A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND: Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS: A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS: We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS: IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

Class II antigens of the major histocompatibility complex are increased in lungs of bleomycin-treated rats.

The expression of class II molecules (Ia) of the major histocompatibility complex by isolated alveolar macrophages (AM) and alveolar type II cells from the lungs of rats with bleomycin-induced pulmonary fibrosis was examined. The percentage of Ia-positive AM and type II cells from rats treated with bleomycin as detected by flow cytometry was increased three times and two times, respectively, over the values obtained from control rats. The relative density of Ia expression, determined with a radioimmunoassay technique, showed a 50% increase in Ia density on AM and a 35% increase on type II cells. Recombinant interferon-gamma increased the expression of Ia on type II cells in vitro by 35% to the level obtained on type II cells in bleomycin-induced lung disease. We conclude that the increase of Ia expression on cells of the immune system and on pulmonary epithelial cells may have an important role in the initiation and/or amplification of inflammatory reactions in the lung and may contribute to the development of pulmonary fibrosis.

Correlation between PGE2 production and suppressor activity of alveolar macrophages from patients with interstitial lung diseases.

The suppressive activity of alveolar macrophages (AM) obtained from bronchoalveolar lavage (BAL), on PHA stimulation of autologous peripheral blood lymphocytes (APL) was evaluated. The effect on lymphocyte stimulation was evaluated by coculturing the AM and APL cells at a ratio of 1:1. PGE2 released by AM during the culture period was measured by a radioimmune assay. The patients included in the study were 11 cases with interstitial lung disease (ILD), 8 cases of lung cancer (CA), and 5 controls (CO). Addition of AM of patients from the CA group resulted in slight suppression of lymphocyte stimulation in 4 cases, slight enhancement in 3 cases and no effect in one case. AM from the CO group induced slight suppression in 4 out of 5 cases. AM from all 11 ILD cases exerted a significant high suppressive activity (65.6% +/- 18.2 - P less than 0.001 by comparison with the CO and CA groups). In ILD cases, a dichotomous pattern was found in regard to relation between high suppressive activity of AM and release of PGE2: in idiopathic pulmonary fibrosis (IPF) patients, high suppressive activity of AM (70.4% +/- 15.4) correlated well with elevated secretion of PGE2: 3.58 +/- 0.26 ng/ml/10(5) cells (P less than 0.02 compared to CO). AM from sarcoidosis patients suppressed PHA stimulation by 61.6% +/- 19.3 but secreted only 0.357 +/- 0.26 ng/ml/10(5) cells of PGE2 (P less than 0.02 compared with the idiopathic pulmonary fibrosis group). Therefore, it seems that other factors, in addition to PGE2, might be involved in the suppressive activity of AM from interstitial lung diseases.

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions.

OBJECTIVE: To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions. DESIGN: A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients. RESULTS: A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization. CONCLUSION: PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.

Nedocromil sodium and placebo in the treatment of bronchial asthma. A multicenter, double-blind, parallel-group comparison.

The efficacy of nedocromil sodium (4 mg twice daily by inhalation) in treating bronchial asthma was assessed by double-blind, placebo-controlled group comparison in 69 adults from three centers. The patients (34 active, 35 placebo) had a history of bronchial asthma with at least 15 percent reversibility. Inhaled corticosteroids, used by 22 and 24 subjects in the active and placebo groups respectively, were discontinued before the study, in which a two-week baseline was followed by six weeks of treatment. Two-weekly clinic assessments of lung function, symptoms and final opinions of treatment were significantly (p less than 0.05 p less than 0.001) in favor of nedocromil sodium. Daily diary cards showed a similar trend with significant drug effects seen after the third week. Blood and urine samples showed no abnormalities and the majority of patient withdrawals (five from nedocromil sodium and six from placebo treatment) were due to worsening asthma. Overall, we found nedocromil sodium to be well tolerated and effective in the management of bronchial asthma.

Blood transfusion and lung function in children with thalassemia major.

Pulmonary function tests were performed at rest and following blood transfusion on 17 patients with thalassemia major. At rest, diffusion capacity was significantly reduced (mean of 57 percent), and forced vital capacity was mildly reduced (mean of 85 percent). In two of the patients, arterial oxygen tension was low. Other pulmonary function results were in the normal range. Following blood transfusion, a significant drop was seen in arterial oxygen tension (PaO2 of 22 mm Hg) and in forced vital capacity (FVC) of 32 percent. These changes were dramatic and require further explanation.

