Role of axillary dissection in mammographically detected breast cancer

The traditional rationale for axillary lymphadenectomy in patients with breast cancer was that the procedure was therapeutic, diagnostic, and needed to determine adjuvant therapy. Recent data have shown that there is little, if any, therapeutic value to this procedure and that the decision to use adjuvant chemotherapy or hormonal therapy may no longer be absolutely contingent on axillary node status. Increasingly, primary tumor factors are being used to establish the aggressiveness of cancers. Therefore, the widespread use of axillary lymphadenectomy especially in small, mammographically detected breast cancers is questioned.

Resection for cure of adenocarcinoma of the head of the pancreas: the greater Hartford experience

BACKGROUND

Nationally, the results of pancreaticoduodenectomy for adenocarcinoma of the pancreas have improved. Therefore, we examined our experience with this operation.

METHODS

A retrospective review of tumor registry data from four greater Hartford, Connecticut, hospitals identified 51 patients who underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas between 1982 and 1992.

RESULTS

The 30-day operative mortality rate for the group was 4%. Life table survival analysis revealed a five-year survival rate of 15% and a median survival of 15 months. Twelve patients had postoperative radiation therapy and chemotherapy. The median survival in this group was 36 months, significantly longer than that of the nonadjuvant therapy group (13 months, P < .02). No difference in operative mortality or ultimate survival was seen between the hospital with the largest experience and the three other hospitals.

CONCLUSIONS

Pancreaticoduodenectomy can be performed safely at hospitals with relatively low pancreaticoduodenectomy volume. Survival rates are longer than in past reviews.

Academic medicine: as threatened as most would have us believe?

All academic health centers (AHCs) are threatened by the complexity of health care reform and by the speed with which it is occurring. We have been forced in all areas of our academic and clinical life to reassess the way in which we have traditionally operated. We must, in fact, do more than reassess. We must change fundamentally. This is true whether one considers medical education, biomedical research, or clinical services. Practically speaking, health care reform forced on us by the business community of America realistically means downsizing unless faculties are willing to change and pursue novel contemporary opportunities. It means less money and the need to do more with what we have. Educationally, we must emphasize the training of generalist physicians. On the research side, it means interdepartmental collaboration around core program project initiatives. It means a sharing of resources (including space) and the need to develop quality relationships with industry and philanthropic organizations. On the clinical side, we must develop a fully integrated, highly competitive, cost-efficient physician/hospital organization, and most AHCs must become part of a larger integrated delivery system to protect not only clinical but academic interests.

Paget's disease of the nipple-areola complex

The histogenesis of Paget's disease has been hotly debated, and only recently has epidermotropic theory become widely accepted. With the evolution of our understanding of breast cancer, it became apparent that the prognosis of Paget's disease was more a reflection of that of the underlying carcinoma, be it intraductal or infiltrating. The standard treatment of Paget's disease remains mastectomy with or without axillary dissection. In this era of breast-conserving surgery, however, there is much evidence to suggest that conservative treatment of Paget's disease of the breast is possible. A breast-conserving algorithm for the treatment of Paget's disease of the breast is proposed. Further refinements or modifications to the algorithm should be made as data from ongoing trials redefine our understanding of breast pathology and treatment.

Evolving strategies for the management of non-palpable breast abnormalities

Increased public and professional awareness has resulted in more women obtaining mammograms. As a result, the surgeon is often called on to diagnose and treat occult breast lesions. The development of new diagnostic modalities has changed the way such breast lesions are approached. Management decisions are made in the context of new pressures applied by the growing managed care imperative and increased mediocolegal exposure. In this review, we establish guidelines for the management of non-palpable breast abnormalities that place the welfare of the patient first.

Surgical residents in the 1990s. Issues and concerns for men and women

OBJECTIVE

To survey the concerns of surgical residents in New England and to determine whether similarities or differences exist based on gender.

DESIGN/SETTING

A survey was distributed to all 21 surgical residency programs. The survey consisted of six demographic questions and 23 items, which the residents coded on a Likert-type scale.

PARTICIPANTS

Surgical residents enrolled in a general surgical residency or specialty residents completing general surgery requirements.

INTERVENTION

Distribution and completion of the survey.

MAIN OUTCOME MEASURE

Prominent concerns among residents during training years and gender differences based on these concerns.

RESULTS

All programs responded. A completed survey was returned by 501 residents (73%), 378 (75%) of whom were male and 123 (25%) of whom were female. On a scale of 1 to 5 (from no concern to major concern), the five most important issues were work hours (mean, 3.4), personal finances (mean, 3.1), quantity and quality of formal education (mean, 3.0 each), and postponement of family plans (mean, 2.9). Six items surveyed were of more concern to women than men; availability of role models, mentors, or both; comfort in expressing emotions at work; initiating and maintaining personal relationships; having children during residency; and postponing family plans.

