Nonpalpable breast masses: radiologic predictability of malignancy.

Of 568 nonpalpable breast lesions detected by screening mammography 242 proved to be noncalcified masses; biopsy showed 165 to be benign and 77 malignant. The lesions were evaluated with respect to contour, radiographic density and size. Of the malignant lesions 90% were infiltrating carcinomas, 88% of which had an indistinct contour and were of moderate to high density. Of the benign lesions 40% of those with an indistinct contour demonstrated high radiographic density. Low-density, distinct masses were all benign. There was no correlation between the size of the lesion and whether it was malignant.

Sensitivity to vecuronium in myasthenia gravis: a dose-response study.

A cumulative dose plus infusion technique and integrated EMG monitoring of the first dorsal interosseous muscle were used to determine the potency of vecuronium in 20 normal patients and in ten patients with myasthenia gravis under thiamylal, N2O, O2, fentanyl anaesthesia. The mean (+/- SEM) values for ED50, ED90, and ED95 in the normal patients were 19 +/- 1, 31 +/- 1 and 36 +/- 2 micrograms.kg-1, respectively. Myasthenic patients showed increased sensitivity to vecuronium, the mean values for ED50, ED90, and ED95 were 10 +/- 2, 17 +/- 2 and 20 +/- 3 micrograms.kg-1, being 50, 55 and 56 per cent of normal, respectively. We did not demonstrate a difference in sensitivity to vecuronium between those myasthenic patients who received pyridostigmine preoperatively and those who did not, nor among those chronically treated with corticosteroids, compared with those who were not.

Surgery for nonpalpable breast lesions.

Nonpalpable lesions detected on mammograms were localized in 475 women between 1976 and 1988 by means of the spot method. A malignant neoplasm was noted in 149 patients (31%), including 69 (33%) of 206 with clusters of microcalcifications, 16 (41%) of 39 with calcifications associated with densities and 64 (28%) of 230 with nonpalpable masses. Infiltrating lesions were present in 89 (60%) of 149 patients. Among women with infiltrating lesions who had axillary dissection, 14 (21%) of 67 had positive nodes. In younger women, microcalcifications were more likely to represent neoplasms, masses frequently represented invasive tumors. Among patients with invasive malignant neoplasms who had calcifications, 39% had positive axillary lymph nodes. Spot localization, rather than monitoring, seems appropriate in young women with microcalcifications suggestive of malignant neoplasms and older patients with nonpalpable masses to achieve earlier and more effective treatment of biologically significant occult neoplasms.

Occult malignant breast lesions in 114 patients: relationship to age and the presence of microcalcifications.

This study evaluates the mammographic findings in 352 patients, aged 30-85 years, who underwent spot localization and biopsy for evaluation of nonpalpable breast abnormalities. Malignancy was found at biopsy in 114 cases. The mammographic appearance (specifically, whether grouped microcalcifications, mass, or both were present) was correlated with patient age and histologic findings (specifically, whether the pathologic changes were infiltrating or noninfiltrating in nature). The prevalence of malignant conditions increased directly with age. The presence of grouped microcalcifications as the sole indicator of malignancy was seen in 100% (seven of seven) of the patients in the 30-39-year age group, 64% (18 of 28) in the 40-49-year age group, 37% (11 of 30) in the 50-59-year age group, 30% (seven of 23) in the 60-69-year age group, and 23% (six of 26) in the 70-85-year age group. Of the 49 tumors that were manifested solely as microcalcifications, 34 (69%) were noninfiltrating. The finding of grouped microcalcifications should be aggressively investigated, since it may indicate noninfiltrating carcinoma in an early stage, when the potential for cure is greatest.

Prognosis in occult thymomas in myasthenia gravis following transcervical thymectomy.

Thymomas were noted in 239 (11%) of 2097 myasthenic patients followed up at our institution. Among 996 patients who had undergone thymectomy, 191 patients (19%) had thymomas compared with 48 (4%) of 1101 patients treated without surgery. A definitive diagnosis of thymoma was not made until after thymectomy in 61 patients (35%); in patients not treated with thymectomy, 23% of associated tumors were diagnosed at autopsy. Patients with occult thymomas treated with the transcervical approach had a clinical course superior to those with tumors diagnosed prior to surgery and treated with the transsternal approach. Most of the advantage could be attributed to the association of occult thymomas with small tumor size and to the association of the latter with absence of invasiveness. Small tumor size was significantly associated with higher remission and lower mortality as shown in a proportional hazards analysis. Occult thymomas were accessible through the transcervical approach, with some operations necessitating a complementary mediastinotomy. Thymectomy, through the transcervical approach if technically feasible, is of benefit to all patients, has minimal morbidity, and should be performed early in the course of the disease as a diagnostic and therapeutic intervention since the risk of occult thymomas in patients with myasthenia gravis is high.

