Long-term outcome after neoadjuvant radiochemotherapy in locally advanced noninflammatory breast cancer and predictive factors for a pathologic complete remission : results of a multivariate analysis.

BACKGROUND: An earlier published series of neoadjuvant radiochemotherapy (NRT-CHX) in locally advanced noninflammatory breast cancer (LABC) has now been updated with a follow-up of more than 15 years. Long-term outcome data and predictive factors for pathologic complete response (pCR) were analyzed. PATIENTS AND METHODS: During 1991-1998, 315 LABC patients (cT1-cT4/cN0-N1) were treated with NRT-CHX. Preoperative radiotherapy (RT) consisted of external beam radiation therapy (EBRT) of 50 Gy (5 × 2 Gy/week) to the breast and the supra-/infraclavicular lymph nodes combined with an electron boost in 214 cases afterwards or-in case of breast conservation-a 10-Gy interstitial boost with (192)Ir afterloading before EBRT. Chemotherapy was administered prior to RT in 192 patients, and concomitantly in 113; 10 patients received no chemotherapy. The update of all follow-up ended in November 2011. Age, tumor grade, nodal status, hormone receptor status, simultaneous vs. sequential CHX, and the time interval between end of RT and surgery were examined in multivariate terms with pCR and overall survival as end point. RESULTS: The total pCR rate after neoadjuvant RT-CHX reached 29.2%, with LABC breast conservation becoming possible in 50.8% of cases. In initially node-positive cases (cN+), a complete nodal response (pN0) after NRT-CHX was observed in 56% (89/159). The multivariate analysis revealed that a longer time interval to surgery increased the probability for a pCR (HR 1.17 [95% CI 1.05-1.31], p < 0.01). However, in large tumors (T3-T4) a significantly reduced pCR rate (HR 0.89 [95% CI 0.80-0.99], p = 0.03) was obtained. Importantly, pCR was the strongest prognostic factor for long-term survival (HR 0.28 [95% CI 0.19-0.56], p < 0.001). CONCLUSION: pCR identifies patients with a significantly better prognosis for long-term survival. However, a long time interval to surgery (> 2 months) increases the probability of pCR after NRT-CHX.

[Staged analgesic therapy in tumor pain]. / Analgetische Stufentherapie bei Tumorschmerz.

Overall, pain is one of the most common symptoms associated with cancer and often produces greater anticipatory distress than other features of the disease. Drug selection depends on the intensity of pain rather than on the specific pathophysiology. Mild to moderate pain can often be treated effectively by so-called "weak" opioids. Non-opioid analgesics, like acetyl-salicylic acid or paracetamol can be added according to the "analgesic ladder" proposed by the World Health Organization (WHO). Opioids should be given on a fixed time schedule thereby, preventing pain from recurring. Additional rescue doses (approximately 50 degrees, of baseline single dose) are given for breakthrough pain. Noninvasive (oral, rectal, sublingual, transdermal and intranasal) routes of application should be maintained as long as possible to preserve independence and mobility. When treatment by infusion therapy (subcutaneous, intravenous, epidural) has been elected, the addition of patient controlled analgesia (PCA), which permits patients to administer a preset amount of narcotic at preset intervals, is an effective means to manage breakthrough and incident pain in selected patients. Antidepressants, anticonvulsants and some antiarrhytmics are used as co-analgesics. Oral medication alone can guarantee pain relief in about 95% of the patients. The WHO analgesic ladder has proven effective in all settings of patients care.

An unusual case of left upper lobe pulmonary edema.

This is a report of an unusual case of left, predominantly upper lobe, pulmonary edema secondary to paravalvular mitral regurgitation (MR) complicating mitral valve replacement. Transesophageal echocardiography proved helpful in making the diagnosis of MR and suggesting the mechanism of the pulmonary edema.

Contiguous pattern spreading in patients with Hodgkin's disease.