CONCLUSIONS

Three of the highest-reported concerns for the entire group are issues that could conceivably be controlled by surgical chairpersons and program directors. In contrast, only one of the six concerns that differed for men and women is directly program related. The remaining five issues require changes in societal values for these differences to dissolve.

Reduction of skeletal muscle injury through stress conditioning using the heat-shock response

The heat-shock response refers to specific reversible changes in cellular metabolism that impart a protective effect on individual cells, as well as entire organisms, against subsequent noxious stimuli. Our objective was to quantify skeletal muscle injury following an ischemic event in a rat model by measuring levels of adenosine triphosphate and creatine phosphate. The animals were divided into two experimental groups. Animals in group 1 (n = 15) were subjected to limb ischemia alone, and animals in group 2 (n = 15) were treated with heat-shock conditioning prior to the onset of ischemia. Skeletal muscle specimens also were examined ultrastructurally by electron microscopy. Levels of creatine phosphate were higher in skeletal muscle obtained from animals in group 2. Mean levels of creatine phosphate +/- SEM for groups 1 and 2 were 1.12 +/- 0.06 mumol/gm and 1.95 +/- 0.11 mumol/gm, respectively (p < 0.0001). This represents 18.4 and 31.9 percent of baseline nonischemic levels for groups 1 and 2, respectively (p < 0.0001). Adenosine triphosphate levels were measured in skeletal muscle samples from a subset of animals in each experimental group, group 1 (n = 6) and group 2 (n = 5), and were not significantly different. Electron microscopy demonstrated mitochondrial changes consistent with ischemic injury in group 1, but only nonspecific changes were noted in specimens from group 2. The presence of the primary 72-kDa heat-shock protein (HSP 72) was confirmed only in those animals treated by heat-shock conditioning. We conclude that prior stress conditioning using the heat-shock response confers significant biochemical and ultrastructural protection against ischemic injury in rat skeletal muscle.

Regional deep hypothermia of the spinal cord protects against ischemic injury during thoracic aortic cross-clamping

We tested in pigs the hypothesis that regional deep hypothermia of the spinal cord achieved by cerebrospinal fluid cooling will protect against ischemic injury during thoracic aortic cross-clamping. Eight control animals underwent aortic cross-clamping at the distal aortic arch and just above the diaphragm for 30 minutes. Eight experimental animals had placement of two subarachnoid perfusion catheters through laminectomies at T4 and the lower lumbar region. The subarachnoid space was perfused with normal saline solution at 6 degrees C delivered by gravity infusion, with infusion rates adjusted to maintain cord temperatures at less than 20 degrees C. After 30 minutes of aortic cross-clamping, the infusion was stopped and the cord allowed to warm to body temperature. Hind limb neurologic function was graded by Tarlov's scale. All of the animals in the control group had complete hind limb paraplegia (Tarlov grade 0) postoperatively. Seven of the 8 animals in the experimental group had preservation of hind limb motor function (Tarlov grade 2), and 1 animal had complete hind limb paraplegia (Tarlov grade 0) (p = 0.002, Fisher's exact test). We conclude that regional deep hypothermia of the spinal cord in pigs does provide some protection from ischemic injury during thoracic aortic cross-clamping. Clinically this may be a useful adjunct for prevention of paraplegia during thoracic aortic operations.

Changing role of splenectomy for hematologic disease

In the past decade the development of accurate imaging and the evolution of the medical management of hematologic diseases has led to changes in the indications for splenectomy for these disorders. To assess the impact of these developments, a multi-institutional, retrospective review was undertaken. One hundred fifty-six splenectomies were performed for hematologic disorders between July 1, 1979 and June 30, 1991. Patients were divided into 2 groups: those undergoing splenectomy from 1979-1985 (Period I), and those undergoing splenectomy from 1986-1991 (Period II). Diseases were classified into 3 groups: cytopenic/anemic conditions, symptomatic splenomegaly, and Hodgkin's disease. Data was compared between the two periods using chi-square analysis. More splenectomies were performed for hematologic disorders during Period II than Period I (P < .005). This increase is secondary to a rise in the number of splenectomies performed for cytopenia/anemia during Period II. In contrast, splenectomies for splenomegaly and Hodgkin's disease decreased during Period II (P < .005 and < .05). More Hodgkin's patients were upstaged on the basis of positive laparotomy findings in Period II, compared to Period I (40% versus 10%, P = .01). Surgeons are now performing more splenectomies for cytopenic/anemic diseases, and fewer for splenomegaly and Hodgkin's disease. These results are consistent with recent trends: (1) earlier splenectomy in patients with cytopenia/anemia; (2) earlier medical intervention in infiltrative splenic disorders; and (3) more reliance on radiologic staging in Hodgkin's disease and widespread use of combination chemotherapy, leaving surgical staging for those cases in which treatment would be changed by laparotomy findings.

