Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer.

Forty-seven (39%) of 120 patients with presumably operable lung cancer were found to have metastatic tumor in mediastinal lymph nodes by mediastinoscopy. Unnecessary thoracotomy was avoided in these 47 patients. Results of anterior mediastinal node biopsy were positive in 16 (38%) of 42 patients with primary tumors of the left lung who were evaluated by anterior mediastinoscopy without resection or division of costal cartilage. Thirty-one (40%) of 78 patients with primary tumors of the right lung had positive results of mediastinal node biopsy as demonstrated by cervical mediastinoscopy. Sixty-seven percent of patients with centrally located tumors, 43% with adenocarcinoma, and 57% with undifferentiated carcinoma had mediastinal lymph node metastasis. Negative results of anterior mediastinoscopy in patients with primary tumors of the left lung predicted resectability in 25 (96%) of 26 instances. Forty-three (91%) of 47 patients with primary tumors of the right lung and negative results of cervical mediastinoscopy had resectable tumors. Anterior mediastinoscopy appears to be as accurate in the evaluation of mediastinal lymph node metastasis in left lung cancer as cervical mediastinoscopy is in the evaluation of right lung cancer.

Improved results of surgical treatment for esophageal and gastroesophageal junction carcinomas after preoperative combined chemotherapy and radiation.

Combined treatment with chemotherapy and radiation (chemoradiation) preceding surgical exploration for esophageal or gastroesophageal squamous cell carcinoma or adenocarcinoma was compared with surgical exploration alone to determine if there was an influence on tumor status at exploration, tumor resectability, disease recurrence, and patient survival. Preoperative chemoradiation resulted in significant tumor response as measured by decreased nodal involvement and 36% incidence of no residual tumor at resection (total response) and was reflected by an improvement in resectability. Local tumor recurrence was eliminated by preoperative chemoradiation preceding resection. Distant recurrence was not reduced and remained the major cause of death. The 2-year survival rate after tumor resection alone was 33% versus 66% after preoperative chemoradiation and resection (p = 0.13). Patient survival after resection alone was predicted by pathologic extent of local disease as measured by lymph node status. In contrast, survival after chemoradiation and resection was not predicted by pathologic extent of local disease. Surgical resection appears to have been an important component of therapy, primarily because survival was improved in patients after resection of residual local disease.

Routine computed tomographic scans, selective mediastinoscopy, and other factors in evaluation of lung cancer.

Routine computed tomographic scan is advocated as the best noninvasive method of evaluating mediastinal nodes for cancer spread. Positive studies should be confirmed histologically. Large size, central location, unfavorable cell type, poor cellular differentiation of the primary cancer, and weight loss also correlate with increased likelihood of mediastinal involvement.

Unpredictable course of small cell undifferentiated lung carcinoma.

Twenty-nine patients with small cell lung carcinoma were examined as to ultrastructural morphology, stage of disease, and survival. Although all tumors met the light microscopic criteria for oat cell carcinoma, only 19 (66%) contained neurosecretory granules characteristic of this tumor. Of 12 patients undergoing pulmonary resection, five of six patients with non-neurosecretory tumors and two of six patients with neurosecretory (true oat cell) tumors survived more than 2 years. Survival of all patients with Stage I or II disease was significantly different from that of patients with Stage III disease. Stage together with ultrastructural morphology may carry important therapeutic and prognostic implications. Pulmonary resection appears to be effective treatment for certain subsets of patients with small cell undifferentiated carcinoma.

The role of fine-needle aspiration in the management of solid breast masses.

Fine-needle aspiration cytology is a safe, inexpensive, rapid method of establishing the diagnosis of breast cancer in patients with solid, palpable masses. The pathologist must be conservative in his interpretation of malignancy so that positive study results occur only in patients with cancer. We compared the cytologic diagnosis of 140 breast masses with the histologic diagnosis. Seventy of 98 breast cancers were diagnosed by this technique. Because 28 cancers could not be diagnosed with certainty, open biopsy should be performed on all breast masses with nonmalignant cytologic findings.

Trisomy 10: age and leukemic lineage associations.

