Treatment options in surgical management of breast cancer.

The surgical approach to primary operable breast cancer has changed greatly within the past millenium. In the last 20 years collaborative patient trials have generated a wealth of valuable information that now allows us the opportunity to offer women a number of surgical options where before there was only one. The long awaited results of the chemoprevention trials will almost certainly change our surgical approach even further. Many questions regarding the management of breast cancer remain unanswered.

Pancreaticoduodenectomy for suspected but unproven malignancy.

BACKGROUND: Pancreaticoduodenectomy is an accepted surgical option for certain benign conditions and biopsy proven cancer. Whether this procedure should be performed when malignancy of the pancreas and periampullary region is suspected but not confirmed represents a fairly common intraoperative dilemma. PATIENTS AND METHODS: Sixty-seven patients who had undergone pancreaticoduodenectomy during a 15-year period were evaluated retrospectively. RESULTS: The indications for resection were symptomatic benign conditions (n = 10, 15%), proven pancreatic or periampullary cancer (n = 37, 55%), and suspected but unproven malignancy (n = 20, 30%). The patients with suspected malignancy ranged in age from 27 to 73 years. Common findings in this group were abdominal pain (75%), jaundice (70%), weight loss (65%), and alcohol use (45%). There were 14 pancreatic and 6 ampullary masses. Biopsies obtained preoperatively (n = 15) and intraoperatively (n = 11) were nonconfirmatory. Postoperatively 9 patients (45%) were found to have tumors, including 6 pancreatic adenocarcinoma, 2 duodenal adenocarcinoma, and 1 islet cell tumor. Six of the 8 adenocarcinomas (75%) were stage I. Seven patients were alive 11 to 108 months later. The most common benign diagnosis was pancreatitis. There were 8 complications and 1 death. CONCLUSIONS: Pancreaticoduodenectomy performed based on suspicion alone frequently reveals malignancy. Immediate and long-term outcomes are acceptable. These findings justify a continued aggressive approach to suspected pancreatic and periampullary malignancy.

Is there a prognostic difference between functional and nonfunctional islet cell tumors?

BACKGROUND: Pancreatic islet cell tumors are categorized as either functioning or nonfunctioning. Functioning islet cell tumors (FIT) elaborate a variety of hormones, producing dramatic symptoms, while the initial presentation of non-functioning islet cell tumors (NIT) is commonly an abdominal mass or symptom complex related to invasion of adjacent structures. As a result, NIT are purported to present at a later stage, with lower resectability rates, and an overall poorer prognosis, when compared to FIT. In addition, a number of reports have indicated that the incidence of NIT has increased significantly in recent years. PATIENTS AND METHODS: Twenty-eight patients were studied retrospectively. All had islet cell tumors of the pancreas and were seen at the University of Nebraska Medical Center and affiliated Nebraska Methodist Hospital during a 19-year period. RESULTS: There were 9 patients (32%) in the NIT group and 19 (68%) in the FIT group. The mean ages at presentation were 61 years for the NIT and 52 years for the FIT group. In the NIT group, all presented with either abdominal pain (n = 7) or jaundice (n = 2). In contrast, over 90% of the patients with FIT had symptoms referable to the specific hormone elaborated by the tumor. Primary tumor size for NIT was 4.1 +/- 0.7 cm versus 5.0 +/- 0.6 cm for the FIT group. No significant difference was found for NIT versus FIT with respect to the incidence of metastatic disease at presentation (44% versus 53%), resectability rate with curative intent (44% versus 53%), or disease-free survival at 2 years (67% versus 40%). CONCLUSIONS: This series, in contrast to earlier reports, suggests that nonfunctioning islet cell tumors do not present at a more advanced stage, have lower resectability rates, or an overall poorer long-term prognosis when compared to functioning tumors.

Motor vehicle deaths: a rural epidemic.

