A study of radiotherapy modalities combined with continuous 5-FU infusion for locally advanced gastrointestinal malignancies.

AIM: We describe the feasibility of combining infusional 5-fluorouracil (5-FU) with intraoperative radiation therapy (IORT). METHODS: Patients with surgically resectable locally advanced gastrointestinal cancers were treated concurrently during surgery with IORT and a 72 h infusion of 5-FU. Patients without previous external beam radiation therapy (EBRT) were subsequently treated with EBRT (40-50Gy) concurrent with a 21-day continuous infusion of 5-FU. Pancreatic, gastric, duodenal, ampullary, recurrent colorectal, and recurrent anal cancer were included. RESULTS: During IORT/5-FU, no chemotherapy-related grade III or IV hematologic or gastrointestinal toxicity was noted. Post-surgical recovery or wound healing was not affected. One of nine patients who received post-operative radiation required a treatment break. During follow-up, there were more complications in patients with pelvic tumours, especially those with previous radiation. Nine patients have had local and/or local regional recurrences, two of these in the IORT field. CONCLUSIONS: Treatment with a combination of IORT and 5-FU followed by EBRT and 5-FU is feasible. However, long-term complications may be increased in previously irradiated recurrent pelvic tumours.

Scrotal temperatures do not differ among young boys wearing disposable or reusable diapers.

BACKGROUND/AIMS: This study investigated the effect of specific, commonly used diaper types on scrotal temperatures in normal healthy, young boys. These included both modern disposable and reusable diapers as well as various types of protective outer coverings that are in common use in both North America and Europe METHODS: Scrotal and skin surface temperatures were continuously monitored in healthy, young males using a computerized data-logging system based on temperature probes specifically designed for paediatric studies. These systems could be used either tethered to the PC or made completely portable depending upon the age and activity of the child being measured. Based on our results from several pilot studies, it became clear that the best way to determine if disposable and reusable diapers differ with regard to their impact on scrotal temperatures is to run these comparisons under controlled laboratory conditions where "diaper type" was the primary variable. A 2-h time period was chosen to ensure that sufficient time had elapsed for thermal equilibrium to be established under the diapers. We also felt it necessary to study the impact of urination and simulated this condition over the last 15 min using standardized methods. In addition to the skin surface temperatures, we also measured the temperature of the tympanic membrane using an infrared thermometer as an estimate of "core" temperature for each individual at various times during the session. RESULTS AND CONCLUSIONS: In this study, we have clearly shown that scrotal temperatures are the same whether the child is wearing disposable or reusable cloth diapers with a protective cover. The only situation in which scrotal temperatures were found to be lower is when the cloth diaper is used alone without a protective cover but this is not representative of how these products are actually used. We also found that on average scrotal temperatures are significantly lower than core for each diaper type. Occasionally, we did see individuals in which the maximal scrotal temperatures approached core temperatures but in every case the thermal sensors were soiled by a bowel movement. We also found that skin surface temperatures increased not only when covered by a diaper but also due to the thermal insulation provided by outer garments and blankets.

Clinical experience with HLA-B7 plasmid DNA/lipid complex in advanced squamous cell carcinoma of the head and neck.

OBJECTIVE: To investigate the safety and efficacy of alloantigen plasmid DNA therapy in patients with advanced head and neck squamous cell carcinoma using Allovectin-7 (Vical Inc, San Diego, Calif), a DNA/lipid complex designed to express the class I major histocompatibility complex antigen HLA-B7. DESIGN: Multi-institutional prospective trial. SETTING: Academic medical setting. PATIENTS: A total of 69 patients were enrolled in 3 sequential clinical trials: a single-center phase 1 trial and 2 multicenter phase 2 trials. Eligibility criteria included unresectable squamous cell carcinoma that failed conventional therapy, Karnofsky performance status score of 70 or greater, and no concurrent anticancer or immunosuppressive therapies. INTERVENTION: Patients received 2 biweekly intratumoral injections of 10 microg (phase 1 and first phase 2 trials) or 100 microg (second phase 2 trial) of Allovectin-7 followed by 4 weeks of observation. Patients with stable or responding disease after the observation period were given a second treatment cycle identical to the first. MAIN OUTCOME MEASURES: Patients were assessed for toxic effects, and tumor size was measured after cycles 1 (at 6 weeks) and 2 (at 16 weeks). RESULTS: Allovectin-7 treatment was well tolerated, with no grade 3 or 4 drug-related toxic effects. Of 69 patients treated, 23 (33%) had stable disease or a partial response after the first cycle of treatment and proceeded to the second cycle. After the second cycle, 6 patients had stable disease, 4 had a partial response, and 1 had a complete response. Responses persisted for 21 to 106 weeks. CONCLUSIONS: Intratumoral plasmid DNA immunotherapy for head and neck cancer with Allovectin-7 is safe, and further investigations are planned in patients with less advanced disease, where it could potentially improve patient survival and reduce the need for radical high-morbidity treatments.

