Breast Cancer Cells in the Blood: A Pilot Study.

The goal of this pilot study was to determine in patients with operable breast cancer the incidence of breast cancer cells present in the blood, the clearance rate after surgical resection of the primary tumor, and the incidence of patients with persistent cancer cells in the blood after the primary tumor was removed. Twenty-one patients with operable breast cancer had 15 ml venous blood obtained twice prior to surgery and after surgery at 2, 4, 8, 12, 24, and 48 hours and also on days 7 and 14. Immunomagnetic selection of malignant cells was performed on each sample. Cells were then fixed on slides and immunocytochemistry performed on the collected cells. Cells that had a rosette of magnetic beads, cytoplasmic staining for keratin, and malignant morphology were counted as breast cancer cells. Eighteen of 19 of patients had cancer cells detected in at least one of the two blood samples preceding surgical removal of the primary tumor. The incidence of cancer cells in the blood of patients rapidly declined during the 48 hours postsurgery. The incidence of cancer cells in the blood remained stable in approximately 30% of patients to 14 days. The majority of breast cancer patients in this pilot study (even with small tumors and negative nodes) had detectable cancer cells in the blood prior to resection of the primary tumor. These findings justify further investigation. Successful application of this methodology may serve as a powerful indicator of which patients need systemic adjuvant therapy, the effectiveness of systemic adjuvant therapy, tumor recurrence, and early detection of breast cancer.

Management of coexistent carotid and coronary artery disease.

Simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CE) were done on 133 patients over an 8-year period. Twenty-seven patients (20%) had previous transient ischemic attacks (TIAs), 12 (9%) had previous strokes, and the remainder (71%) were asymptomatic. All asymptomatic patients had greater than 85% stenosis of the internal carotid artery demonstrated by noninvasive ultrasonography and four-vessel angiography. CE was performed prior to the sternotomy for coronary artery bypass, under the same anesthesia. Nineteen patients had bilateral carotid artery disease. Postoperatively, three patients (2.3%) suffered strokes, an additional three patients (2.3%) suffered transient upper extremity weakness, and one patient from each of these groups died. There were no postoperative strokes or TIAs in patients with bilateral carotid artery disease. Average length of hospital stay was 10 days. Our experience leads us to conclude that the morbidity and mortality of the simultaneous procedure are not affected by bilateral carotid artery disease. In patients with symptomatic coronary artery disease and symptomatic carotid artery disease or asymptomatic carotid artery disease with a high-grade stenosis, we think that simultaneous repair of both lesions should be done.

Laparoscopy and the general surgeon.

Laparoscopic cholecystectomy has belatedly awakened the general surgical community to the concept of closed abdominal surgery. Current techniques have largely been developed by our colleagues in gynecology. The unanticipated demand by the public has placed unprecedented pressure on our systems for training, credentialing, developing, supplying, and evaluating changes in surgical technique. The diagnostic value of laparoscopy has been documented by a handful of general surgeons over the past several decades and is likely to become a more widely accepted technique. The potential of future developments in video-controlled operations is immense.

Occluded peripheral arteries: clinical utility of argon laser recanalization.

Optically diverged direct argon laser light energy was used prior to conventional balloon angioplasty to recanalize 30 occluded peripheral arteries in 26 patients. Three of five (60%) iliac and 22 of 25 (88%) femoropopliteal lesions ranging in length from 1 to 47 cm (mean, 17.3 cm) were successfully treated, for an overall technical success rate of 83%. In the femoropopliteal system, 13 of 14 (93%) procedures in lesions less than 20 cm and nine of 11 (82%) procedures in lesions greater than 20 cm were treated successfully. No statistically significant differences in success rate based on lesion site, lesion length, degree of lesion calcification, or severity of peripheral vascular disease were found. Major complications were a laser perforation resulting in treatment failure in one case (3%) and a successfully treated distal embolus in another (3%). No reocclusions occurred in the immediate postoperative period. While long-term follow-up will be required to assess continued patency, this system can potentially increase the number of patients amenable to conventional balloon angioplasty and is currently advocated as an alternative to amputation in patients in whom surgical bypass grafting is contraindicated or unfeasible.

The content of tumor DNA as an indicator of prognosis in patients with T1N0M0 and T2N0M0 carcinoma of the breast.

To determine if the flow cytometric measurement of the content of the tumor DNA could provide prognostic information in T1N0M0 and T2N0M0 carcinoma of the breast, we isolated nuclei from paraffin-embedded tumor specimens from 128 consecutive patients who underwent modified radical mastectomy and were found to have a T1 or T2N0M0 carcinoma of the breast. The content of DNA of the nuclei was determined by flow cytometry. Although the average tumor size was not significantly different, 17 of 56 patients with aneuploid tumors died of cancer compared with 2 of 72 with euploid tumors. The 10-year overall actuarial survival rate of the euploid and aneuploid groups was 72% and 67%, respectively (p less than 0.02). A hazards model of the data shows that the DNA content of the tumor is the most significant indicator of prognosis, with a 2.25-fold increased risk of death for patients with aneuploid tumors. These data show that the tumor DNA content can be used to identify a group of patients with T1 or T2N0M0 carcinoma of the breast with the same prognosis as a group of patients without carcinoma of the breast that would be unlikely to benefit from adjuvant therapy.

STRETCH: a rehabilitative program for patients with breast cancer.

Participants in an exercise-based rehabilitative program for women with breast cancer were evaluated for physical disability. Of 114 women who were evaluated initially, there was almost universal evidence of restriction of range of motion or abnormal posture. Of the 47 women who were available for evaluation after completion of the eight-week program, 42 showed increases in one or more movements with no concomitant decreases. Five patients had a decrease in a single measurement. Of 96 participants evaluated for psychosocial benefits, two thirds reported positive psychologic effects.

Pseudo-occlusion of the internal carotid artery: how not to miss it.

Although pseudo-occlusion of the internal carotid artery has been previously reported, it is not widely appreciated. The purpose of this report is to demonstrate methods of making the diagnosis. We present two cases illustrating the angiographic findings in pseudo-occlusion of the internal carotid artery. Its recognition is important to the vascular surgeon in making recommendations for surgery.

Transluminal angioplasty in a community hospital: a surgeon's viewpoint.

We have found transluminal angioplasty to be a safe and effective procedure for the relief of arterial obstruction. In a community hospital over a 20-month period, we did 100 consecutive dilatation procedures, many involving multiple dilatations, with no morbidity or mortality. Iliac lesions were dilated successfully (74/80) more often than femoral lesions (15/20). Several patients had relief of impotence. Transluminal angioplasty was used successfully as an adjunct to operation both as staged and combined procedures to dilate the donor artery for a femoral-femoral bypass graft or femoral-popliteal graft, or to dilate the outflow of a new or existing graft.

Paradoxical embolization with Ebstein's anomaly.

A 48-year-old woman with known Ebstein's anomaly had bilateral, lower-extremity arterial emboli after a total abdominal hysterectomy. She underwent embolectomy, placement of a Greenfield caval filter, subsequent tricuspid valve replacement, and closure of an atrial septal defect. Antemortem diagnosis of a paradoxical embolus is rare. To our knowledge, this is the first case associated with this congenital cardiac anomaly in a survivor.

Abdominal aortic aneurysmectomy: a community hospital experience.

Resection of abdominal aortic aneurysms during a five-year period at two community hospitals was reviewed. The low mortality compares very favorably with results from large university hospitals.