OBJECTIVE: To determine the magnitude of the discrepancy in injury death rates between urban and rural counties and which types of injury deaths contribute most to this discrepancy. DESIGN: A review of Nebraska death certificates over the period 1985-1989 was undertaken. Counties were divided into four groups according to population. Group I: urban counties (n = 3); group II: counties with a town of greater than 10,000 (n = 9); group III: counties with a total population of greater than 10,000 (n = 19); group IV: counties with a total population of less than 10,000 (n = 62). Age-adjusted death rates for heart disease, cancer, cerebrovascular disease, pneumonia, and injury were tabulated. Injury deaths were further categorized by intentional injury (homicide, suicide), and unintentional injury (motor vehicle-related, falls, drownings, poisoning, farm machinery-related, choking, firearms-related, fire-related and burns). INTERVENTIONS: None. RESULTS: Age-adjusted death rates per 100,000 population (with 95% confidence intervals) in group IV were lower than in group I for heart disease: 209 (193.9-224.1) vs. 227.4 (216.3-238.5); cancer: 135.9 (123.7-148.1) vs. 176.3 (166.6-186.0); cerebrovascular disease: 39.9 (33.3-46.5) vs. 44.6 (39.7-49.5); pneumonia: 19.6 (15.0-24.2) vs. 23.4 (19.8-27.0); and intentional injury deaths: 13.3 (9.5-17.0) vs. 15.1 (12.2-18.0). However, age-adjusted unintentional injury death rates were 54.2% higher in group IV than in group I: 42.7 (35.9-49.5) vs. 27.7 (23.8-31.6). Motor vehicle-related death rates were 93% higher: 23.3 (18.2-28.4) vs. 12.1 (9.5-14.7); and farm machinery-related deaths were 1250% higher: 2.7 (1.0-4.4) vs. 0.2 (-0.1-0.5). CONCLUSION: Age-adjusted unintentional injury death rates are higher in the rural counties of Nebraska, even though death rates for the four other leading causes of death (heart disease, cancer, cerebral vascular disease, and pneumonia) and intentional injury are lower. Although farm machinery-related deaths have the largest percentage difference between rural and urban counties, motor vehicle-related deaths are the major contributor to the unintentional injury death rate discrepancy in rural Nebraska.

Duplex scans before subclavian vein catheterization predict unsuccessful catheter placement.

Subclavian catheterization in patients with cancer is associated with up to a 38% incidence of subclavian vein thrombosis. These thrombi seldom recanalize. The persistent occlusion of the subclavian vein may hinder subsequent catheter placement. To determine the frequency of this occurrence and to determine if preoperative duplex scanning could identify these individuals, we performed preoperative duplex scanning in 22 patients who had previously had an indwelling subclavian catheter for chemotherapy. Subsequent subclavian vein catheterization was attempted without knowledge of the results of the duplex scan. Nineteen scans were normal. Of these, 18 patients underwent successful catheter placement. In one patient, catheterization was unsuccessful and an intraoperative venogram showed a focal obstruction of the proximal portion of the subclavian vein. Three scans showed noncompressibility of the vein, and catheter placement was unsuccessful in these three veins. In patients who have had previous subclavian catheters, persistent obstruction of the vein prevents subsequent catheter placement in 14%. Duplex scanning before subsequent catheter placement generally identifies these individuals.

Influence of the etiology of pancreatitis on the natural history of pancreatic pseudocysts.

We reviewed our experience with 90 patients with pancreatic pseudocysts to determine if the cause of pancreatitis influenced the patients' outcome. Acute pancreatitis (AP) occurred in 57 (63%) patients due to alcoholic (n = 15), postoperative (n = 14), biliary (n = 12), and other etiologies (n = 16). Thirty-three (37%) patients had chronic pancreatitis (CP) secondary to alcohol use (n = 27) or other causes (n = 6). Multiple pseudocysts were significantly more frequent in patients with acute alcoholic pancreatitis than in patients with chronic pancreatitis (47% versus 19%, p < 0.05). Spontaneous resolution occurred within 8 weeks in 10 (11%) patients with pseudocysts (AP = 9%, CP = 15%, p = NS). However, no patient with pseudocyst associated with biliary or postoperative pancreatitis underwent spontaneous resolution. Although pseudocysts associated with chronic pancreatitis were smaller in size (8.0 +/- 4.7 versus 5.7 +/- 3.8 cm, p < 0.05), a similar proportion of them required operation compared with AP pseudocysts (56% versus 58%). There were significantly more deaths in patients with postoperative pancreatitis compared with all other groups (29% versus 7%, p < 0.05). The outcome of pseudocysts was similar regardless of size (greater than 6 cm versus less than 6 cm) and presentation (acute versus delayed). Thus, the etiology of pancreatitis was a more important determinant of pseudocyst outcome than pseudocyst size or presentation.

