Hypothenar hammer syndrome. Form of reversible Raynaud's phenomenon.

Hypothenar hammer syndrome is a reversible yet uncommonly encountered cause of Raynaud's phenomenon. Characteristic findings include coldness in the dominant hand of a male, absence of triphasic color change and thumb involvement, and occupational or recreational use of the hand as a hammer. Angiography demonstrates the specific findings of irregularity or occlusion of the ulnar artery, downstream occluded proper digital arteries, and intraluminal emboli at the sites of distal obstruction. A vulnerable area of traumatic occlusion is provided by the anatomic relationship of the superficial branch of the ulnar artery to the hamate bone and the palmar aponeurosis. Pathologic studies separate the hypothenar hammer syndrome from clinically similar vasculitis. It is important to recognize the hypothenar hammer syndrome as a distinct entity because treatment is curative and consists of resection of the affected vascular segment and avoidance of the aggravating conditions.

Features of cancer in nonagenarians and centenarians.

OBJECTIVE: To describe the incidence rates and sites of cancer, the causes of death, and gender and ethnic variations in patients with cancer in a population of people 90 years of age and older. DESIGN: Analysis of the 14,088 cases of cancer in this age group, accessioned by the California Cancer Registry from 1988 through 1993, and comparison with those less than age 90. MEASUREMENTS: Incidence rates and numbers and percents of cases with various features (gender, ethnicity, site of tumor, stage, causes of death). RESULTS: The peak age-specific incidence (ASI) of cancer is in the group 80 to 84 years of age. Those 90 to 94 years of age had a higher ASI than any group except those ages 75 to 89. There are ethnic variations in the sites of cancer in people aged 90 or older. Colorectal cancer accounts for more than one-fifth of the new cases of cancer in people 90 or older. In women aged 90 or older, the most common sites of cancers are colorectal, breast, and lymphoma/leukemia. In men of the same age, prostate, colorectal, and lung/bronchus are the most common sites. As age increases, fewer people have their cancers staged, and for lung/bronchus, prostate, and breast, more cancers are first diagnosed in the distant stage in people aged 90 and older. Of the people with cancer who die, the proportion dying of cancer decreases as age increases. CONCLUSION: Cancer is a common disease in nonagenarians and centenarians and will be an increasing healthcare problem. Knowledge of its features is essential to those planning, delivering, and financing health care.

Risk factors for the development of distant metastases in patients undergoing pelvic lymphadenectomy for prostatic cancer.

Sixty-two patients with clinically localised prostatic cancer underwent pelvic lymphadenectomy between 1972 and 1975. Thirty-one patients had concomitant total prostatectomy. The objectives of this study included determination of the relation of findings at lymphadenectomy, with and without total prostatectomy, to subsequent clinical course, identification of histologic parameters related to the subsequent appearance of distant metastatic disease, and determination of the vital status of patients initially having a staging pelvic lymphadenectomy. Follow-up of at least 5 years was obtained for 52 patients, including 28 who had concomitant total prostatectomy. Ten patients were lost to follow-up. Fifty-four percent are alive with metastatic disease 10 percent have died with metastatic disease, 10 percent have died with metastatic cancer, and 12 percent have died without prostate cancer. Metastases have developed in 11 (37 percent) of 30 patients with negative pelvic lymph nodes, reflecting either seminal vesicle or transcapsular invasion. Minimal lymph node involvement (one or two pelvic nodes) alone may not be as poor a prognostic sign as originally thought. Metastases have developed in 22 percent of nine patients with tumor considered stage B2. No recurrences or metastases were noted in the seven patients with stage B1 disease. Patients with high grade lesions were at no increased risk for distant metastases, although they constituted a relatively small segment of our series. Thus the extent of local disease correlates with the subsequent development of distant metastasis. Adjuvant systemic treatment (endocrine manipulation, chemotherapy, or both) has a rational basis in patients with one or more of these identifiable risk factors.

Recruiting older women to research studies: the san diego cooperative mammography project.

