Abstract P4-02-05: Predictors of MRI detection of occult lesions in newly diagnosed breast cancer

BACKGROUND: The appropriate use of preoperative magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains a topic of debate. We aimed to determine the usefulness of MRI in the detection of occult multicentric, multifocal and contralateral lesions not seen by ultrasound or mammography.

METHODS: We performed a retrospective analysis of consecutive patients who underwent preoperative MRI for newly diagnosed biopsy-proven stage 0-III breast cancer who were treated surgically from January 2006-March 2013. All newly diagnosed breast cancer patients at our two affiliated institutions were evaluated with pre-operative MRI. Patients who received neoadjuvant systemic therapy or surgery at an outside institution were excluded from our study. Demographic, radiographic and pathologic data points including age, race, body mass index (BMI), lesion size, mammographic density, biopsy histology, and biomarkers were assessed for each patient with respect to the findings of multifocality, multicentricity, and the presence of contralateral lesions on all three imaging modalities. We performed univariate analysis associating factors separately in each of three models with multicentric, multifocal and contralateral disease on surgical pathology followed by multivariable analysis using logistic regression to calculate odds ratios.

RESULTS: Of 857 patients undergoing breast MRI within this time period, 770 patients were identified who met inclusion criteria. All patients underwent diagnostic mammogram and ultrasound followed by MRI. The patient population was 44.2% Hispanic, reflective of the population of our two institutions. Mean age was 54.7 years. MRI identified 86 patients with biopsy-proven multicentricity compared to 66 on conventional imaging. MRI identified 170 patients with biopsy-proven multifocality compared to 132 on conventional imaging. Finally, MRI identified 24 patients with biopsy-proven contralateral cancers compared to 7 on conventional imaging. Biopsy histology of invasive lobular carcinoma was predictive of the presence of multifocality on MRI (p=0.038, OR=1.95, 95% CI 1.09-3.48). Mammographic density was found to be a predictor of multicentricity (p=0.015, OR=2.22, 95% CI 1.13-3.33). Lesion size trended towards statistical significance on multivariate analysis of the multicentric lesions (p=0.057, OR=1.88, 95% CI 1.00-3.51). For contralateral cancers seen on MRI the presence of invasive lobular carcinoma on biopsy (p=0.027, OR=4.83, 95% CI 1.25-16.21) was predictive of finding a contralateral cancer.

CONCLUSIONS: Predictive factors including breast density, biopsy histology, and lesion size should be taken into account as clinical predictors of utility of pre-operative breast MRI. This data is being used to construct nomograms to predict multicentric, multifocal and contralateral disease to aid clinicians in evaluating the potential clinical utility of preoperative breast MRI.

Citation Format: Wecsler JS, Raghavendra A, Mack WJ, Tripathy D, Yamashita M, Sheth P, Hovanessian-Larsen L, Sener SF, Russell CA, MacDonald H, Lang JE. Predictors of MRI detection of occult lesions in newly diagnosed breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-05.

P3-07-32: The Role of Axillary Ultrasound in the Detection of Metastases from Primary Breast Cancers

Background: The value of ultrasound (US) in the preoperative evaluation of axillary nodes has yet to be completely clarified. Preliminary experience with this technique in our institution was examined.

Methods: Patients with a radiographic or palpable abnormality of the breast had simultaneous breast and axillary US. The exams were performed by dedicated breast radiologists using a 12 MHz linear array transducer (HDI 5000: Philips Ultrasound). Results were reviewed for all patients with invasive cancers who were cN0 and had definitive surgical procedures between June 2006 and May 2008. Criteria for abnormal lymph nodes were loss of reniform shape, focal or diffuse cortical thickening, or eccentric/replaced fatty hilum. US-guided biopsies were done using a 16g spring-loaded core biopsy device (16g MD TECH SuperCore). Patients with positive axillary node biopsies bypassed sentinel lymph node biopsy (SLNB) and had axillary dissection, whereas those with sonographically normal nodes or benign/non-diagnostic biopsy results had SLNB at the time of definitive surgery.

Results: Of 128 patients diagnosed with invasive cancer, 23 (18%) had abnormal axillary US at the time of initial diagnosis. Biopsies were performed in 18 of the 23, of which 12 (67%) were malignant and 6 (33%) were benign. Ultrasounds were negative in 105 (82%) patients. SLNB was done in 110 patients: 103 with negative US; 4 patients with abnormal US but negative axillary biopsies; 2 patients with abnormal US but no core biopsies; and 1 patient with a positive US biopsy. SLNB was negative in 91 (83%) patients and positive in 19 (17%). The node-positive status was N1a in 14 patients and N1mic in 5. Axillary dissection was done in 32 (25%) of 128 patients, comprised of 11 patients with US-guided positive biopsies, 12 with positive sentinel nodes, 2 with US-guided negative biopsies, 2 with negative ultrasounds, 3 with unbiospied abnormal ultrasounds, and 2 with a false-negative SLNB. For determining axillary metastases with US, sensitivity was 16/31 (52%), specificity was 90/97 (93%), positive predictive value was 16/23 (69%), and negative predictive value was 90/105 (86%).