BACKGROUND: In 1966, Rosenberg and Kaplan hypothesized that Hodgkin's disease (HD) arises at a discrete primary site and subsequently spreads in a predictable manner via functionally contiguous lymph nodes. However, their results were not statistically evident. It was our aim to describe the spreading in the lymphatic system more precisely and to confirm their postulate. METHODS: Between 1971 and 1992, 297 patients underwent pathological staging for HD. Our subsequent evaluation was restricted to the 236 cases with cervical involvement (65 bilateral, 80 dextral and 91 sinistral), those with lymph nodes on the right side (65 + 80 = 145) being analyzed separately from those with tumours on the left (65 + 91 = 156). Spreading via the lymphatic system was assessed by scoring of the number of involved and uninvolved nodes in six regions, which are functionally contiguous in the lymph system but not necessarily anatomically neighboured. The number of 'gaps' (i.e. missed nodes) observed according to a systematic spreading model was compared with that expected (probability model) if a random course had been followed. RESULTS: Of the 156 patients with left cervical HD, 117 (75%) had para-aortic or spleen involvement, 90 (58%) had mediastinal involvement, 65 (42%) had right cervical involvement, 50 (32%) had axillary involvement and 23 (15%) had inguinal involvement. Of the 145 patients with right cervical HD, 112 (77%) had mediastinal involvement, 89 (61%) had para-aortic or spleen involvement, 65 (44%) had left cervical involvement, 44 (30%) had axillary involvement and 16 (11%) had inguinal involvement. In patients with left or right cervical lymph nodes, the proportions observed with gaps in the spreading were 37 and 27% (SE 7%), respectively, whereas the corresponding values of gaps expected in a probability model if a random course of spreading had been followed would have been 84 and 73% (P = 0.0001 and 0.0001, respectively). CONCLUSION: Our data support the concept that HD spreads in a predictable manner via functionally contiguous lymph nodes. In patients with right cervical lymph nodes, HD spreads via the upper mediastinum and pulmonary hila to the upper abdominal nodes and the spleen. In those with left cervical tumours, HD spreads directly to the abdomen (bypassing the mediastinum), then upward again via the pulmonary hila and upper mediastinum to the neck region (bilateral involvement) and from here it proceeds to the axillary nodes. Finally the inguinal nodes are involved.

Spectral analysis of demodulated ultrasound returns: detection of scatterer periodicity and application to tissue classification.

Ultrasound returns from tissue display variations in amplitude on several spatial scales. Although large-scale variations result from factors such as attenuation, variations on smaller scales are caused by tissue characteristics such as variations in scatterer spacing and reflectance. These small scale variations cause a corresponding variation in the amplitude of the ultrasound return. A simple and direct method for detecting and quantifying periodicity in these variations in the presence of attenuation is described. The radiofrequency ultrasound return is first demodulated by full-wave rectification. The normalized power spectrum of the demodulated return then yields an index that we call the relative Fourier energy. Both computer simulations and in vitro experiments were performed in order to study how relative Fourier energy performed in discriminating between periodic and random scatterer distributions. Computer simulations demonstrated significant differences between the returns from periodic and random scatterer distributions. Ultrasound returns from aortic tissue yielded a relative Fourier energy index that was significantly different between normal vs. atherosclerotic tissue (normal: 0.868 +/- 0.076, mean +/- s.d., fibrofatty plaque: 0.705 +/- 0.109, p < 0.01 vs. normal, calcified plaque: 0.753 +/- 0.078, p < 0.01 vs. normal). In contrast, no difference was found in comparisons of overall reflectance.

[Radiotherapy of primary non-Hodgkin lymphoma of the stomach]. / Strahlentherapie primärer Non-Hodgkin-Lymphome des Magens.

Primary gastric non Hodgkin's lymphoma is a localized disease, which tends to local recurrences. Local treatment by surgery and/or radiotherapy is adequate for small low malignant primary gastric lymphomas of stages IE and IIE. Larger tumors should be resected before radiotherapy and systemic treatment. Chemotherapy alone has its impact in high grade lymphomas and as adjuvant treatment for tumors < 5 cm. Prospective randomized studies are underway to establish the respective role of the treatment modalities. The radiotherapeutic technique for gastric lymphomas is outlined. The risk of blocking part of the tumor volume by shielding the kidneys is mentioned.

[Interdisciplinary therapy of anal carcinoma]. / Interdisziplinäre Therapie des Analkarzinoms.