Preliminary assessment of a scientific curriculum in a surgical residency program

A structured, basic science curriculum was instituted for surgical residents of the University of Connecticut (Farmington) Integrated Residency Program during the 1990-1991 academic year in concordance with American Board of Surgery guidelines. The impact of the new program was measured by comparing performance on monthly basic science examinations, the in-training examination, and "mock" oral examinations for the 1990-1991 academic year with that of the preceding academic year. While monthly examination scores improved for the entire group of residents (67.7 vs 64.6), in-training and oral examination scores did not change significantly. Categorical residents generally demonstrated superior performance and greater improvement than did preliminary residents. Data analysis suggested that the new curriculum was an effective educational device and that university-designed monthly examinations were valid testing instruments, but there was an apparent incongruity between the goals of the curriculum and the American Board of Surgery In-Training Examination.

Intrarectal sonography. A new technique for the assessment of rectal tumors

Preoperative staging of rectal tumors provides a selective therapeutic approach. Twenty-three patients were evaluated with prospective intrarectal sonography. Endosonography identified all 21 rectal lesions. Two patients with previous rectal carcinoma had no evidence of recurrence. Thirteen of 17 patients (76%) with rectal carcinoma were correctly staged by endosonography. A submucosal leiomyosarcoma and pararectal arachnoid cyst were correctly identified. Preoperative assessment of lymph node status was accurate in five of ten patients (50%). Results of preoperative digital rectal examination predicting rectal wall involvement correlated with pathologic findings in 11 of 15 patients (73%). Intrarectal sonography is an important staging technique for preoperative evaluation of rectal wall invasion and guides appropriate surgical intervention.

Survey of residents' attitudes toward reform of work hours

Traditional work schedules of surgical residents have been cited as a factor that negatively influences residency education and the quality of patient care. As an adjunct to the formulation of recommendations for the development of the environment for general surgery training, the New England Association of Program Directors in Surgery set out to sample the attitudes of surgical residents in New England relative to their perceived need to reform work hours. Seventy-two percent of the residents thought there was a need for some level of resident work schedule change. The major variable that correlated with this opinion was the reported amount of sleep that a resident needed before returning to work after a 24-hour shift. The ultimate effect on education, patient care, and fiscal resources of these potentially sensitive changes remains to be determined.

Clinical and pathologic prognostic variables in oropharyngeal squamous cell carcinoma

Eighty-five patients with squamous cell carcinoma of the oropharynx were studied to assess the value of histopathologic parameters related to their survival. The overall survival was 58 percent at 3 years and 51 percent at 5 years. Stepwise logistic regression analysis was used to determine the prognostic value of each of the histopathologic features. The extent of in situ carcinoma and presence of multifocality were positive predictors of survival, and perineural invasion and nodal involvement on clinical examination were negative predictors. None of the other parameters used in this study attained statistical significance. We conclude that the histologic grade traditionally used to predict clinical behavior may not be useful. Clinical stage, particularly nodal status; perineural invasion; and the multifocal or in situ disease, should be considered in pathologic reports to provide better prognostic profile in oropharyngeal carcinoma.

Comparative pharmacokinetics of cefotetan and cefoxitin in patients undergoing hysterectomies and colorectal operations

Forty patients undergoing hysterectomy and 16 patients undergoing colorectal surgery were given intravenous 2 g doses of cefotetan (20 in the hysterectomy group and 8 in the colorectal group) or cefoxitin (20 in the hysterectomy and 8 in the colorectal group) before surgery. Serum samples were obtained simultaneously with tissue samples. Concentrations of each drug in serum and tissue were measured by high-pressure liquid chromatography. In both experiments, the composite drug concentration profile as a function of time in serum was consistent with that observed in nonsurgical patients; that is, a half-life of approximately 3.5 hours and 0.8 hours for cefotetan and cefoxitin, respectively. This also was true of tissue kinetics, in that tissue profiles appeared parallel to, but somewhat lower than, serum. At 20 minutes after administration, the peak myometrium concentration was 158 micrograms/g for cefotetan, and the corresponding serum concentration was 298 micrograms/ml. For cefoxitin, the corresponding values were 66 micrograms/g and 101 micrograms/ml. At 47 minutes, the cefotetan tissue and serum concentrations were 29 micrograms/g and 235 micrograms/ml respectively, and the corresponding values for cefoxitin were 15 micrograms/g and 43 micrograms/ml. Similar relationships were observed with these drugs in colorectal tissue. Although both antibiotics provide good concentrations during the early phase of surgery, cefotetan's concentrations persisted longer, which may be relevant in the prevention of infection in prolonged surgical procedures.