Conclusions: US examination was a valuable method of evaluating the axilla in newly diagnosed breast cancers. Of 32 patients having an axillary dissection, abnormal US eliminated the need for SLNB in 17 (53%). Patients with US-guided positive nodes were submitted to axillary dissection without SLNB. Therefore, we were unable to determine how often US identified an abnormal non-sentinel node, thus upstaging the axilla relative to SLNB alone. This question should be the topic of further clinical study.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-32.

P3-14-21: Neoadjuvant Therapy Response, Subtype and BRCA Status in an Underserved Population

Background

Preoperative (neoadjuvant) chemotherapy is typically used for larger operable breast cancer cases, and the degree of pathological response correlates with long term outcome. Therapeutic response also depends on biological and molecular subtype and is increasingly studied in the research setting to identify prognostic biomarkers and potential therapeutic targets. Little is known about the interactions of neoadjuvant response with biomarker subtypes and genetic predisposition in underserved and minority populations.

Methods: IRB approval was obtained to capture demographic, clinicopathological and genetic testing data on patients diagnosed with invasive breast cancer and treated with preoperative chemotherapy and definitive surgery between 2005 and 2010 at Los Angeles County Medical Center, which serves a primarily Hispanic and indigent population. Treatment followed NCCN guidelines with the exception that not all patients with HER2+ disease received trastuzumab. Genetic counseling and testing has been available at this center since 2007. Pathological complete response (pCR) was defined as no residual invasive disease in breast or nodes. Chi-square or Fisher's Exact test was used to examine associations between pCR and clinical factors, and logistic regression analyses were applied to assess each variable's contribution to pCR.

Results: Among 104 patients, of whom 79% were Hispanic, the overall pCR rate was 27%. Significantly higher pCR rates were seen in age ≥50, clinical N0, HER2+, triple negative, and lumpectomy cases. No differences in pCR rate was seen in Hispanics vs. others, Grade III vs. I and II or in the 9 BRCA mutations carriers among 45 tested compared to no mutation or those not tested. Of the 43 patients with HER2+ disease, the pCR rate was higher in the 32 patients who received trastuzumab (pCR 50.0 vs. 27.3%). Subset pCR rates and odds ratios (OR) of achieving pCR are shown below:

Lymphedema after sentinel lymphadenectomy for breast carcinoma

BACKGROUND

Initial studies of sentinel lymphadenectomy for patients with breast carcinoma confirmed that the status of the sentinel lymph nodes was an accurate predictor of the presence of metastatic disease in the axillary lymph nodes. Sentinel lymphadenectomy, as an axillary staging procedure, has risks of morbidity that have yet to be defined.

METHODS

Patients were enrolled in a two-phase protocol that included concurrent data collection of patient characteristics and treatment variables. During the first (validation) phase, 72 patients underwent sentinel lymph node excision followed by a level I-II axillary dissection. After the technique had been established, the second phase commenced, during which only patients with positive sentinel lymph nodes underwent an axillary dissection.

RESULTS

During the second phase, lymphedema was identified in 9 of 303 patients (3.0%) who underwent sentinel lymphadenectomy alone and in 20 of 117 patients (17.1%) who underwent sentinel lymphadenectomy combined with axillary dissection (P < 0.0001). Of 303 patients who underwent sentinel lymphadenectomy alone, 8 of 155 patients (5.1%) with tumors located in the upper outer quadrant and 1 of 148 patients (0.7%) with tumors in other locations developed lymphedema (P = 0.012).

CONCLUSIONS

The risk of developing lymphedema after undergoing sentinel lymphadenectomy was measurable but significantly lower than after undergoing axillary dissection. Tumor location in the upper outer quadrant and postoperative trauma and/or infection were identifiable risk factors for lymphedema.

The spectrum of vascular lesions in the mammary skin, including angiosarcoma, after breast conservation treatment for breast cancer

BACKGROUND

With the general acceptance of lumpectomy, axillary staging, and radiotherapy as local treatment for infiltrating breast cancer, an appreciation is evolving for the spectrum of vascular lesions that occur in the mammary skin after this treatment. Most of these lesions develop within the prior radiation field after breast conservation treatment.