Primary radiation therapy is a safe sphincter sparing treatment for anal carcinomas less than 4 cm. In larger tumors results have improved dramatically in recent years by use of chemoradiation. Simultaneous radiochemotherapy of anal carcinoma leads to a 5-year survival rate of 80% with only 3 to 8% severe side effects, a local control of 75% and a conservation of sphincter function in 80%. If the tumor is smaller than 4 cm, radiotherapy alone is sufficient in patients with contraindications for chemotherapy; however, the risk of severe late side effects increases to 10%. A colostomy is indicated in patients with severe or complete stenosis of the anal canal with incontinence or obstruction by the tumor, in case of tumor nonresponding to radiotherapy or inoperable with painful defecation. Abdominoperineal resection should be limited to residual tumors increasing two months after radiotherapy, to salvage after relapse, to fistulas and necroses developing as complications of radiotherapy, to ulcers and fecal incontinence and to cases of a extended primary tumor (T4). Clinically suspicious lymph nodes should be biopsied. Histologically positive inguinal nodes should be treated with radiochemotherapy without groin dissection. A monthly follow-up is necessary in cases with residual tumor. If the size of the tumor increases, a biopsy is indicated. In case of relapse a second radiochemotherapy should be considered. Otherwise an abdominoperineal resection is indicated.

Echocardiographically guided electrophysiologic testing in pregnancy.

Electrophysiologic testing is usually performed with fluoroscopy to guide catheter positioning. This method of visualizing catheter placement may not be ideal for patients who are pregnant. We report four cases of echocardiographically guided placement of catheters for electrophysiologic testing because of the consideration of pregnancy. Adequate visualization of catheters was possible, allowing for proper catheter positioning and complete electrophysiologic testing, including the recording of atrial, His-bundle, and ventricular potentials, as well as cardiac stimulation and induction of tachycardia. This method holds promise for patients in whom fluoroscopy may be relatively contraindicated, such as pregnant patients, as well as patients in whom it is desirable to avoid x-ray exposure such as women of childbearing age and young children.

Early and rapid prediction of patency of the infarct-related coronary artery by using left ventricular wall thickness as measured by two-dimensional echocardiography.

OBJECTIVES: The aim of this study was to determine whether echocardiography can distinguish between persistent coronary occlusion and reperfusion. BACKGROUND: There are no adequate clinical or noninvasive laboratory markers to accurately predict successful reperfusion in an acute myocardial infarction. METHODS: In a closed chest swine model, the effect of reperfusion on myocardial wall thickness was studied by comparing a 150-min total coronary artery occlusion (group 1) with 120 min of occlusion followed by 30 min of reperfusion (group 2) in the area of risk as measured by echocardiography. Wall thickness was measured at baseline and at 90 and 150 min. RESULTS: In group 1 (n = 4), there was no appreciable change in mean wall thickness from 90 min to 150 min of occlusion at either end-diastole or end-systole (0.54 +/- 0.02 to 0.52 +/- 0.03 cm, 0.55 +/- 0.03 to 0.54 +/- 0.03 cm, respectively; p = NS). In contrast, in group 2 (n = 6), an increase in mean wall thickness from 0.53 +/- 0.02 to 0.97 +/- 0.05 cm at end-diastole and from 0.56 +/- 0.04 to 1.04 +/- 0.07 cm at end-systole was found from 90 min of occlusion to 30 min of reperfusion (p < 0.001). Reperfusion resulted in an increase in wall thickness of 83 +/- 11% at end-diastole and 92 +/- 17% at end-systole. In contrast, persistent coronary occlusion showed minimal changes of -3.0 +/- 5% at end-diastole and -2.0 +/- 6% at end-systole. CONCLUSIONS: This study confirms the hypothesis that an increase in wall thickness can accurately distinguish between reperfusion and permanent coronary occlusion.

Nurse burnout: work related and demographic factors as culprits.

This study was an examination of the combined ability of perceived work environment, demographic, and work-related variables to predict burnout among 314 nurses at a large metropolitan hospital. The three dimensions of burnout measured were emotional exhaustion, depersonalization, and personal accomplishment. High work pressure and low work involvement and supervisor support predicted emotional exhaustion. Task orientation, work pressure, work involvement, and age predicted both depersonalization and personal accomplishment. Burnout among nurses on each of the three work shifts also was examined. Results are discussed from the perspective of how to decrease or to prevent burnout among nurses.