Negative findings on fine-needle aspiration biopsy of solid breast masses: patient management

A series of 245 fine-needle aspirations of solid breast masses has been reviewed. Seven aspirations were reported as unsatisfactory, 178 revealed benign masses, 7 were indeterminate, and 53 revealed malignancy. Fifty-two of 53 masses diagnosed on aspiration as malignant were confirmed by surgical biopsy (98 percent sensitivity). Open biopsy was carried out on 50 of 178 masses reported as negative on needle biopsy and benign masses were revealed in 46 cases (92 percent specificity). The remaining 128 masses with negative findings were observed and follow-up of 101 patients obtained. Cancer did not develop in any of these patients. Careful physical examination and mammography can predict if a breast mass is malignant or benign in 85 to 90 percent of patients. If fine-needle aspiration biopsy is added and performed by physicians and cytopathologists experienced in the technique, additional information is obtained which allows greater diagnostic accuracy and may eliminate many breast biopsies.

Electrocoagulation for intraoral cancer

Electrocoagulation of 58 intraoral lesions (1 to 6.5 cm in diameter) resulted in a three-year absolute disease-free survival rate of 59% (34/58). During the 20-year study, 43 (74%) of the 58 patients were cured. Though an initial 28% local failure rate was observed, 31% (5/16) of these patients were subsequently cured by a second electrocoagulation. Electrocoagulation has distinct advantages over conventional surgery and irradiation. Relatively little tissue beyond the tumor is coagulated. Such tissue sparing allows better postoperative function and cosmesis. The deleterious effects of irradiation, including the serious "dry-mouth" syndrome, are avoided. These treatment results are competitive with those of conventional surgery and irradiation. The limited field treated, the tissue conservation, the minimal morbidity, and the cost-effectiveness should make electrocoagulation a real consideration in treating selected invasive intraoral tumors. Ideally suited for electrocoagulation are those patients whose lesions are small, easily visualized, mobile, and well differentiated.

Quality care and cost-effectiveness. An organized approach to problem solving

The reflexive approach to rising hospital costs and decreased revenue is to balance the budget by curtailing expenses. This places budgetary limitations on personnel, supplies, and equipment and ultimately has an impact on the quality of care. An alternative approach is to modify traditional practice patterns so that quality is preserved and costs are reduced. We reviewed elective class I and II coronary artery bypass graft surgery on a cost basis to identify potential problems. High costs in blood and blood-product usage were identified. An in-depth analysis of practice patterns was conducted, and comparisons were made between data from our hospital and other institutions. Modifications that improved quality and reduced costs were designed. Blood and blood-product usage was reduced from an average of 9.2 U to 3.4 U per case, resulting in an estimated cost avoidance of $111,286 per year. No cost advantage was observed with the use of cell savers, membrane oxygenators, or automated coagulation analysis in these routine short pump run surgeries. Though not cost-effective, the cell saver did allow the salvage of 2 U of blood per case. Mediastinal drainage systems (Sorenson) as well as reeducation regarding the safe, albeit low, hematocrit (no transfusions for hematocrits above 25% [0.25]) were effective in eliminating unnecessary use of potentially dangerous and expensive blood products.

Threatened carotid artery rupture: a complication of radical neck surgery

Carotid artery rupture is an infrequent but highly dangerous postoperative complication of radical head and neck surgery. The principal predisposing factors are radiation therapy, infection, tissue necrosis, vessel exposure, and pharyngeal fistula formation. Actual or threatened carotid artery rupture has been most commonly managed by ligation of the involved vessel. We present a patient who showed signs of impending carotid artery rupture after both irradiation and radical neck surgery. Balloon embolization was employed in preference to traditional carotid artery ligation. The patient's risk factors for carotid artery rupture are analyzed and the application of balloon embolization is discussed.

Cholecystitis secondary to infusion chemotherapy

This report centers on a patient with metastatic colorectal cancer who developed acute and chronic cholecystitis secondary to the infusion of FUDR (fluoro-deoxyuridine) into the hepatic artery. This was documented by sonography, cholescintigraphy, and, ultimately, pathologically on the surgically removed specimen. Undoubtedly, with increasing cumulative treatment days made possible through technological advances in delivery systems, this complication will be seen more frequently. Prophylactic removal of the gallbladder, at the time of pump placement, which does not significantly prolong the operative time nor increase the operative mortality, should be performed to prevent this complication from occurring.