STUDY DESIGN

A retrospective chart and slide review was conducted, consisting of five patients with cutaneous vascular lesions after breast conservation treatment for infiltrating breast cancer.

RESULTS

The latent time interval from definitive treatment of breast cancer to the clinical recognition of vascular lesions ranged from 5 to 11 years. Two patients did not have either arm or breast edema, two patients had breast edema, and the fifth patient had arm edema. Lesions arising in the irradiated mammary skin included extensive lymphangiectasia (one), atypical vascular lesions (two), and cutaneous angiosarcoma (four).

CONCLUSIONS

Atypical vascular lesions at the skin margins of mastectomy may be predictive of recurrence after resection of angiosarcoma. Excision of skin from the entire radiation field may be necessary to secure local control of the chest wall in patients with cutaneous angiosarcoma after therapeutic breast radiotherapy.

Spectrum of mammographically detected breast cancers

Mammographic screening of women at both ends of the age spectrum presents a number of challenges. The purpose of this study was to characterize experience with mammographic detection of breast cancer. The two goals were 1) to establish the cancer detection rate of screening mammography and 2) to compare the tumor size of cancers found by mammography, physical examination, or both modalities. From January 1994 through June 1997, data on 609 consecutive female primary breast cancer patients were collected concurrent with definitive surgical therapy. The method of detection was determined by the surgeon, after reviewing mammogram and physical examination. Screening ultrasound was not used. For the 184 patients under 50 years of age, 53 (29%) cancers were detected by mammography only and 48 (26%) by physical examination only. Women under 50 years of age had fewer cancers detected by mammography only (P < 0.001) and more cancers detected by physical examination only (P = 0.0014) than those over 50. With increasing age, the proportion of women with ductal carcinoma in situ decreased (P = 0.004), and the proportion with T1c or T2 tumors increased (P = 0.006). We conclude that 1) when examining women under 50 years of age, the surgeon must be clearly focused on the double-edged sword of screening mammography in this age group, and 2) community cancer programs should encourage annual screening of women over 40 years of age but focus on those over 70, without an arbitrary upper age limit.

Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985-1995, using the National Cancer Database

BACKGROUND

The National Cancer Database is an electronic registry system sponsored jointly by the American College of Surgeons Commission on Cancer and the American Cancer Society. Patients diagnosed with pancreatic adenocarcinoma from 1985 to 1995 were analyzed for trends in stage of disease, treatment patterns, and outcomes.

STUDY DESIGN

Seven annual requests for data were issued by the National Cancer Database from 1989 through 1995. Data on 100,313 patients were voluntarily submitted using a standardized reporting format.

RESULTS

The anatomic site distribution was: head, 78%; body, 11%; and tail, 11%. The ratios of limited to advanced disease (Stage I/Stage IV) were 0.70 for tumors in the head, 0.24 for body tumors, and 0.10 for tail tumors. Of all patients, 83% did not have a surgical procedure and 58% did not have cancer-directed treatment. Resection was done for 9,044 (9%) patients, including 22% of those with Stage I disease. The overall 5-year survival rate was 23.4% for patients who had pancreatectomy, compared with 5.2% for those who had no cancer-directed treatment.

CONCLUSIONS

Overall survival rates for pancreatic cancer have not changed in 2 decades. A small minority of patients presented with limited, resectable disease, but the best survival rates per stage were achieved after surgical resection. Five-year survival rates after resection reported herein corroborated the improved survival rates of more recent large, single institution studies.

Sentinel lymphadenectomy for breast cancer: experience with 180 consecutive patients: efficacy of filtered technetium 99m sulphur colloid with overnight migration time

BACKGROUND

Axillary node status remains the most important prognostic indicator of survival in breast cancer patients. Only 25% to 35% of patients having standard level I/II axillary dissection have involved nodes, yet all accept the potential for morbidity after the operation. This study was conducted to assess whether status of the sentinel node(s) was an accurate predictor of the presence of metastatic disease in axillary or internal mammary nodes.

STUDY DESIGN

In 180 patients, technetium 99m sulphur colloid was injected in a 4-quadrant peritumoral distribution. During the first phase of the study, 72 patients had sentinel node excision followed by a level I/II axillary dissection. During the second phase of the study, 108 patients had sentinel node excision and only those with positive nodes had completion axillary dissection. Nodes were examined after formalin fixation by taking 10 sections at 20-microm intervals and staining with hematoxylin-eosin.