[The results of the endocavitary irradiation of early-stage rectal tumors]. / Ergebnisse der endokavitären Bestrahlung von Rektumtumoren im Frühstadium.

Intracavitary contact radiotherapy was used according to the guidelines of J. Papillon in 91 patients with early rectal tumors (72 adenocarcinomas and 19 villous adenomas) at the Dijon Cancer Institute. Most of the patients were referred because of poor surgical risk. Ten patients had interstitial implants in addition, 96% of the patients had a complete response. The local control rate after five years was 74% (67/91). Including salvage the ultimate control rate was 91% (83/91). 85% (77/91) had preservation of the sphincter function. The size of the rectal cancer and the degree of rectal wall invasion were of prognostic impact as proposed by the clinical staging system of Dijon.

[Radiotherapeutic quality assurance in the Hodgkin's disease study HD4 supported by the BMFT (Bundesministerium für Forschung und Technologie)]. / Radiotherapeutische Qualitätssicherung in der BMFT-Studie Morbus Hodgkin (HD4).

In the German Hodgkin Study Group a radiotherapy assurance program is being carried out at the radiotherapeutic reference centre in Göttingen since April 1988: 74 patients were entered from 27 radiotherapeutic institutions. 18 of them participated in a quality assurance program and submitted the data of 29 patients: In 21 of the 29 patients the protocol was followed correctly. Physical aspects of quality control showed two major deviations from the protocol: one center used photon energies of more than 15 MVX without mould; another had a anterior-posterior loading of 3:1. The radiation oncology assessment detected six inadequate treatments: The safety margin was inappropriate in three of 26 mantle fields. Another center used a multiple field technique, and in two patients the paraaortic region was not irradiated.

The Dijon clinical staging system for early rectal carcinomas amenable to intracavitary treatment techniques.

The Dijon clinical and endoscopic staging system for intracavitary radiotherapy of rectal cancer takes into account the size and the depth of penetration of the rectal wall. Its prognostic value was evaluated in a series of 72 patients with rectal adenocarcinoma treated at the Centre de Lutte Contre le Cancer G. F. Leclerc in Dijon: 30 presented with a clinical stage (CS) T1A (purely exophytic tumors of less than 3 cm). The 5-year local relapse-free actuarial survival (LRFS) was 97%. Fourteen patients with CS T1B (infiltrative component and less than 3 cm diameter) had a LRFS of 77%. Nine patients with CS T2A tumors (with larger exophytic tumors) has a LRFS of 65%. Nineteen CS T2B cases (larger than 3 cm with an infiltrative component) presented a LRFS of 60%. The size of the tumor and the clinical estimate of the infiltration of the rectal wall both have a significant prognostic value: adenocarcinoma of less than 3 cm (n = 44) had a LRFS of 93% versus 59% in larger ones (n = 39; p = less than 0.01). Free mobile lesions (n = 39) did better (n = 33; LRFS = 86%) than infiltrated tumors (n = 33; LRFS = 66%; p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the nasopharynx. The significance of lymphocytic infiltration.

From 1974 to 1985, 76 patients with nasopharyngeal carcinoma (NPC) received irradiation with curative intent and 14 with palliative intent in our department. Of the 76 patients, 59 presented with UICC stage IV. The 5-year actuarial survival rate was 41% and the relapse-free survival rate (RFS) 45%. The slides were reviewed according to the World Health Organization (WHO) histologic classification, also taking into account the degree of lymphocytic infiltration according to its Cologne modification. Undifferentiated carcinoma and non-keratinizing carcinoma had similar 5-year RFS (47 and 44% respectively). Patients with major lymphocytic infiltration in the tumor presented with younger median age, with smaller primary tumors and with more advanced neck disease than the other patients. There was, however, no obvious association between the degree of lymphatic infiltration in the tumor and the prognosis. Patients with major lymphocytic infiltration had a 5-year RFS of 44%, versus 49% for patients without such infiltration.