Utility of duplex ultrasound in the diagnosis of asymptomatic catheter-induced subclavian vein thrombosis.

Asymptomatic thrombosis of the subclavian vein is common after placement of indwelling catheters. The sequelae of these thrombi are not known. Investigation is hampered by the requirement for venography for diagnosis; consequently, a noninvasive method of diagnosis would be welcome in this context. We have studied prospectively 32 subclavian catheters to determine the usefulness of duplex ultrasound in diagnosing asymptomatic thrombosis. Sixteen arm venograms were normal and all gave normal duplex scans. No false-positive scans were obtained. Eleven venograms demonstrated nonocclusive mural thrombi. Only three of these were seen with duplex ultrasound. Five totally occlusive thrombi were seen on venography, of which only two were detected with duplex sonography. The three thrombi not found with duplex ultrasound were short proximal venous occlusions. The insensitivity of this technique to asymptomatic subclavian thrombi limits its usefulness as a screening tool.

Limitations of magnetic resonance imaging and ultrasound-directed (duplex) scanning in the diagnosis of subclavian vein thrombosis.

To investigate the potential role of magnetic resonance imaging and duplex scanning in the diagnosis of catheter-induced subclavian vein thrombosis, we correlated the results of 43 arm phlebograms with duplex scans; 28 of these phlebograms were also correlated with magnetic resonance imaging scans of the thoracic veins. Eighteen of the 43 phlebograms were normal, and all had normal magnetic resonance imaging and duplex studies. Eleven subclavian veins were totally occluded on phlebography; all had duplex scans, and five were also scanned with magnetic resonance imaging. Duplex scans detected 6 of 11 occlusions, whereas magnetic resonance imaging detected 4 of the 5 occlusions scanned. The five occlusions that were not detected by either magnetic resonance imaging or duplex scans were short segmental occlusions of the medial one third of the left subclavian vein. Of 14 nonocclusive thrombi seen on phlebography, duplex scans correctly identified 8. Magnetic resonance imaging was done on eight nonocclusive thrombi but identified only two. All abnormal findings on duplex scanning and magnetic resonance imaging were confirmed by phlebography. Short occlusions of the proximal portion of the left subclavian vein were often undetected by duplex scanning but occasionally seen with magnetic resonance imaging. Neither modality was sensitive to the presence of nonocclusive mural thrombi. Magnetic resonance imaging is highly reliable in ruling out the presence of a thrombotic process in the subclavian vein, but it may on occasion fail to detect the presence of subclavian thrombi. For this reason, in cases with suspected subclavian vein thrombosis magnetic resonance imaging cannot be used as the only diagnostic modality.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters.