RESULTS

Sentinel nodes were found in 162 (90%) of 180 patients. The mean number of sentinel nodes examined was 3.1. Of the 162 patients with successful lymphatic mapping, positive sentinel nodes were found in 44 (27%). In 23 (66%) of 35 patients with positive sentinel nodes who had a completion level I/II axillary dissection, the sentinel nodes were the only positive nodes. The concurrent negative predictive value was 4% in the first 72 patients who had completion axillary dissection after sentinel node excision, and 2% for the entire series. With evolution of technique, identification of sentinel nodes with radiolabeled colloid was successful in 97% of the last 100 patients.

CONCLUSIONS

Because the concurrent negative predictive value was low, sentinel node excision appeared to accurately identify node status, potentially avoiding the need for standard level I/II axillary dissection in sentinel node-negative patients.

Estrogen replacement therapy and breast cancer: analysis of age of onset and tumor characteristics

BACKGROUND

The use of exogenous estrogen has been scrutinized as a risk factor for breast cancer formation. This prospective study addresses the relationship between the use of estrogen replacement therapy and the age of onset of breast cancer. In addition, an analysis of differences in pathological features of breast cancer between estrogen users and non-estrogen-users was evaluated.

METHODS

A total of 425 women (age, > or = 50 years) were evaluated during a 4-year period (1994-1997). Data, including the age at diagnosis, method of detection, family history, use of estrogen therapy, and tumor ploidy, S-phase fraction, histological category, estrogen receptor positivity, and grade, were prospectively collected. Data from a control group of 657 women without a diagnosis of breast cancer were obtained from the Evanston Northwestern division of the Women's Health Initiative. Significant associations between the use of estrogen and pathological parameters were determined using the chi2 test and t-test (P < .05).

RESULTS

At the time of breast cancer diagnosis, 140 patients were currently receiving estrogen and 202 patients had no history of estrogen use. Eighty-three patients were excluded from analysis (76 patients had a history of previous but not current use of estrogen therapy, four women used only progesterone, and three patients provided incomplete information). There was no difference between patients with breast cancer using estrogen at the time of diagnosis and those with no history of estrogen use with respect to tumor size, age of menopause, family history, mammographic sensitivity, axillary lymph node status, and histological features. Women using estrogen at the time of diagnosis were younger at the time of breast cancer diagnosis, by an average of 5.1 years (61.3 years vs. 66.4 years, P < .001). Women without a history of breast cancer who were receiving estrogen therapy were an average of 2.4 years younger (63.3 years vs. 65.7 years, P < .001) than women without a history of breast cancer who were not receiving estrogen therapy. Patients with breast cancer receiving estrogen also tended to have more grade II tumors (45.9% vs. 36.5%, P = .045) and fewer grade III tumors (25.6% vs. 37.0%, P = .015), compared with women not receiving estrogen therapy at the time of their diagnoses. Estrogen receptor positivity was noted to be more frequent for estrogen users presenting with lobular carcinoma (85% vs. 76%, P = .042) and less frequent for estrogen users presenting with ductal carcinoma (72% vs. 85%, P = .003).

CONCLUSIONS

A significantly earlier age of diagnosis for women receiving estrogen therapy suggests that exogenous estrogen may accelerate the pathogenesis of postmenopausal breast cancer. Estrogen therapy may also play a role in altering the grade and estrogen receptor positivity for certain histological types of breast cancer.

Prognostic significance of occult lymph node metastases in node-negative breast cancer

BACKGROUND

Lymph node status, established by a single hematoxylin and eosin (H&E) section from each node, remains an important prognostic indicator in patients with breast cancer, but used alone it is insufficient to identify patients who will develop metastatic disease. This study was conducted to assess the significance of detecting occult metastases in 86 patients with breast cancer originally reported to be histologically node negative. None of the patients received adjuvant systemic therapy.

METHODS

Five additional levels from formalin-fixed, paraffin-embedded nodes were examined at 150-microns intervals with H&E staining and a cocktail of antikeratin antibodies (AE1/AE3) recognizing low molecular weight acidic keratins.

RESULTS

Nodes from 11 (12.8%) of 86 patients contained occult metastases. All metastases identified by cytokeratin antibody were also detected in H&E-stained sections. With median follow-up of 80 months, distant metastases occurred in five of 11 occult node-positive patients (45%) and 13 of 75 patients whose nodes were negative on review (17%). Median time to recurrence was 89 months for occult node-positive patients and not yet reached for node-negative patients (p = 0.048). The disease-specific 5-year survival rate was 90% for occult node-positive patients and 95% for node-negative patients.

CONCLUSIONS

The presence of occult metastases shortened the disease-free interval and suggested that more diligent axillary staging would more accurately identify patients who would benefit from systemic adjuvant treatment.

