alive without evidence of recurrence after a median follow-up of 171 months, or died without evidence of lymphoma with a median survival of 147 months. Centrocytic (Kiel) or cleaved cell (Lukes-Collins) types were seen in 13% and 21%, and high grade (Kiel) or large noncleaved and immunoblastic (Lukes-Collins) in 33.3% and 30% of the cases, respectively. These groups had a high rate of extra-abdominal recurrences, and over 60% of the patients died of lymphoma, with a median survival of 8 for the centroblastic-centrocytic and 7 months for the high-grade tumors. Histological type and clinicopathological staging emerge as useful factors for the identification of patients with high risk of systemic recurrence, probably best treated with chemotherapy in addition to surgery and local radiotherapy.

Primary gastric lymphoma. A review of 50 cases.

The records of 50 patients with localized primary gastric lymphoma were reviewed and clinical and prognostic factors characterized. Pathologic material was reclassified according to Rappaport's, Lukes-Collins, and Lennert's Kiel classifications. Factors with the greatest prognostic significance included initial stage as determined by surgery and pathology, absolute tumor size, degree of penetration through the stomach wall, and histologic grade of the lymphoma. After surgical resection for cure, the overall 5-year disease-free survival was 47%. For stage I disease, this was 78% vs 29% for stage II (P = 0.006). Patients with lymphomas less than 5 cm in diameter had 58% 5-year disease-free survival vs 32% for those with tumors greater than 10 cm (P = 0.06). Full-thickness penetration decreased 5-year survival from 75% to 38% (P = 0.06). Patients with histologically low-grade lymphomas had a better prognosis than those with high-grade lymphomas. The most significant correlation of histology to survival was seen with the Kiel classification with a 5-year survival of 39% for centroblastic polymorphous lymphoma vs 66% for LP immunocytoma. When lymphoma recurred it developed outside the abdomen in a majority of patients. The addition of abdominal radiation therapy to surgical resection made no significant impact on survival for either stage I or II disease.

Primary gastrointestinal lymphoma: a 30-year review.

The authors reviewed all cases of non-Hodgkin's lymphoma primarily involving the gastrointestinal tract treated at Memorial Hospital during the period from 1949-1978. Complete clinical records were available in 104 cases. Slides of original pathology specimens were available in 81 cases. Tumors were classified by Rappaport, Lukes-Collins and modified Kiel classifications. All patients were staged retrospectively, using modified Ann Arbor staging. The primary tumor was in the stomach in 76 patients, in the small bowel in 15 and in the large bowel in 13. The life-table survival for all patients at five years was 44% and for the 81 Stage I and II patients it was 53%. We found a trend toward improved survival for patients treated in the last decade (P = 0.05). Using Cox regression analysis, survival was found to be correlated with stage (P less than 0.0001) and involvement of adjacent structures (P = 0.007). For Stage I patients, resection and radiation therapy were equally effective alone in controlling local tumor even though factors responsible for the selection of either treatment could not be identified. For Stage II patients, resection combined with radiation therapy controlled local disease better than either treatment alone. For Stage II, patient survival was correlated with the pattern of nodal involvement (P less than 0.0001). Neither the choice of treatment (resection, radiation therapy, or resection with radiation therapy; P = 0.17) nor the involvement of resected margins (P = 0.22) affects survival. Among 81 Stage I and II patients, 68% had recurrences outside the primary field of treatment and 60% outside the abdomen. Systemic multiple modality therapy should be considered for patients at high risk for recurrence.

Aspergillus Peritonitis complicating perforated appendicitis in adult acute leukemia.

A 38-year-old male with terminal transferase positive acute lymphoblastic leukemia experienced fever, polymicrobial bacteremia, gastrointestinal bleeding, abdominal pain during induction therapy, and remission. Cecal perforation, Aspergillus peritonitis, and subsequent disseminated aspergillosis were successfully managed with colon resection, drainage, and antibiotic and antifungal therapy. Serologic tests for antibody to Aspergillus were repeatedly negative.

Paraplegia due to posttraumatic pelvic arteriovenous fistula treated by surgery and embolization. Case report.

A case is presented in which a posttraumatic pelvic arteriovenous fistula caused progressive paraplegia because of voluminous shunting into the epidural venous system. Surgical ligation and transcatheter embolization of major and minor arterial feeders decreased shunt flow sufficiently to permit direct embolization of the fistula by an injectable plastic. This combined approach may allow obliteration of unresectable acquired or congenital arteriovenous malformations.

Early lymphatic spread of osteogenic and soft-tissue sarcomas.

Records of 374 patients referred to the National Cancer Institute with a diagnosis of sarcoma over a 24-year period were reviewed to study the incidence of lymph node involvement in this disease. One hundred and thirteen patients had operations involving the draining nodal area and evaluation of these nodes for tumor. Only three patients (2.6%) had evidence of sarcoma metastatic to draining lymph nodes. Prophylactic removal or radiotherapy of draining lymph node areas in most adults with sarcomas does not appear to be worthwhile. A comprehensive analysis of the literature is presented.