Efficacy of polyglycolic acid mesh sling in keeping the small bowel in the upper abdomen after abdominal surgery: a 12-month study in baboons

The purpose of this study was to determine if a "sling" made of polyglycolic acid (PGA) would be a reliable method of preventing small bowel descent into the pelvis following abdominal surgery. Baboons were used, as they respond to infection and ambulate similarly to humans. Animals had the small bowel mobilized to the upper abdomen and had the PGA "sling" sewn into place. Documentation of small bowel position was evaluated by upper gastrointestinal series over the 12-month study. Small bowel descent into the pelvis was prevented by utilization of the PGA "sling." Animals were sacrificed and autopsied, and sections of small bowel were taken. There was no evidence of mesh, obstruction, sepsis, fistulae, or herniation in animals at autopsy. Small bowel sections were considered normal histologically. Utilization of PGA sling appears to be a safe and reliable method of preventing small bowel descent into the pelvis after abdominal surgery.

Contributions of pathologic margins and Dukes' stage to local recurrence in colorectal carcinoma

Two hundred fourteen patients with colorectal carcinoma who underwent curative resection for biopsy-proved or autopsy-proved local recurrences with a minimum of 2 years follow-up were evaluated. The only predictive variables for anastomotic recurrence were Dukes' stage and tumor margins. There were 49 Dukes' A lesions with no observed recurrences. There were also 83 Dukes' B lesions and 84 Dukes' C lesions with a total of 18 local recurrences in 214 cases or 8.4 percent (of Duke's B lesions or 6 percent and 14 of Dukes' C lesions or 17 percent). When proximal or distal margins were less than 5 cm there were seven total recurrences (three Dukes' B lesions and four Dukes' C lesions). However, when margins were greater than 5 cm, 11 local recurrences were observed (1 Dukes' B and 10 Dukes' C lesions). It appears that margins are not as important in preventing local recurrences of Dukes' A lesions as they are of both Dukes' B and C lesions. Although the numbers are small in this study, it appears that Dukes' B lesions can be satisfactorily resected with a very low incidence of local recurrence if their margins are 5 cm or greater, whereas if the resected margins are less than 5 cm, the incidence of local recurrences increases from 9 percent (1 of 11 lesions) to 43 percent (3 of 7 lesions), or almost a fivefold increase. Therefore, it appears that good surgical technique and adequate margins of greater than 5 cm are very important in reducing local recurrences of Dukes' B lesions. However, when margins are greater than 5 cm, this does not guarantee freedom from local recurrence of Dukes' C lesions. This may merely reflect the difference in the biologic characteristics among Dukes' A, B, and C lesions and the fact that limited resection, particularly in the rectosigmoid region, cannot possibly remove all intralymphatic disease, which is the presumed culprit in locally recurrent Dukes' C lesions.

Tumor-associated metabolism in the rat is a unique physiologic entity

The metabolic responses associated with the tumor-bearing state, as compared to states of sepsis and prolonged starvation, were examined. Tumor-bearing rats manifested significant elevation of triglycerides, significant reduction of glucose and insulin levels, significantly increased plasma skeletal muscle proteolysis-inducing activity, and an unchanged hepatic protein synthetic activity compared to control rats. Prolonged starvation produced an adaptation characterized by significant hypoglycemia and hypoinsulinemia, reduced hepatic protein synthesis, and increased peripheral protolysis compared to controls. Septic animals had glucose, insulin, and lipid levels similar to control animals but had increased hepatic protein synthesis. Each state manifested its own unique metabolic response compared to controls. It appears that the metabolic consequences of cancer in this sarcoma rat model is different than septic and prolonged starvation states.

Hyperlipidemia in tumor-bearing rats

Hyperlipidemia occurs in animals bearing tumors but the mechanism of its development is uncertain. We have measured triacylglycerol clearance and production rate in rats bearing a transplantable sarcoma. The plasma content of very-low-density lipoprotein triacylglycerol was increased in these tumor-bearing rats but our data excluded a primary clearance defect because the rate of triacylglycerol accumulation (mg/min) after Triton injection was equal to or greater than in normal control rats, except in cachectic rats with very large tumors. The fractional clearance of injected radioactive triacylglycerols was less in tumor-bearing rats than in controls, but the turnover (mg/min) was probably not decreased in the tumor-bearing rats because of their expanded plasma pool. Also inconsistent with a decreased turnover was our finding of a greater production of radioactive plasma triacylglycerols after injection of a tracer dose of radioactive free fatty acid, and unchanged production in Triton-treated rats. Therefore, in the fasted state, the hyperlipidemia of the tumor-bearing rats was associated with an unchanged or possibly an increased flux of hepatic triacylglycerols and a primary clearance defect was excluded. After fat-feeding, rats with tumors developed a higher post-prandial hyperlipidemia than control rats. Therefore, the clearance mechanism for the plasma triacylglycerols was close to saturation in the fasted state, and the added influx of exogenous triacylglycerols was removed less efficiently in the tumor-bearing rats.