Breast cancer in older women: screening and selection of locoregional therapy

As the proportion of the population older than 65 years increases during the next several decades, breast cancer will be a more substantial health problem for older women. Screening mammography detects cancers and reduces mortality from breast cancer in older women. There does not appear to be an inherent reason to impose an upper age limit for breast cancer screening. Older women with breast cancer who are selected for therapy on the basis of severity of comorbidity rather than chronological age can be safely treated using standard surgical and radiation procedures. The elective addition of axillary radiation to breast radiation after lumpectomy appears to lower risk of regional relapse vs. the untreated axilla, avoids the morbidity of axillary dissection, and provides the best local control after breast conservation surgery.

Hepatic and vena cava resection using cardiopulmonary bypass with hypothermic circulatory arrest

When large hepatic or retroperitoneal tumors encroach upon hepatic veins or vena cava and make conventional resection hazardous, the most commonly used method of hepatic resection or vena cava reconstruction includes hepatic vascular exclusion, at times with venovenous bypass or aortic occlusion. These techniques result in warm liver ischemia, and may be accompanied by significant systemic hypotension, despite aggressive central venous preloading. Hepatic lobe (two patients) and retroperitoneal sarcoma (one patient) resections were done in a cold, bloodless field without significant complications. Standard cardiopulmonary bypass techniques with heparin and cardioplegia were used. Systemic circulatory arrest was done at 15 degrees C with isolated retrograde perfusion of the brain through the jugular veins. Hepatic vein and vena cava reconstructions were performed with arrest times of between 30 and 78 minutes. Blood loss was gradual and easily controlled, occurring during the rewarming phase when clot formation was inhibited by cold and heparin.

Cystic neoplasms of the pancreas. A clinicopathologic study, including DNA flow cytometry

OBJECTIVE

To review the classification, clinical behavior, and appropriate therapy for cystic neoplasms of the pancreas. We examined patient demographics, clinical parameters, preoperative imaging modalities, histologic findings, and tumor DNA content to determine which best predict outcome.

DESIGN

Case series and survey of pathologic specimens.

SETTING

Tertiary care center.

PATIENTS

Twenty-two patients with cystic neoplasms of the pancreas treated at affiliates of Northwestern University Medical School, Chicago, Ill.

MAIN OUTCOME MEASURES

Predictive value of preoperative testing, tumor DNA content, patient survival.

RESULTS

In 20 patients undergoing computed tomographic scan, the tumor was visualized in every case. All other imaging studies evaluated were less likely to demonstrate the lesion. Eight of 10 patients with serous cystadenomas were alive with no evidence of disease at the time of this report; one patient was alive with local recurrence, and a second patient had died of unrelated causes. All patients with mucinous cystadenomas were alive with no evidence of disease. Three of seven patients with cystadenocarcinomas had aneuploid, high S-phase tumors, and one had a diploid, high S-phase tumor; all four died (mean survival, 4.8 months). Two patients with cystadenocarcinomas had diploid, low S-phase tumors; both were long-term survivors but died of their disease at 8.6 and 9.3 years.

CONCLUSIONS

(1) Computed tomographic scan is the most valuable diagnostic imaging study for preoperative evaluation of these patients. (2) Precise preoperative determination of tumor type is not possible. (3) DNA flow cytometry may help identify patients with aggressive tumors who may benefit from adjuvant chemoradiation.

Renal cell carcinoma: tumor size, stage and survival. Members of the Cancer Incidence and End Results Committee

In an attempt to define the relationship among tumor size, stage and survival, the Cancer Incidence and End Results Committee of the American Cancer Society, Illinois Division, Inc. reviewed the records of 2,473 patients with a histological diagnosis of renal cell carcinoma. Tumor size was related to stage and survival. Larger tumors were generally associated with an increased stage (p < or = 0.0005) as well as poorer survival (p < or = 0.005). For Robson stages II, III and IV, tumor size may contribute additional prognostic information for patient survival.

Cancer of the male breast presenting as an axillary mass

The authors describe a 55-year-old man with an axillary mass. Physical examination of the breast was normal, and the patient had not risk factors for cancer of the male breast. A workup for other possible cancers was normal. Excisional biopsy of the mass revealed metastatic adenocarcinoma. The histology favored a primary breast cancer. The patient had a right modified radical mastectomy. The pathologic examination showed infiltrating ductal adenocarcinoma of the breast. Adjuvant therapy included combination chemotherapy followed by tamoxifen. Physicians must be aware of the differential diagnosis of an unknown primary cancer when it presents as an axillary mass.