Thrombosis is common after placement of silicone rubber subclavian vein catheters in patients with malignancy receiving conventional doses of chemotherapy. To determine the incidence of this complication in marrow transplant patients and the effect of different catheter designs on thrombosis rates, patients were randomized to receive either open-ended Hickman catheters or valve-ended Groshong catheters for venous access during the transplantation procedure. A total of 35 catheters were placed, of which 23 were double-lumen (11 Groshong and 12 Hickman) and 12 were single-lumen (six Groshong and six Hickman). Arm venograms were performed on all patients at the time of hematopoietic recovery or occurrence of symptoms of subclavian vein thrombosis. There were 10 cases of total subclavian vein thrombosis (three were symptomatic) and 12 cases of asymptomatic non-occlusive mural thrombi. Only 13 normal veins were found. There was no difference in thrombosis rate between the Hickman and Groshong catheters. Double lumen catheters tended to be more likely to cause total venous occlusion (nine of 23) than single lumen catheters (one of 12) (p = 0.06, Fisher's exact test). We conclude that subclavian vein thrombosis is a common occurrence after placement of silicone rubber catheters for venous access during marrow transplantation. Most cases are asymptomatic. Groshong catheters are just as likely to cause this complication as Hickman catheters.

Anesthesia for glucagonoma resection.

Anesthetic experience with three cases of the resection of glucagonoma, a rare tumor of alpha cells of pancreatic islets, is presented. Marked increases of blood glucagon and glucose levels, with the potential for clinically significant metabolic and myocardial dysfunction, did not occur during anesthesia and surgery. Associated tumors of other endocrine cell types also were absent in the three study patients. Strategies for anticipating and managing other perioperative problems associated with glucagonoma also are discussed.

Glucagonoma syndrome is an underdiagnosed clinical entity.

Glucagonomas, considered among the rarest of the islet cell neoplasms, produce a well-defined clinical syndrome characterized by necrolytic migratory erythema, diabetes mellitus, glossitis, anemia, and weight loss. This report describes seven patients with glucagonoma treated at our institution. All seven had the characteristic dermatologic manifestations, present from 1 to 6 years prior to diagnosis. Five patients had extensive disease at the time of initial operation, three of whom underwent aggressive cytoreductive surgery, whereas the other two had biopsy only. The remaining two patients presented with a single nodule each, underwent distal pancreatectomy and splenectomy, and remain free of disease 2 and 6 years postoperatively. Earlier recognition of the distinctive physical findings peculiar to this syndrome should increase survival. Aggressive cytoreductive surgery results in prolonged remission.

Comparison of ulcer surgery at a Veterans Administration and University Hospital.

We compared the patient populations and outcome of surgery for peptic ulcer disease in 81 patients at a Veterans Administration Hospital (OVAH) and 97 patients at an affiliated University Hospital (UNH). The surgeons and choice of operation were comparable at both facilities. Patients were similar with respect to severity of ulcer disease, percentage of elderly patients and distribution of comorbid conditions. There were significantly more female patients (45% vs 2%, P less than 0.05), patients less than 40 years old (22% vs 6%, P less than 0.05), and patients with gastric ulcers (27% vs 12%, P less than 0.05) at UNH. Alcoholism was more prevalent at OVAH (57% vs 22%, P less than 0.05). Postoperative morbidity and mortality rates were 27 per cent and 14 per cent at OVAH and 25 per cent and 16 per cent at UNH. These data suggest that quality of care for surgical therapy of ulcer disease at a VA Hospital is comparable to its tertiary care affiliate with a similar patient population.

Seat belts: personal choice or necessity?

The use of occupant restrains in motor vehicles has become an issue which has received increasing legislative attention in recent years. This has occurred due to the supposition that seat belt use would be effective in preventing automobile related fatalities and injuries. Twenty-five states and the District of Columbia now have mandatory safety belt laws in effect which have increased usage rates from 20% or less prior to enactment of the law to between 50% and 70% after implementation. Safety belts have proven effective in minimizing morbidity and mortality. In a study of four states enforcing mandatory usage and neighboring states without seat belt laws as a comparison, between 250 and 350 fatalities were prevented. This extrapolates to an estimated 12,000-15,000 lives saved nationally if restraints were mandatory. Nebraska is one of two states in which a seat belt law has been enacted and subsequently repealed. As a result of the repeal, seat belt usage dropped from 40% in 1986 to 29% in 1987 with an associated increase in injuries. The economic impact associated with this increase in accident related injuries is enormous. The Nebraska repeal campaign was based on the issue of individual rights versus mandatory safety requirements. As health care providers we need to examine the validity of personal rights in comparison to the documented impact of personal restraints on the morbidity and mortality of accident victims.