We observed three cases of acute leukemia with trisomy 10 (+10) as the sole abnormality, two were adult patients with ANLL (subtype M0 and M1 respectively), and the third that of a child with ALL. The literature describes nine additional cases, four with ALL (all of whom were children) and five with ANLL (all of whom were adults). Cell marker studies on the ANLL cases showed a common positivity for CD7 and CD33 in our two cases, as well as in four of the previously reported cases, whereas in ALL the only two informative cases were classified as early pre-B ALL. There appears to be an age-related pattern in the specificity of the leukemic lineage. Trisomy 10 appears to be associated exclusively with ALL in children and with ANLL (usually M0-M1) in adults. The prognosis appears to be also divided between the two groups, being good in the pediatric group and moderate in the adult group.

Analysis of a mass colorectal cancer screening program for cost-effectiveness.

Mass screening of the general population with the stool blood test is a costly means of increasing the incidence of colorectal cancer identification; however, the test is worthwhile as a screening tool in patients at risk. We found the incidence of positive results to increase with age, as does the risk of colorectal cancer. Further efforts to increase the incidence of colorectal cancer detection should be directed toward increasing the awareness of primary care physicians and improving their screening practices. We stress that high-risk populations should be given special attention and the use of flexible proctosigmoidoscopes should be encouraged.

Nonpalpable breast cancer: needle-localized biopsy for diagnosis and considerations for treatment.

Screening mammography as an adjunct to physical examination led to the discovery of 237 radiographically suspicious but nonpalpable breast lesions. Needle localization of the lesion preoperatively in the mammography suite followed by breast biopsy led to the diagnosis of 64 nonpalpable carcinomas, including 25 invasive, 16 minimally invasive, and 23 noninvasive cancers. Noninvasive and minimally invasive cancers were microscopic. Of the invasive lesions, 7 were 10 mm or less in diameter and 14 were 11 to 20 mm in diameter. Noninvasive and minimally invasive cancers tended to occur in younger women (average age 52 and 51 years, respectively), and almost uniformly appeared as clustered calcifications mammographically. Invasive cancers affected an older population (average age 65 years), and the mammographic appearance was that of a mass in the majority of cases. A variety of surgical procedures were carried out subsequent to biopsy to provide definite treatment of these nonpalpable breast cancers. A review of surgical specimens available from these procedures demonstrated a 27 percent incidence of residual disease at the biopsy site. In patients who underwent mastectomy, 34 percent had an unsuspected focus of cancer in another quadrant of the breast and an additional 14 percent had an unsuspected focus of epithelial atypia. No patient with either noninvasive or minimally invasive cancer was found to have axillary lymph node metastases. Twenty-nine percent of patients with invasive tumors demonstrated lymph node metastases in the axilla. Our results demonstrate the efficacy of preoperative needle localization to assist in the biopsy of nonpalpable breast lesions and the diagnosis of a significant number of early breast cancers. The treatment plan for patients with these cancers must address the high incidence of residual disease at the biopsy site, multicentricity, and the proved capacity for invasive lesions to metastasize to the axillary lymph nodes, regardless of the size of the primary tumor.

Factors affecting the incidence of lymph node metastases in small cancers of the breast.

Six hundred twenty-six cases of breast cancer treated at the Mason Clinic during the period from January 1, 1977 to December 31, 1987 were retrospectively reviewed. The review included only tumors 2 cm or less in maximal diameter and sought to determine the degree of correlation between axillary lymph node metastases in each of the following: patient age, estrogen receptor status, tumor location, degree of histologic differentiation, and tumor size. Only tumor size correlated significantly with the incidence of axillary lymph node metastases (p = 0.000001). The degree of differentiation appeared to correlate with the incidence of lymph node involvement but was not statistically significant (p = 0.17). No other subset of the above factors could be identified in association with axillary lymph node metastases. Forty-five noninvasive tumors were encountered in this series; none were associated with axillary lymph node metastases. The findings of this review lend support to the importance of screening mammography in the detection of breast cancer.

Role of surgery in the treatment of inflammatory breast carcinoma.