Primary renal sarcoma in adults. A natural history and management study by the American Cancer Society, Illinois Division

BACKGROUND

Primary renal sarcomas in adults are rare and unusual neoplasms. This study was performed to better define the natural history and current management of these sarcomas in a typical medical setting in the United States.

METHODS

The hospital records of 4018 adult patients with renal neoplasms treated in the state of Illinois from 1975 to 1985 were examined by American Cancer Society professional volunteers.

RESULTS

A primary renal sarcoma occurred in 34 patients (0.8% incidence). Eleven adult patients had Wilms tumor, 21 had primary renal sarcoma (47% leiomyosarcoma), and 2 were not found to have sarcoma on review. The median age of the patients with Wilms tumor was 30 years, whereas that of the patients with non-Wilms sarcoma was 65 years. Four of the patients with Wilms tumor (36%) are long-term survivors and all received adjuvant chemotherapy after radical nephrectomy. Six of the patients with non-Wilms sarcoma (29%) are long-term survivors after radical nephrectomy alone.

CONCLUSIONS

Primary renal sarcomas, when treated with radical nephrectomy and, in the case of Wilms tumor, adjuvant chemotherapy, appear to be curable in 29-36% of cases. Histologic review of patients younger than 40 years of age with renal neoplasia is recommended.

Achieving local control for inflammatory carcinoma of the breast

A single institution, retrospective study of 28 patients with inflammatory carcinoma of the breast treated from 1984 to 1990 was performed. Patients received two to four cycles of cyclophosphamide, doxorubicin and 5-fluorouracil (CDF) and were then evaluated for mastectomy. Mastectomy was accomplished in 26 patients after CDF. In 21 patients, the breast was resectable after the initial doses of chemotherapy and modified radical mastectomy was done. Radiation therapy was given to 16 of the 21 patients after six to nine cycles of postoperative chemotherapy. The remaining five of 26 patients had a marginal response to CDF and underwent preoperative radiation therapy. Local recurrence occurred in four of five patients receiving preoperative radiation, in three of 16 receiving postoperative radiation and in one of five receiving mastectomy without radiation therapy. The overall observed five year survival rate was 18 percent, with a median of 34 months. Neither dermal lymphatic invasion nor estrogen receptor status were statistically significant variables when analyzing patients for local recurrence or survival. Despite poor long term survival results, the combination of induction CDF, mastectomy and postoperative radiation achieved local control in 81 percent of patients.

Pancreatic cancer in Illinois. A report by 88 hospitals on 2,401 patients diagnosed 1978-84

A retrospective study of survival results for pancreatic cancer was performed. The study had two objectives: 1) to relate the extent of disease and management to survival, and 2) to determine whether newer treatment combinations have altered prognosis. Cancer registrars from 88 Illinois hospitals reviewed original medical records and submitted standardized report forms on 2,401 patients diagnosed between 1978-84. Three-year survival time was longer after laparotomy/bypass plus radiation/chemotherapy than for laparotomy/bypass alone (P less than .02). But the difference in survival between resection versus resection, radiation, and chemotherapy was not significant (P = .16). After resection, the median survival for 78 Stage I patients was 12.5 months, whereas for 181 Stage I patients after laparotomy/bypass it was 6.8 months (P less than .00001). For patients without metastases, 3-year survival was significantly better for 249 patients in whom cancer was resected versus 568 unresected patients (P less than .001). Survival was longer for 568 unresected patients without gross metastases than for 954 patients with metastatic disease found at laparotomy (P less than .05). From this study the authors concluded that: 1) since 3-year survival results were higher than expected after resection for localized cancers, resection is still desirable when it can be done with acceptable complication risks, and 2) the use of multiple treatment modalities for pancreatic cancer warrants further study in organized trials.

Technique and complications of reconstruction of the pelvic floor with polyglactin mesh

A polyglactin mesh sling was used to reconstruct the pelvis in eight patients after colorectal or urologic resections in preparation for postoperative radiation therapy. There were three perioperative complications--a pelvic abscess requiring percutaneous drainage, a wound dehiscence and a herniation of the small intestine between the pelvic sidewall and mesh requiring small intestinal resection. There were two delayed complications, both partial small intestinal obstructions. One occurred just after the conclusion of radiation treatment and the other occurred five months after the conclusion of radiation therapy. Both obstructions responded to conservative management. None of the common acute radiation effects occurred during radiotherapy. One patient with delayed partial small intestinal obstruction had possible late radiation effects. The median follow-up period after radiation therapy was 12.5 months. Despite the complications described in this report, the use of a polyglactin mesh sling as an adjunct to resection of carcinoma of the pelvis has merit and should be studied further.