Intolerance to administered lipids in tumor-bearing animals

Cancer cachexia is a poorly understood phenomenon that contributes to patient intolerance of operations, radiation, and chemotherapy. Reversal of this dysmetabolic state has been attempted by administration of carbohydrates, proteins, and lipids, with little demonstrated clinical benefit. Identification of elevated serum triglycerides (TG) in two tumor-bearing (TB) animal models and recently reported in humans with cancer may be a part of this dysfunctional state. Because lipids makeup energy repletion in patients receiving TPN, the question of how exogenous lipids affect these TB animals needed to be resolved. Intralipid administered by intravenous or gastrointestinal routes raised serum levels in TB animals to greater than 600 mg/dl, even when their baseline TG levels were comparable to nontumor-bearing control animals. The addition of glucose concomitantly with Intralipid failed to prevent TG levels from rising abruptly. Increased lipolytic activity in TB sera was demonstrated and that was not due solely to hypoglycemia or hypoinsulinemia. Administration of lipids to TB animals results in excessively high serum TG levels that appear to be due, in part, to the demonstrated lipolytic activity in TB animal sera.

Small bowel exclusion from the pelvis by a polyglycolic acid mesh sling

Radiation enteritis is seen in patients receiving radiation therapy for various pelvic malignancies. Attempts to prevent this have included various surgical as well as nutritional approaches with little success. The use of a polyglycolic acid mesh sling sewn above the pelvic inlet has prevented small bowel descent into the true pelvis in rats and in humans. The technique has been successful in both with no attendant morbidity during an 11-month follow up. Several patients have received additional doses of radiation therapy that would not have been given if the small bowel were not removed from the area to be irradiated.

Pyogenic sacroiliitis. An absolute indication for computerized tomographic scanning

Pyogenic sacroiliitis (PSI) resulted from direct injection of a foreign substance, pumice, in a 32-year-old woman and was complicated by iliopsoas abscess. The symptoms of PSI are unspecific, and similar complaints may accompany such conditions as herniated disc and arthritis. Results of physical examination may be misleading, especially if movements that stress the sacroiliac joint are omitted. Early roentgenograms are normal and rarely aid in the diagnosis. Scintiscanning with gallium and technetium may indicate an inflammatory pelvic focus. These methods lack specificity, however, and may underestimate the extent of disease. The computerized tomographic (CT) scan was effective in detecting interosseous gas with an associated soft tissue abscess. It also proved invaluable in precisely delineating the location and extent of the lesion in and around the sacroiliac joint, facilitating use of the most expeditious surgical approach. Through follow-up CT studies the course and end results of therapy can be objectively determined.

The prognostic significance of preoperative carcinoembryonic antigen levels in colorectal cancer. Results from NSABP (National Surgical Adjuvant Breast and Bowel Project) clinical trials

This analysis explores the prognostic significance of preoperative carcinoembryonic antigen (CEA) levels in patients with colorectal cancer. The data were derived from 945 patients entered into two randomized prospective clinical trials of the National Surgical Adjuvant Breast and Bowel Project. A strong correlation was evident between preoperative CEA level and Dukes class. The mean CEA progressively increased with each Dukes category and the mean value for each of the four classes was significantly different. This relationship was prevalent whether the data were analyzed for all colorectal lesions regardless of location or specifically for right-sided colon tumors. The prognostic function of preoperative CEA level was independent of the number of positive histologic nodes. Preoperative CEA level correlated with the degree of lumen encirclement by tumor. Tumors that did not encircle more than one half the lumen were associated with significantly lower preoperative CEA levels than those that did. The presence or absence of lumen obstruction was unrelated to the preoperative CEA level. The relative risk of developing a treatment failure was associated with preoperative CEA, in both Dukes B and C patients, demonstrating that the prognostic significance of preoperative CEA was independent of Dukes class.