Effects of thymectomy in myasthenia gravis.

Factors influencing onset of remission in myasthenia gravis were evaluated in 2062 patients, of whom 962 had had thymectomy. Multivariate analysis showed that appearance of early remissions among all patients was significantly and independently influenced by thymectomy, by milder disease, and by absence of coexisting thymomas. Patients with mild generalized symptoms treated with thymectomy reached remission more frequently, even when compared with those with ocular myasthenia treated without surgery. Short duration of disease before thymectomy in mild cases was another factor associated with earlier remissions. Mortality for all patients was significantly and independently influenced by severity of symptoms, age, associated thymomas, and failure to remove the thymus. Patients without thymectomy and with thymomas had, in addition, earlier onset of extrathymic neoplasms. Morbidity after the transcervical approach was minimal. This study demonstrates that early thymectomy by the transcervical approach, when technically feasible, has significant clinical advantages over the transthoracic approach and should be advocated for all patients with myasthenia gravis, including those with ocular disease.

Clinical experience in more than 2000 patients with myasthenia gravis.

The vast strides in terms of pathophysiologic understanding which have been made in the past 25 years of research in myasthenia gravis are remarkable. This period of time has also seen the evolution of many applicable technological advances to better our care of these patients. Myasthenia's place in the autoimmune family of diseases has been demonstrated. No clear-cut strategy resulting from these discoveries has, however, been more than one of temporary relief or clinical improvement. In our center over these years the performance of early thymectomy in all cases of generalized myasthenia seems to be the one demonstrably reliable technique available. The effect of this procedure on coexisting neoplasia and other autoimmune disease suggests continuing avenues of investigation.

Association of tumor differentiation with caffeine and coffee intake in women with breast cancer.

Caffeine, which has been linked to benign breast disease, has an antineoplastic effect in experimental animals, whereas in tissue cultures it inhibits mitoses and induces cell differentiation. We examined caffeine and coffee intake in 101 women with breast cancer to determine whether either or both influence cell differentiation in tumors as well. Nutrient analysis was performed by the Nutrition Coding Center of the University of Minnesota with the Nutrition Data system from the National Heart, Lung, and Blood Institute. Stepwise logistic regression, with tumor differentiation (well and moderate versus poor) as the dependent variable, was used. The analysis indicates that caffeine and/or coffee intake has a significant association with tumor differentiation as women with moderately to well-differentiated tumors had higher caffeine and coffee intake. This raises the question whether caffeine or coffee consumption may help induce cell differentiation and slow tumor growth.

Association between prognosis and hormone receptors in women with breast cancer.

Axillary node involvement, hormone receptors, tumor differentiation, and obesity have been linked to breast cancer prognosis. We have evaluated which of these factors have an independent association with disease-free survival using the Cox Proportional Hazards model. The study was carried out in 377 patients with breast cancer who underwent mastectomy and axillary node dissection between 1977 and 1984. In the univariate analysis all of the above factors were associated with differences in disease-free survival, and all entered the stepwise model. Among women with negative nodes and those with one to three positive nodes, tumor differentiation was a significant indicator of prognosis, while hormone receptors did not have prognostic significance. The opposite was noted in women with four or more involved nodes, among whom negative hormone receptors was the only significant marker of poor prognosis together with presence of obesity. Among young women node involvement and hormone receptors were significant prognostic indicators, while among older women all four variables were independent prognostic markers. These results indicate a marked heterogeneity among subgroups of women with breast cancer in relation to prognostic markers.

Perioperative blood transfusion has prognostic significance for breast cancer.

The transfusion-induced immune suppression that prolongs kidney graft survival for transplant patients may be detrimental to patients with malignancies. We studied the relationship of blood transfusion to the disease-free survival of 169 patients with operable breast cancer who had undergone mastectomy with axillary dissection at Mount Sinai Hospital between 1964 and 1972. The cumulative 5-year disease-free survival rate for patients who had received transfusions was 51% compared with 65% for patients who had not received blood (p = 0.0210). The two groups of patients were comparable in age, stage, discharge hemoglobin values, proportion of radical mastectomies, and duration of follow-up. Admission hemoglobin values were lower and operative blood loss was higher among patients who had received transfusions, and significant survival differences were noted in relation to operative blood loss: 69% of women with estimated blood loss less than the mean of 370 ml were free of disease at 5 years compared with 50% of women with higher intraoperative losses (p = 0.0279). However, the first year after operation the association of survival with transfusion was highly significant (77% for those who had received transfusions, 94% for those who had not, p = 0.0096), whereas survival rates in relation to operative blood loss differed by only 7% during the same interval (p = 0.1182). These results indicate that perioperative blood transfusion may be a significant prognostic factor for patients undergoing mastectomy for operable breast cancer.