The use of cancer registry data to study preoperative carcinoembryonic antigen level as an indicator of survival in colorectal cancer

A retrospective analysis of survival results for colorectal cancer patients in Illinois was performed by the Cancer Incidence and End Results Committee of the Illinois Division of the American Cancer Society. Cancer registry data on 1,774 patients from 63 hospitals were used to investigate whether the preoperative level of serum carcinoembryonic antigen (CEA) was a prognostic indicator of survival for cancers diagnosed between 1976 and 1978. A direct relationship was found between the preoperative level of serum CEA and both the thickness and stage of the tumor at initial diagnosis. For Stage B2/3 colorectal cancer, the actuarial survival curves corresponding to normal, elevated, and markedly elevated CEA levels were significantly different (p less than 0.0001). The five-year survival rates for these patients were 61, 50, and 32 percent, respectively. Similar trends for patients with Stage C2/3 cancer were observed (p = 0.0058). The corresponding five-year survival rates were 44, 30, and 26 percent, respectively. Using a statewide cancer registry system, the analysis suggested that the preoperative level of serum CEA was an indicator of survival in patients with colorectal cancer, independent of the stage of disease at diagnosis.

Limitations of mammography in the identification of noninfiltrating carcinoma of the breast

A retrospective study of 321 patients who underwent localizing mammography and excisional biopsy of the breast from 1984 to 1985 was performed. The study was undertaken to refine selection criteria for biopsy in women with nonpalpable mammographic abnormalities by comparing mammographic features and impression with histologic findings. Twenty-eight of 36 (78 per cent) noninfiltrating carcinomas presented with microcalcifications alone; in contrast, 27 of 39 (69 per cent) infiltrating carcinomas presented with a mass alone. As the number of microcalcifications increased, so did the incidence of carcinoma. The size of the mass was not a guide for predicting carcinoma. Although only 11 of 75 carcinomas presented as a mass with microcalcifications, 11 of 21 calcified masses were carcinoma. There were no significant differences in the mammographic presentation between ductal and lobular carcinoma. The sensitivity of the mammographic impression was 48/75 (0.64), and the specificity was 221/246 (0.898). The false-positive rate was 25/73 (0.34), and the false-negative rate was 10/141 (0.07). From this study, we concluded 1, the incidence of noninfiltrating carcinoma was significantly higher and the incidence of positive nodes was significantly lower in nonpalpable abnormalities than in palpable masses; 2, noninfiltrating carcinomas were generally associated with microcalcifications alone, but infiltrating carcinomas were generally associated with a mass alone, and 3, the diagnostic accuracy of mammography was limited by under-interpretation of the subtler signs of noninfiltrating carcinoma and by over-interpretation of mammographic findings generally accepted as criteria for carcinoma.

Enterovesical fistula secondary to mucinous adenocarcinoma of appendix

We report an unusual case of an enterovesical fistula secondary to adenocarcinoma of the appendix.

Early onset of tetany following thyroidectomy: report of two cases

The most common complication of total thyroidectomy is hypocalcemia. Following thyroidectomy, especially total thyroidectomy, the serum calcium usually falls gradually and patients do not usually require supplementary medication before 24 hours. Two cases of total thyroidectomy are presented in which the preoperative serum calcium levels were normal and hypocalcemic tetany developed in the recovery room immediately after the operation. The hypocalcemia was a temporary phenomenon, and neither patient requires supplementary calcium at the present time. There is no good explanation for this precipitous drop in the serum calcium levels in these two patients.

Identical laryngeal cancers in two non-twin sibling pairs: case reports and a review of the literature

The occurrence of identical laryngeal cancers in two nontwin sibling pairs is reported for the first time. To understand the relative importance of genetic and environmental factors in the etiology of laryngeal cancer, the evidence in the literature for the development of identical cancers in genetically unrelated and related pairs sharing the same environments was examined.

The spectrum of polyposis

Familial polyposis is a systemic defect of growth regulation. Extracolonic expressions are common and serious, about equal in risk to carcinoma of the large intestine. Periodic surveillance of the upper gastrointestinal tract is particularly important. More intensive surveillance of the large intestine may lead to better results in patients with polyposis who have carcinoma of the large intestine develop.

Causes and evaluation of tumor-induced hypoglycemia

We treated four patients who had hypoglycemia and nonpancreatic tumors. Two had pleural mesothelioma, one had primary fibrosarcoma of the liver, and one had pheochromocytoma metastatic to the liver. We propose four mechanisms for this syndrome: (1) insulin or insulin-like activity produced by the tumor, (2) decreased gluconeogenesis, (3) disruption of glucagon metabolism, and (4) increased utilization of glucose by the tumor. The local effects of the tumor in hepatic parenchyma may also play an important role. The important diagnostic tests are an insulin-glucose ratio, to rule out insulinoma, and fasting glucose levels. An assay of nonsuppressible insulin-like activity can be performed and is of investigative interest, but does not aid in individual patient therapy. Treatment consists of control of the tumor.