Non-spore-forming clostridial bacteremia

The significance of the non-spore-forming clostridium as a blood-borne pathogen has been underemphasized. Over a 7-year period, these bacteria were cultured 40 times in 30 patients. Overall mortality rate for non-spore-forming clostridial bacteremia was 39%. Patients with polymicrobial infections had a 58% mortality rate, while those with only clostridium in their blood had a mortality of 23%. Mortality increased as the number of positive cultures. Patients who were clinically septic at the time of their cultures fared poorly. Advanced age and underlying malignant disease were associated with increased mortality. Patients who have positive blood cultures for non-spore-forming clostridium are at a significant risk and should be treated aggressively.

Radiation-associated impotence. A clinical study of its mechanism

External beam pelvic irradiation in men is frequently complicated by erectile dysfunction. We tested the erectile function in 23 patients (mean age, 65 years) who received radiation therapy for prostate cancer. Fifteen patients experienced changes in erectile potency following radiotherapy. Neurological, endocrine, and vascular testing revealed abnormalities in 0, 5, and 15 of these patients, respectively. In two, arteriography revealed bilateral occlusive disease in the distal internal pudendal and penile arteries overlying the pelvic radiation field. A significant difference with cigarette smoking was found among the 15 patients whose erectile capacity decreased and the four patients whose capacity remained unchanged. Vasculogenic impotence is the most consistent organic erectile abnormality in RAI.

Superficial lymph node infarction

Superficial lymph node necrosis is an unusual pathologic diagnosis encountered in clinical practice. When seen it is usually indicative of involvement of the affected lymph nodes with either metastatic cancer or lymphoma. Occasionally it has been associated with hypersensitivity phenomena with arteriolar involvement. The underlying etiology in all of these instances is extensive occlusion of the rich vascular supply to the node. Rarely cases are seen where no clear-cut etiology can be found. Ten such cases have been reported in the medical literature including the case published in this report. Its occurrence, however, may be more common than previously recognized. Preoperatively it is usually not possible to distinguish this entity from the other diagnoses for which it is generally mistaken. These other diagnoses most commonly include femoral hernia and mass in the axillary tail of the breast. The patient reported here is unusual in regard to the size of the lesion encountered. In other published reports very few lymph nodes were involved. In this case extensive involvement of a large mass of nodes was noted. Once the diagnosis is made limited work-up as well as further close observation is important since it may herald the occurrence of a lymphoproliferative disorder.

Metastatic malignant disease of unknown origin

The charts of 106 patients with metastasis from an unknown primary cancer were reviewed to formulate a more appropriate investigative strategy than is presently employed. The spinal column was the most common site for initial presentation of metastatic disease (26.5 percent). The primary tumor was identified before death in 31.3 percent of patients and after death in 6.6 percent. Lung cancer was found in 40 percent of patients with identified primary tumors. Diagnostic studies directed at specific symptoms had a significantly greater yield. Electroencephalograms, gallium scans, thyroid scans, and mammograms were not useful as screening studies. Conversely, bone scans were positive in 46.5 percent of asymptomatic patients and in 88 percent of symptomatic patients. Chest roentgenograms were suggestive of malignant tumors in 43.6 percent of patients. Results of liver scans were predictable on the basis of changes in the alkaline phosphatase level and clinical liver examination. History and physical examination should clearly document the stage of disease, evaluate possible primary sites, and rule out impending acute complications. Chest roentgenograms and bone scans should be obtained early and open biopsy of accessible lesions scheduled promptly. Efforts should be directed at ruling out the more treatable malignant tumors. Further work-up is then indicated only by the development of specific symptomatology. Since median patient survival after initial presentation is only 6.6 months, prolonged hospitalization for numerous nonproductive diagnostic tests seems inappropriate.

Serological detection of common human melanoma membrane antigens by microcomplement fixation and immunofluorescence

An antiserum to human melanoma antigens was obtained from a melanoma patient after immunization with autologous irradiated cultured melanoma cells and bacillus Calmette-Guerin. Using the microcomplement fixation assay, the antiserum, at a titer of 1/1,800, was noted to bind strongly with 7 of 10 allogeneic cultured human melanoma cells lines. However, using the indirect immunofluorescence test and serum at a much lower titer (1/8), only 3 of the 10 melanoma cell lines were positive. Using both microcomplement fixation and indirect immunofluorescence, no significant reactivity was noted in several nonmelanoma cell lines including Hela, human lung adenocarcinoma, human prostatic carcinoma, WI-38 and VA-13 cell lines. These data suggest that common melanoma membrane antigens exist on 7 of 10 cultured human melanoma cell lines as tested by microcomplement fixation and that this assay is more sensitive than immunofluorescence. These common melanoma membrane antigens may eventually be extracted, purified and used for specific immunodiagnosis and immunotherapy.