BACKGROUND: Despite the growing number of older people in the population, this age group continues to be under represented in clinical trials. As a result, physicians must base treatment decisions for older patients on data from studies involving primarily younger, and presumably healthier, adults. Little experience is available to guide the development of study methodologies that will enhance the recruitment of older patients to clinical studies. METHODS: This pilot study compared two methods of recruiting women 75 years and older to a clinical research study related to their most recent screening mammogram. The effectiveness of a single, "in-person" invitation to participate made during the screening mammogram appointment was compared with the effectiveness of a single invitation to participate sent "by-mail" following a screening mammogram. RESULTS: Both methods succeeded in recruiting a sizable sample (N=2,394). The "in-person" invitation to participate was more labor-intense and less likely to be inclusive of all eligible women, but secured a significantly greater proportion of the women to participate. However, once recruited, women in the "by-mail" method were significantly more likely to comply with the optional elements of the study and to express a willingness to continue with follow-up studies than those recruited by the "in-person" method. CONCLUSIONS: Lack of participation of older women in clinical research may be more a reflection of not being asked, rather than their lack of willingness to participate, thus reinforcing the key role health care providers can play in recruiting older women to clinical studies.

The dilemma of the second surgeon.

The dilemma of the second surgeon is created when a patient is seen who has received advice and/or treatment by a colleague in the same specialty. The problem is compounded when conflicting opinions as to diagnosis, treatment, and results occur. This is discussed in the context of providing optimal care, maintaining effective communication, and avoiding the obvious pitfalls.

Sudden infant death syndrome: plasma vitamin E levels and dietary factors.

Vitamin E and selenium deficiency have previously been suggested to be responsible for the Sudden Infant Death Syndrome (SIDS). New experimental data reveal that this is not the case since vitamin E as well as plasma selenium levels of SID infants are approximately equal to those of normal controls. Although breast feeding was believed to have a protective effect against SIDS, a statistical study of groups of SID- and control infants in San Diego County indicate no such correlation. Totally or partially breast-fed SID infants actually died at an earlier age than those fed by formula only (p=0.02). Compared to matched normal controls, SID infants appear to have received a less varied diet with a lower incidence of extradietary vitamin supplementation (p=0.02). There is also a somewhat greater prevalence of mothers smoking during pregnancy in the SID group (one-tail p=0.05).

The association of ethnicity and the incidence of mammary carcinoma in situ in women: 11,436 cases from the California Cancer Registry.

Ethnic differences in the incidence of mammary carcinoma in situ (CIS) in women, as well as differences in the percentages of carcinomas diagnosed in the in situ stage, have been calculated from the 11,436 cases of CIS in the California Cancer Registry (CCR) for the years 1988 through 1992. White women have an average annual age-adjusted incidence (AAAIR) of 17.4/100,000; black women, 11.4/100,000; Hispanic women, 7.6/100,000; and Asian/other women, 8.3/100,000. White women have 11.8% of their carcinomas diagnosed in the in situ stage; black women, 10.2%; Hispanic women, 9.7%; and Asian/other women, 12.2%. In all ethnicities, CIS is predominantly a disease of postmenopausal women and is first diagnosed at an earlier age in nonwhite women. All of these observations have implications in the planning and evaluation of health care delivery and cancer control activities. Moreover, the younger age at diagnosis of women with CIS compared with those with invasive carcinoma supports the concept that CIS proceeds to invasive cancer.

Potential limits of physical examination and breast self-examination in detecting small cancers of the breast. An unselected population-based study of 1302 cases.

Neither a change in the average or median size of breast cancers, nor in the extent of axillary lymph node involvement, was seen in a total, unselected population study before and after an intensive public and professional education project in San Diego County. Comparison of these data with those from the Breast Cancer Detection Demonstration Project lends strong support for the greatly increased use of mammography if it is to be possible to detect the smaller, more curable cancers of the breast.

Impact of ethnicity on the incidence of high-risk endometrial carcinoma.

OBJECTIVE: To evaluate the impact of race/ethnicity on histology in endometrial cancer. METHODS: California Cancer Registry data on 11,674 white and 423 black women with endometrial cancer registered from 1988 to 1992 were used to compare the average annual age-adjusted incidence rate/100,000 women of low-risk (grades 1 and 2 endometrioid adenocarcinoma) and high-risk (grade >2 endometrioid carcinomas, papillary serous, clear cell, and adenosquamous histologies) lesions in black and white women. RESULTS: Of the white patients, 9059 (78%) had low-risk and 2615 (22%) had high-risk lesions. Of the black patients, 236 (56%) had low-risk and 187 (44%) had high-risk lesions. The overall average annual age-adjusted incidence of endometrial cancer in white women is 20.1/100,000 and for black women is 9.4/100,000; however, the incidence of low-risk tumors is 15.9/100,000 in white women and only 5.3/100,000 in black women. The incidence of high-risk disease is identical in black and white women (4.2/100,000). CONCLUSIONS: Black women in the general population have the same likelihood as white women of developing high-risk endometrial cancer. Black women have a significantly lower incidence of low-risk tumors compared to white women. The increased incidence of low-grade lesions in white women may be due to differences in socioeconomic factors or other factors yet to be identified.