Head and neck neoplasia following irradiation for benign conditions

A retrospective review of 143 patients with head or neck tumors who had received radiation therapy in the head and neck area for benign conditions during childhood or adolescence was conducted. This included an analysis of 1,080 patients from the Evanston Hospital Irradiated Thyroid Evaluation Clinic, which was established to define the relationship between irradiation and the subsequent development of thyroid neoplasia. The data support the following concepts of irradiation-induced neoplasia: (1) The thyroid, parathyroid, and salivary glands can develop benign and malignant changes after irradiation for benign conditions, with latent periods averaging about 30 years; (2) Once a glandular abnormality within the irradiated field appears, the risk of other glands in the field developing neoplastic changes is significantly increased.

Irradiation induced salivary gland neoplasia

Twenty-six patients with a prior history of irradiation for benign conditions of the head and neck and salivary gland abnormalities are reported. All the patients had preoperative physical findings suggestive of tumor, not glandular infection. Forty-six per cent of the patients had one carcinoma and 11% had two carcinomas within the irradiated field. Eight of the 11 malignant tumors in these 26 patients were in the parotid gland. The nonmalignant salivery changes were similar to those previously reported in glands receiving therapeutic irradiation for carcinoma.

Preoperative physical assessment of thyroid glands in previously irradiated patients

The Evanston Hospital maintains an Irradiated Thyroid Evaluation Clinic that has evaluated 695 patients since 1975. One hundred fourteen patients were retrospectively analyzed, and an attempt was made to correlate the preoperative physical examination with the pathologic specimen after thyroidectomy. There was no statistically significant difference between the incidence of carcinoma in glands containing a single nodule (23 per cent) and in multinodular glands. Postirradiation thyroiditis complicated the physical description of glands preoperatively. The categorization of physical findings served only to identify persistent thyroid abnormalities, which must be explored surgically. The overall incidence of carcinoma in the 114 available cases was 34 per cent, with nodal metastases in 18 per cent of the patients with carcinoma.

Symptomatology as an indicator of recurrent or metastatic breast cancer

Eighty-seven patients with recurrent breast cancer after mastectomy were analyzed for patterns of recurrence and methods of detection. After an average disease-free interval of 30 months, 38% developed osseous metastases, 16% recurred locally, 10% had local plus systemic disease, 10% showed pulmonary metastases and the remainder were distributed among liver, brain, and remaining breast disease. In 79 patients recurrence was heralded by symptoms. Physical examination in five asymptomatic patients revealed local or supraclavicular recurrence. In only three asymptomatic patients was recurrence documented by "routine" chest x-rays (in two), or liver enzymes/liver scan (in one). No asymptomatic disease was found by bone scan. It is concluded that periodic history, physical examination, and chest x-rays are the most important components in the follow-up of breast cancer patients. Radioisotope scans and other radiographs are valuable in confirming symptomatic disease and detecting additional diseases, but cannot be recommended routinely in the asymptomatic patient because of low yield and cost.

Parathyroid adenomas following irradiation

Parathyroid adenomas have been demonstrated to occur following external head and neck irradiation. The median latency interval is 30 years. In a series of 74 consecutive patients with histologically diagnosed parathyroid adenomas, 25% gave a history of prior radiation exposure. When compared to a matched control incidence of 7.9%, statistical significance is reached at p less than 0.01. Thyroid abnormalities were present in 68% of the irradiated patients, and 30% of these were malignant. Tumor of skin, breast, and parotid gland also occurrred more frequently than expected. Forty-seven percent of the irradiated group had malignant neoplasms within the radiation field. The histopathology of the radiation-associated parathyroid adenomas is similar to that seen experimentally.

Lung lamellar bodies lack certain key enzymes of phospholipid metabolism

Palmitoyl CoA-glycerol-3-phosphate acyltransferase, phosphatidate phosphohydrolase, and phospholipase A were assayed in subcellular fractions of rat lung, including lamellar bodies, the putative site of storage and secretion of lung surfactant. The specific activity of each of these enzymes in lamellar bodies was relatively low and could be entirely accounted for by a small contamination of the lamellar bodies fraction by microsomes, as quantitated by the presence of the microsomal marker reduced triphosphopyridine nucleotide cytochrome c reductase. These data indicate that lamellar bodies are not the site of synthesis of the lipid component of pulmonary surfactant by pathways involving these enzymes.