In vivo delayed hypersensitivity reactions to partially purified human melanoma antigens

Sera from patients receiving autologous cell immunization were shown to contain antibody specific for melanoma cells by immunofluorescence, microcomplement fixation, and mixed hemadsorption. These hyperimmune specific sera were used to define antigens shed into tissue culture media from human malignant melanoma cells. When supernatants from cultured melanoma cells were passed over a Sephadex G-200 column, melanoma antigens were found in Peak 2. The active fraction was further purified by carboxymethylcellulose ion exchanger and found in the 0.4 M NaCl gradient. This fraction has been tested in four immunized patients and in one nonimmunized melanoma patient. All five patients developed lymphocytic vasculitis compatible with delayed hypersensitivity reaction. These antigens should be of benefit in studying delayed hypersensitivity in melanoma patients and as potential agents for specific immunotherapy.

Leptomeningeal spread of breast cancer: report of case and review of the literature

Leptomeningeal metastasis--so-called "meningeal carcinomatosis"--of breast carcinoma has become a problem of some magnitude in recent years, in part a result of the increasing use of combination chemotherapy in the treatment of this disease. Early clinical diagnosis, based on the recognition of multifocal neurologic dysfunction, and aggressive therapy combining irradiation to severely symptomatic sites with intrathecal chemotherapy are considered primordial in order to improve the poor prognosis of the untreated lesion. This is especially true in view of the fact that meningeal metastasis often occurs as the sole site of recurrence in an otherwise asymptomatic patient. Hence, relief of neurologic symptoms can provide meaningful palliation and an occasional long-term survivor. If meningeal metastasis continues to increase in breast cancer patients, prophylactic CNS treatment may become a consideration.

Electrocoagulation for skin cancer: an old oncologic tool revisited

Two-hundred-sixty-two squamous cell and basal cell carcinomas were treated by electrocoagulation over a six-year period. Eighty-four percent of these lesions were basal cell carcinomas. The overall recurrence rate was 3% in a personal 2--9-year follow-up. Those lesions measuring 2--5 cm had a 4% recurrence rate. All operations were done on an ambulatory basis. One-third of the patients were 70 years of age or older. This method has been found to be effective in the treatment of postradiation recurrences of skin cancer. Up to now such recurrences have defied attempts at cure. The technique is simple, safe, convenient, economical, and highly effective. It is believed that electrocoagulation and curettage should be considered the ideal therapy for those skin cancers in all locations in which surgical excision and primary closure cannot be done without plastic surgical intervention.

Antibody-induced movement of common melanoma membrane antigens on the surface of unfixed human melanoma cells

Antisera to common human melanoma antigens were obtained from melanoma patients receiving autologous immunization with their own irradiated cultured melanoma cells and Bacillus Calmette-Guérin. The antibody thus derived was used to detect common antigens on the plasma membrane of three different human melanoma cell lines by membrane immunofluorescence. The antigen-antibody complexes on the surface of melanoma cells would move to a pole (capping) and would subsequently be extruded into the extracellular milieu at room temperature. Approximately 25 to 30% of viable cells were positive by immunofluorescence. However, when the cells were fixed with methanol, 60 to 70% of cells demonstrated membrane binding. Capping was inhibited at 0 degrees or when the cells were pretreated with vinblastine sulfate. It can be concluded that common tumor antigens exist on the surface of viable human melanoma cells and that the redistribution of antigen-antibody complexes is an active process. The extrusion of antigen-antibody complexes in vitro may represent a mechanism of antigenic modulation in vivo and could indicate a basic method of tumor survival since presumably the antigen-denuded cell is viable and capable of replication but not of recognition by subsequent effector immune events.

Effect of different fixatives on the localization of human melanoma antigens by immunofluorescence

This study was designed to study the effect of different fixatives on melanoma antigens by immunofluorescence. Two postautoimmune antimelanoma sera were tested on two human malignant melanoma cell lines fixed with different fixatives by indirect immunofluorescence. Ethanol, methanol, formalin, trichloroacetic acid and acetone gave sharp membrane fluorescence. Minimal to moderate cytoplasmic fluorescence was seen with acetone but none with the others. Formalin gave the highest membrane fluorescent antibody titers at 1/512. Isopentane and isooctane yielded bright cytoplasmic fluorescence. Weak diffuse cytoplasmic fluorescence was seen with glutaraldehyde. Fluorescence was completely abrogated by paraformaldehyde. No fluorescence was seen with four nonimmunized melanoma sera and phosphate-buffered saline when used as controls. It can be concluded that different fluorescent patterns were seen on melanoma cells when different fixatives were used.