Assessment of hazardous dust exposure by BAL and induced sputum.

OBJECTIVES: BAL, an important tool in assessing occupational lung diseases, is unsuitable for screening programs, exposure evaluation, or monitoring hazardous dust because it is an invasive technique. The results of induced sputum (IS) analysis were compared with BAL and evaluated as a possible alternative. METHODS: We compared BAL with IS analysis of 5 workers exposed to asbestos and 14 exposed to silica and hard metals. Pulmonary function tests and BAL were performed by conventional methods. IS induction was performed after a 20-min inhalation of 3.5% saline solution with an ultrasonic nebulizer. Giemsa-stained cytopreparations were differentially counted. T-lymphocyte subsets were analyzed by flow-activated cell sorter, and messenger RNA (mRNA) was transcribed by reverse transcriptase-polymerase chain reaction. Mineralogic particles were analyzed by scanning electron microscopy and polarizing light microscopy and quantified by an analyzer. RESULTS: The percentage of neutrophils was significantly lower in BAL fluid than in IS specimens, whereas no differences were found in the percentage of lymphocytes and subsets profile. Asbestos fibers were found in BAL but not in IS samples from workers exposed to asbestos. Polarizing particles were found in both samples. Similar mineral elements were found in qualitative analysis by scanning electron microscopy. Quantitative studies showed similar size distribution with a small shift toward larger particles in sputum; mRNA showed the same cytokine profile. CONCLUSIONS: A comparison of BAL and IS specimens in the evaluation of the study population yielded similar quantitative and qualitative results. Further research is needed to evaluate the hypothesis that IS, being a noninvasive technique, may be useful in monitoring exposed workers.

Eosinophilic lung reaction to aluminium and hard metal.

A nonsmoker drill polisher with interstitial lung disease is presented. The environmental exposure was mainly to aluminum oxide, aluminum silicate, and hard metals. Bronchoalveolar lavage revealed high eosinophilia, and transbronchial biopsy specimen disclosed interstitial pneumonia with giant cell infiltrates and peribronchiolar accumulation of macrophages laden with opaque dust. Mineralogic studies done from the tissue revealed a high concentration of exogenous particles that were identified as hard metals and aluminum silicate. These findings are compatible with hard metal pneumoconiosis.

Pleuropulmonary metastasis from an intracranial glioblastoma.

We present an unusual case of glioblastoma with intrathoracic and liver metastasis. The clinical diagnosis was confirmed by a percutaneous core needle biopsy from a metastatic lung lesion. The pathogenetic and diagnostic aspects of the case are discussed.

Percutaneous core needle biopsy in the diagnosis of mediastinal tumors.

OBJECTIVE: to determine the contribution of percutaneous core cutting needle biopsy (PCNB) in the diagnosis of mediastinal tumors. DESIGN: retrospective review of 70 patients with mediastinal lesions who underwent CT-guided PCNB between 1988 and 1996. RESULTS: PCNB provided adequate material in 62/70 cases, giving a total sample rate of 88.6%. Of these 62 patients, 57 were diagnosed correctly by PCNB whereas 5/62 were misdiagnosed as nonspecific inflammation, providing an overall sensitivity of 91.9%. PCNB established a specific histologic diagnosis in 90.3% of the patients, mainly in cases of lymphoma, bronchogenic carcinoma, and thymoma. Pneumothorax was the most commonly encountered complication (11%). Hemoptysis (30-50 ml) occurred in only one (1.6%) of the patients. CONCLUSION: CT guided PCNB is an easy and safe procedure which can provide a precise diagnosis in the majority of mediastinal tumors and can obviate the need for exploratory thoracic surgery in cases which are medically treatable or non-resectable.

Severe allergic bronchopulmonary aspergillosis in an infant with cystic fibrosis and her asthmatic father.

An infant with cystic fibrosis and her asthmatic father were diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA). Cystic fibrosis was diagnosed in the infant at 6 weeks of age, and gene mutations were W1282X/G542X. She was diagnosed definitively as suffering from ABPA at age 3.5 years, but had suggestive symptoms from age 11 months. This may be the youngest age described to date for ABPA. The child responded well to systemic steroid therapy, but remained steroid-dependent over the next 4 years. Treatment with itraconazole enabled a marked reduction in steroid dosage. The father was an asthmatic, and a heterozygote for the cystic fibrosis transmembrane regulator (CFTR) mutation W1282X. He had a normal sweat test, atopy, and moderate reversible airway obstruction. There was no proven exposure to Aspergillus in the home environment. The importance of considering the diagnosis of ABPA even in infancy, the therapeutic dilemmas, and the possible role of abnormal CFTR function in the development of ABPA are discussed.