Twenty-eight patients with inflammatory carcinoma of the breast have been retrospectively reviewed. Overall 5 year survival was 25 percent. There was a trend toward improved survival in patients who received chemotherapy which did not achieve statistical significance. Sixteen patients underwent mastectomy as part of their treatment. These patients had a 48 percent 5 year survival which was significantly better than the survival in patients who did not undergo mastectomy. Furthermore, mastectomy resulted in better control of the local disease. Of 12 patients who did not undergo mastectomy, local control was initially obtained in only 2, and both of these patients suffered local recurrence within 1 year. Our data support the conclusion that mastectomy be combined with preoperative and postoperative multiagent cytotoxic chemotherapy in the treatment of inflammatory carcinoma of the breast. More precise staging may permit better prognostic stratification of patients with this highly malignant cancer.

Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection.

Tylectomy with axillary lymph node dissection and radiotherapy (TAD) has become an accepted treatment for early breast cancer and has been shown to result in equal 5- and 8-year survival when compared with modified radical mastectomy (MRM). In order to determine the safety of TAD with respect to wound complications and to identify potential risk factors, we reviewed the charts of 560 patients undergoing MRM (n = 387) and TAD (n = 173) at Virginia Mason Medical Center from 1983 through 1989. The incidence of infection, seroma, hematoma, and epidermolysis were compared, and obesity, age 60 years or older, smoking, antibiotics, and wound drainage were examined as possible risk factors. There were more wound complications in the MRM group versus the TAD group (49% versus 35%; p less than 0.01), specifically more seromas (29% versus 18%; p less than 0.01) and epidermolysis (18% versus 0%). In the MRM group, age 60 years or older was associated with seroma (p less than 0.01) and smoking was associated with epidermolysis (p less than 0.01). In the TAD group, obesity was associated with infection. In both groups, volume of drainage from closed suction wound drains greater than 30 mL in the 24 hours prior to removal of the last drain was associated with seroma (p less than 0.05).

Outpatient inguinal herniorrhaphy with both regional and local anesthesia.

Fifty-three patients who were undergoing outpatient inguinal herniorrhaphy with short-acting regional anesthetic agents and local infiltration of a long-acting anesthetic were retrospectively compared with a matched population of 53 hospitalized patients who were undergoing herniorrhaphy with a long-acting regional anesthetic. There was a significantly greater incidence of urinary retention in the hospitalized patients who received long-acting regional anesthetic agents. Otherwise, complications in the two groups were similar. Inguinal herniorrhaphy can be accomplished as an outpatient procedure without increased morbidity. This can result in significant savings in hospital bills. We suggest that anesthesia for inguinal herniorrhaphy is most satisfactorily provided by the combination of a short-acting regional anesthetic agent and a long-acting local one.

Choices of operation for subclavian-vertebral arterial disease.

Subclavian-vertebral artery disease requires careful delineation of symptoms and offers a wide selection of operative procedures. The transition over a 10 year period from intra- to extrathoracic operations in a series of 35 patients is described.

Endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.

The results of surgical treatment of bowel obstruction caused by peritoneal carcinomatosis.

Thirty-four patients with malignant bowel obstruction have been evaluated with particular regard to survival, success of decompression and incidence of reobstruction. In patients with intestinal obstruction caused by peritoneal carcinomatosis the following have been determined: 1) surgery is not urgent, 2) surgical decompression usually is possible, 3) surgical decompression may facilitate additional adjuvant therapy, and 4) death is usually not caused by reobstruction after surgical decompression.

Reduction of morbidity after radical mastectomy.

In spite of all the conflicting literature concerning carcinoma of the breast, there has been little data available on the very common problem of postmastectomy skin flap necrosis. Other than age, the dominant predisposing factor appears to be the type of incision employed. Transverse incisions are associated with a significantly lower incidence of skin flap necrosis. The incidence of postmastectomy lymphedema is increased after adjuvant irradiation and in patients who have had skin flap necrosis. These data will hopefully be of practical use to the surgeon performing mastectomy, as an aid in reducing postoperative morbidity.