Thrombotic complications of subclavian apheresis catheters in cancer patients: prevention with heparin infusion.

Twenty-two silicone rubber apheresis catheters were placed into the subclavian veins of 18 cancer patients to allow serial leukapheresis for collection of circulating hematopoietic stem cells. The tips of the catheters were placed in the innominate vein to avoid reinfusion of citrate into the right atrium and the resulting tendency to cardiac arrhythmias. Sixteen catheters were placed without prophylactic anticoagulation. Anticoagulation was prematurely discontinued in one patient because of the inconvenience of the portable heparin infusion pump. Six of these 17 catheters developed venographically proven thrombotic complications and five others had presumed thrombosis-related access failure or caused symptoms of venous obstruction, but confirmation of the presence of a thrombus with venography was not obtained. Three catheters spontaneously withdrew from the vein, one during urokinase infusion for thrombosis. Only three catheters had uncomplicated apheresis courses. Prophylactic heparin infusions via portable infusion pumps were given after placement of six catheters. As long as the heparin infusions were continued all patients had uncomplicated apheresis courses. One patient's heparin was prematurely discontinued. Within 3 days of its discontinuance, radiographically proven thrombotic catheter occlusion occurred. Patients given heparin were less likely to develop complications (P less than 0.001). No unexpected complications of apheresis were encountered as a result of the use of these catheters. Silicone rubber subclavian catheters can be used for peripheral stem cell collection but have a high frequency of thrombotic complications. Systemic anticoagulation with heparin can minimize the likelihood of these complications.

Peritoneovenous shunts palliate malignant ascites.

Fifty-five peritoneovenous shunts (PVS) were implanted in 45 patients (29 LeVeen and 26 Denver shunts). Seventy-five percent of patients experienced relief of symptoms referable to their ascites. The mean survival time post-shunt placement was 33 weeks; however, considerable variation was noted in survival times for the various tumor types (pancreas 7 weeks, ovary 71 weeks). Significant alterations in coagulation parameters consistent with subclinical disseminated intervascular coagulation (DIC) were present in all patients with functioning shunts. These coagulation changes have proven reliable indicators of shunt patency. Shunt revision was necessary in 18 percent of patients. No significant difference in shunt patency was detected when Denver and LeVeen shunts were compared. This experience indicates that PVS offers effective palliation without undue morbidity for malignant ascites. The best results can be expected in those patients with ovarian and breast primary tumors. Because of the short time from onset of disabling ascites until death, PVS is not indicated in the majority of patients with pancreatic cancer.

Postoperative adjuvant irradiation of rectal and rectosigmoid cancer.

Local recurrence is a major problem for approximately 40% of stage B and C rectal cancer patients following successful complete resection by either anterior (AR) or abdominoperineal resection (APR). We retrospectively analyzed the sites of local recurrence in 138 patients following curative surgery, and evaluated the effect of 5,000 rad adjuvant postoperative pelvic EXRT in reducing the incidence of local recurrence in 40 patients.

Urinary polyamines in colorectal cancer.

Urine polyamine content is increased in patients with colorectal malignancy and may be a useful tumor marker in the management of these patients. Urinary excretion of putrescine and spermidine was measured preoperatively and in the first week postoperatively in nine patients with inflammatory bowel disease, eight with other benign colorectal disease, and 13 with colorectal cancer. Preoperative urine putrescine levels were elevated similarly in patients with inflammatory bowel disease and malignancy. Polyamine levels were increased in all three groups in the early postoperative period. Urinary polyamine excretion did not correlate with serum CEA levels, tumor volume, or stage of disease in patients with cancer. Because elevated levels of urinary polyamines are not specific for malignancy and do not correlate with other prognostic indicators, such measurements are unlikely to be useful in tumor detection and determining prognosis. Polyamine levels, however, may prove useful in monitoring response to therapy and detecting recurrences in individual patients.