Eosinophil influx into the airways in patients with exercise-induced asthma.

Exercise-induced asthma is a common phenomenon, the mechanism of which is undetermined. Eosinophils have been suggested as playing a role in its occurrence. We studied the effect of exercise-induced asthma on the cellular and mediator composition of spontaneously obtained sputum. Twenty-five patients with bronchial asthma were investigated by studying sputum spontaneously obtained before and following challenge. One group with (n=9) and one without (n=9) exercise-induced asthma performed exercise challenge. A third group (n=7) performed methacholine challenge. The sputum was analysed using Giemsa staining for differential cell count, measuring eosinophil cationic proteins and mixtures of leukotrienes (D4, E4 and C4) in the liquid phase using ELISA. The group with exercise-induced asthma had a mean drop of 23.7+/-7.4% in FEV1, significantly (P=0.001) higher than the group without it. Following challenges, there were significant increases in sputum eosinophils only in the group with exercise-induced asthma (from 8.1+/-13.9% to 18.3+/-20.2%, P=0.0017) and not in control groups (from 0.9+/-0.9% to 1.5+/-15%) or in those who had methacholine challenge (from 23.6+/-27.2% to 22.3+/-23.8%). Eosinophil cationic proteins did not change significantly in any group. In the liquid phase of the sputum, the amount of leukotrienes increased following exercise in six of the seven patients with exercise-induced asthma in whom it was measured. The influx of eosinophils to the airway in patients who develop exercise-induced asthma can be partially explained by the leukotrienes in the airways of those patients.

Induced sputum compared to bronchoalveolar lavage for evaluating patients with sarcoidosis and non-granulomatous interstitial lung disease.

Bronchoalveolar lavage (BAL), an important tool for evaluating interstitial lung diseases (ILDs), has limited utility due to its invasiveness and the difficulty of performing it in clinically contraindicated patients. We compared BAL with the induced sputum (IS) technique to analyse cells and T lymphocytes in patients with sarcoidosis (SA) and non-granulomatous ILD (NG-ILD). Pulmonary function tests and BAL were performed by conventional methods. IS induction was done 20 sec after inhalation of 3.5% saline with an ultrasonic nebulizer. Giemsa-stained cytopreps were differentially counted. T lymphocyte subsets were analysed by flow activated cell sorter (FACS). Patients with NG-ILD had impaired total lung capacity (TLC). Transbronchial biopsy demonstrated lung fibrosis in NG-ILD and non-caseating granuloma in SA. The differential cell count in both groups demonstrated a significantly lower percentage of neutrophils and a significantly higher percentage of macrophages in BAL than in IS. The IS samples of patients with SA were significantly richer in metachromatic cells and eosinophils, but had a lower percentage of lymphocytes, compared to the BAL samples. The profiles of T cell subsets showed the same pattern, in both samples, in both groups. A CD4/CD8 ratio of 2.5 or greater had a sensitivity of 100% and a specificity of 81.2%, with a positive predictive value of 81.2% to distinguish SA from NG-ILD. IS is an effective non-invasive technique to identify CD4+ inflammation which distinguishes sarcoidosis from other NG-ILDs.

Endobronchial metastasis of ovarian cancer. A case report.

An 83 years old woman with known ovarian carcinoma complained of dyspnea, dysphagia and hoarseness. Clinical and radiological investigations revealed a mediastinal metastasis involving and penetrating the right main bronchus. Palliation of dyspnea was achieved by laser therapy.

Percutaneous core needle biopsy vs. fine needle aspiration in diagnosing benign lung lesions.