Estimation of the duration of the preclinical phase of cervical adenocarcinoma suggests that there is ample opportunity for screening.

OBJECTIVE: The purpose of this study was to determine the mean time for progression from cervical adenocarcinoma in situ (ACIS) to invasive cervical adenocarcinoma in order to assess the feasibility of screening and secondary prevention. METHODS: To approximate time to progression from in situ to invasive lesions, we calculated and compared mean ages at diagnosis of ACIS and invasive adenocarcinoma from patients registered in the SEER (NCI's Surveillance, Epidemiology, and End Results) public-use database from 1973 to 1995 [1]. Findings are contrasted with means calculated from patients with squamous lesions registered during the same period. Statistical significance was tested with the t test for independent samples. RESULTS: The database includes 5845 patients with glandular lesions; 1476 (25%) have ACIS and 4369 (75%) have invasive adenocarcinoma. There are 143,333 women with squamous lesions; 120,317 (84%) have squamous CIS and 23,016 (16%) have invasive squamous cancers. Mean age (std error) at diagnosis is 38.8 (0.3) years for ACIS and 51.7 (0.3) years for invasive adenocarcinoma; the mean difference is 13.0 (0.5) years. Mean age (std error) for squamous CIS is 33.6 (0.0) and for invasive squamous cancer is 51.4 (0.1); mean difference is 17.9 (0.1). CONCLUSIONS: While not quite as long as for squamous lesions, the average of 13 years that elapses during progression from cervical ACIS to invasive adenocarcinoma allows ample time for screening for the preinvasive lesion and for secondary prevention of invasive cervical adenocarcinoma. The similar mean ages at diagnosis suggest that women who will develop cervical adenocarcinoma should be as amenable and accessible to screening programs as are those with squamous lesions.

Clinicopathologic features of unsuspected regional lymph node metastases in prostatic adenocarcinoma.

Histologic features of the primary tumor and their effects on the incidence of unsuspected pelvic lymph node metastases have been studied in a prospective series of 62 patients with clinical stage B1, B2, or C prostatic adenocarcinoma who underwent pelvic lymph node removal. Twenty-one patients (34%) proved to have unsuspected nodal metastases. Differentiation of the primary tumor and extent of involvement of the prostate by carcinoma were the only two features that correlated significantly with the incidence of pelvic nodal metastases, 56% of those with undifferentiated tumors had metastases. Thirty-one of these patients underwent total prostatectomy; an average of only 46% of the sections of prostate contained tumor in the patients without metastases but an average of 65% of the sections were involved by carcinoma in those patients who did have nodal metastases.

Gender-related differences in the distribution of thoracic versus abdominal malignant mesothelioma.

The relationship between malignant mesothelioma (MM) and asbestos is well established, but the determinants of host factor susceptibility of MM are not. This study probes susceptibility issues by examining gender-related differences in the distribution of 417 thoracic and 42 abdominal cases of MM from 1988-1989 California Cancer Registry databases. The age-adjusted incidence rate ratio (IRR) for male/female thoracic MM was 6.9 (95% confidence interval [CI]; 5.0-9.6) consistent with greater occupational exposure among men. However, the IRR for male/female abdominal MM was 1.5 (95% CI: 0.6-3.6). Also, average age of onset for thoracic MM was greater than for abdominal MM. Thus, some abdominal MMs may be due to nonoccupational asbestos exposure, occurring over a lifetime, interacting with host factor susceptibility. This study gives impetus to research regarding the importance of host factors and nonoccupational asbestos exposure in the etiology of malignant mesothelioma.

Adenocarcinoma occurring in association with a chronic sinus tract and biliary fistula.

Malignant change can occur in various types of fistulae, draining sinuses, chronic inflammatory tracts, scars, and old wounds. An unusual case of an adenocarcinoma arising in association with a chronic sinus tract and biliary-cutaneous fistula of twenty years' duration is presented. Literature review reveals this to be the first reported case.