Reassessing the role of axillary lymph-node dissection in patients with early-stage breast cancer.

INTRODUCTION: There is considerable controversy regarding the value of axillary lymph-node dissection in the adjuvant systemic therapy of patients with early-stage breast cancer. Our objective was to assess the impact of nodal status in assigning adjuvant chemotherapy to these patients. METHODS: We carried out a review of all patients with stage I or II breast cancer treated at 3 university-affiliated hospitals in Saskatoon between Jan. 1, 1998, and Dec. 31, 2000. Data collected included: patient age, sex, tumour size, hormone receptor status, nuclear grade and presence of lymphovascular invasion. Patients were categorized as being at low, high or intermediate risk for recurrence based on Canadian consensus guidelines and at low or high risk according to criteria established by the United States National Institutes of Health (NIH). The influence of nodal status on subsequent treatment was determined assuming that all patients younger than 70 years at high risk of recurrence would receive chemotherapy. RESULTS: We identified 327 women with stage I or II breast cancer in whom all prognostic factors were available for analysis. Applying the Canadian criteria to determine the need for adjuvant chemotherapy, 68% of women would receive chemotherapy regardless of lymph-node status. Applying the NIH criteria, 82.5% of women younger than 70 years would receive adjuvant chemotherapy regardless of nodal status. CONCLUSIONS: Nodal status has little influence on subsequent management. Adoption of a selective approach to axillary lymph-node dissection could avoid the potential morbidities of this procedure in many patients with early-stage breast cancer.

Gastrocolic fistulae as a consequence of benign gastric ulcer disease.

Gastrocolic fistulae are a rare entity, occurring most commonly in the context of a malignant process or less frequently as a complication of a benign gastric ulcer. Presenting symptoms tend to be nonspecific, but the diagnosis can be confirmed with near certainty by barium enema examination or an upper gastrointestinal series. Although the management of gastrocolic fistulae has historically been surgical, medical management has recently been recommended as the first line of treatment when an underlying malignancy can be excluded.

Decline in popularity of general surgery as a career choice in North America: review of postgraduate residency training selection in Canada, 1996-2001.

There has been a perception that fewer medical students are currently pursuing careers in general surgery. To investigate the validity of this premise we reviewed the Canadian Residency Matching Service (CaRMS) database from 1996 to 2001 and identified recent trends in graduates' selections. Three surgical specialties--general surgery, orthopedic surgery, obstetrics and gynecology--were chosen for analysis as "poor lifestyle" specialties. They were compared to anesthesia, diagnostic radiology, and ophthalmology, which were chosen as representative "good lifestyle" specialties. Linear regression and chi-square analyses were performed to identify significant changes in applications to each specialty. A negative trend in first-choice applications to all three "poor lifestyle" specialties was observed, whereas all three "good lifestyle" specialties experienced increased first-choice applicants. Potential factors influencing medical student residency selection are discussed, emphasizing the reduced number of first-choice applicants to general surgery.

Thymoma: a review of the clinical and pathological findings in 65 cases.

INTRODUCTION: Although rare, thymoma is the most common tumour of the anterior mediastinum. In an effort to assess the clinical and pathologic characteristics of this tumour and to determine whether clinicopathologic stage or histopathologic classification correlates with clinical outcome, in the Department of Pathology and the Department of Surgery at the University of Saskatchewan we reviewed all cases of thymoma registered in the province of Saskatchewan using the database of the Saskatchewan Cancer Centre. METHODS: In 65 patients with a diagnosis of thymoma or thymic carcinoma identified from the Saskatchewan Cancer Centre database between Jan. 1, 1960, and Dec. 31, 2000, we studied the presentation, diagnostic investigations, therapeutic interventions, tumour size, postoperative course, clinical stage, histopathologic classification, disease recurrence and mortality. RESULTS: Of the 65 patients, 17 (26%) were asymptomatic and 11 (17%) had symptoms consistent with myasthenia gravis. Surgical resection is most commonly performed through a median sternotomy and frequently requires en bloc resection of one or more adjacent structures. The overall survival of patients with thymomawas found to correlate with the clinical stage as described by Masaoka and colleagues and with complete tumour resection. A trend to clinicopathologic correlation was observed when applying the histologic classification systems of Suster and Moran and the World Health Organisation, but this trend was not statistically significant. CONCLUSIONS: Thymoma is a rare tumour with a variable clinical presentation. Clinical outcome correlates with clinical stage and the ability to achieve complete tumour resection.

Nontraumatic massive hemoperitoneum from melanoma metastatic to the uterus.

We have reported a case of nontraumatic massive hemoperitoneum caused by melanoma metastatic to the uterus that was readily managed with surgery. We believe this strategy provided effective palliation, improved quality of life and potentially prolonged survival for this patient.

The sarcomatous guise of cervical ectopic hamartomatous thymoma.

BACKGROUND: Ectopic hamartomatous thymoma is a rare benign neoplasm occurring in the deep soft tissues adjacent to the sternoclavicular joint. Although clinical presentation and diagnostic imaging can be consistent with a malignant lesion such as a sarcoma, recognition of pathologic features can readily exclude such a diagnosis. However, this remains a challenge caused by their unusual histologic features and diverse composition. Recognition of this tumor is, however, important, because it follows a benign clinical course, and conservative surgical excision is the therapy of choice. METHODS: A literature review of all reports of ectopic hamartomatous thymoma was undertaken and compared with our indexed case. RESULTS: From this review, we identified 26 previous reports. Most patients were men, with a 4.5:1 predominance. There was a wide range of ages at presentation, from 26 to 79 years. All tumors were located in the lower neck, with the exception of one arising presternally. Treatment predominantly consisted of tumor resection, with no reported recurrences on follow-up. CONCLUSIONS: We conclude that ectopic hamartomatous thymoma is an extremely rare neoplasm usually presenting in the lower neck. Correct identification of this tumor is important, because it follows a benign course, and surgical excision is adequate therapy.