OBJECTIVE: To determine the diagnostic value of percutaneous core needle biopsy (PCNB) in comparison with fine needle aspiration (FNA) in patients with benign pulmonary lesions. STUDY DESIGN: A retrospective review was undertaken of computed tomography-guided PCNBs and FNAs performed between 1988 and 1997. Both FNA and PCNB biopsies were carried out sequentially at the same visit in every patient. RESULTS: A specific benign diagnosis was made in 10/60 cases (16.7%) by FNA and in 49/60 (81.7%) by PCNB. PCNB findings resulted in significant modification of the diagnosis established by FNA. The only significant complication encountered was pneumothorax, at a rate of 11.7%, which is compatible with that reported in the literature for complications induced by FNA alone. CONCLUSION: Radiologically guided PCNB is a safe procedure, can provide sufficient histologic material for a specific diagnosis of peripheral lung disease and can avoid more-invasive surgical procedures in many cases. Our experience demonstrated that the histologic analysis provided by PCNB can greatly increase the diagnostic accuracy in benign pulmonary diseases as compared with the yield of FNA.

Tattooing and body piercing. Body art practices among college students.

Tattooing and body piercing are increasing, especially among college students. A study of 766 tattooed and/or body-pierced college students in 18 universities across the United States and one in Australia was conducted to discover the demographic characteristics, motivational factors, and health concerns. The traditional college time of 18 to 22 years of age (69%) was when they obtained their tattoo (73%) and/or body piercing (63%). More frequent health problems and impulsive decision making were noted for those with body piercing when compared to those tattooed. Three cases of hepatitis were reported. Health professionals should openly discuss body art with students, convey a nonjudgmental attitude, and assist with informed decision-making information to either reduce risks or dissuade. Open communication and applicable health education will be very important.

Preoperative whole-gut lavage vs. traditional three-day bowel preparation in left colon surgery.

Isotonic, isosmotic lavage is a safe and effective means of mechanical preparation of the large bowel for left colon surgery. In this prospective, randomized trial comparing lavage with a more traditional three-day bowel preparation, the lavage was well tolerated, led to decreased preoperative hospital days, and produced no higher incidence of infectious complications when compared to the traditional three-day technique.

The living canvas.

In the United States, body art has gradually moved from the fringes of society into the mainstream. This article focuses on the health issues surrounding this practice. The literature cites numerous infectious diseases and complications resulting from or linked to body art. Tattoos have been linked to skin neoplasms, piercing has been associated with hepatitis B and C risk, and branding is strongly associated with infection. Although it is a theoretical risk, no documented cases of HIV have been acquired from a tattoo or piercing. In general, tattooing, piercing and branding are unlicensed and unregulated industries. In many communities, tattoo artists and establishments are not subject to health inspections, body art practitioners are not required to be trained in anatomy, infection control or universal precautions, and the contents of tattoo dyes have never received FDA approval. Healing times for body art are variable, depending on type and location. Obtaining body art is a long-term commitment, and patients should be fully aware of this.

Home administration of nutritional & medical therapies for persons with AIDS.

With the increasing numbers of AIDS patients in home care settings, professional caregivers will be required to provide home infusion and to help informal caregivers in enteral and total parenteral nutrition. The first thing all caregivers--both professional and informal--need to understand is how the infusion devices work and what pointers will help keep the patients healthy.

Attenuation of cue-induced smoking urges and brain reward activity in smokers treated successfully with bupropion.

Twenty-two regular smokers (15+ cigarettes per day) were treated with bupropion and group therapy for 2 months. Subjects underwent positron emission tomography (PET) studies using measures of brain global and regional glucose metabolism (regional cerebral metabolic rates of glucose [rCMRglc]) with [18F]-Fluorodeoxyglucose (FDG) twice, after watching a videotape showing smoking scenes and after watching a control movie in counter-balanced order. A questionnaire of smoking urges (QSU) was filled in before and after watching both the movies. Changes in brain metabolic rates of FDG were analysed using Statistical Parametric Maps (SPM 2) in 11 smokers who abstained from smoking in comparison with 11 smokers who continued to smoke during the second month of treatment. Still-smokers had higher craving scores after watching the videotape showing smoking scenes compared with non-smokers. Second, watching the videotape showing smoking scenes compared with the control videotape in still-smokers resulted in increased metabolic rates in the striatum, thalamus and midbrain. Third, the ratings of the urge to smoke cigarettes while watching the videotape showing smoking scenes in still-smokers were associated with brain metabolic activity in the ventral striatum, anterior cingulate, orbitofrontal cortex, middle temporal lobe, hippocampus, insula, midbrain and thalamus. In conclusion, successfully treated smokers showed attenuated craving and reduced activity in the mesolimbic reward circuit.