Surgical palliation at a cancer center: incidence and outcomes.

HYPOTHESIS: Surgical intervention in palliative care is common; however, the indications, risks, and outcomes are not well described. DESIGN: Retrospective review of surgical cases during a 1-year period with a minimum 1-year survival update. SETTING: A National Cancer Institute-designated comprehensive cancer center. PATIENTS: Patients with a cancer diagnosis undergoing operative procedures. MAIN OUTCOME MEASURES: Number of palliative surgeries and analysis of length of stay, morbidity, and mortality. RESULTS: Palliative surgeries comprised 240 (12.5%) of 1915 surgical procedures. There were 170 major and 70 minor procedures. Neurosurgical (46.0%), orthopedic (31.3%), and thoracic (21.5%) surgical procedures were frequently palliative. The most common primary diagnoses were lung, colorectal, breast, and prostate cancers. Length of hospital stay was 12.4 days (range, 0-99 days), with 21.3% of procedures performed on an outpatient basis. The 30-day mortality was 12.2%, with 5 patients dying within 5 days of their procedure. The overall mortality was 23.3% (56/240). Mortality for surgical procedures classified as major was 21.9% (44/170) and 10.0% (7/70) for those classified as minor (Fisher exact test, P<.01). CONCLUSIONS: Significant numbers of palliative procedures are performed at our cancer center. Overall morbidity and mortality were high; however, a significant number of patients had short hospital stays and low morbidity. Palliative surgery should remain an important part of end-of-life care. Patients and their families must be aware of the high risks and understand the clear objectives of these procedures.

Clinical and cost effectiveness of a new hepatocellular MRI contrast agent, mangafodipir trisodium, in the preoperative assessment of liver resectability.

BACKGROUND: Improved preoperative assessment of focal liver disease and tumors could have a potentially significant impact on their treatment. Mangafodipir trisodium (Teslascan; Nycomed Amersham Imaging, Little Chalfont, UK) is a new hepatocellular contrast agent for use with state-of-the-art MR imaging that, in early reports, is accurate in detection and characterization of liver lesions. METHODS: Records and diagnostic images of all patients undergoing enhanced Teslascan MRI (T-MRI) at our institution were reviewed. We assessed the relative sensitivities of contrast-enhanced CT scan (CECT) and T-MRI in detecting lesions, as well as the impact of T-MRI in the decision to operate or not on patients. In those patients taken to surgery, the correlation between T-MRI and intraoperative palpation and intraoperative ultrasound (IOUS) was determined. RESULTS: Fifty-four patients were noted on CECT to have focal liver lesions and subsequently underwent imaging with T-MRI. The T-MRI correlated with CT findings in 22 patients (41%), upstaged the liver disease in 26, and demonstrated fewer lesions in 6. Only 43 patients were considered operative candidates and T-MRI influenced the operative decision in 32 patients (74%), dissuading operative intervention in 14. In the 25 patients without clear preoperative evidence of unresectability who were taken to the operating room, T-MRI correlated with findings of intraoperative palpation in 19 (76%). In the 20 patients who underwent IOUS, T-MRI correlated with IOUS in 14 patients (70%). IOUS detected an additional nine lesions, all of which were <1 cm. Seventeen patients underwent resection and/or ablation of their liver lesions. Compared with pathology, sensitivities of CECT, T-MRI, and intraoperative evaluation were 61%, 83%, and 93%, respectively. T-MRI failed to predict hepatic-specific unresectability in only one of eight patients, the other seven having extrahepatic disease. CONCLUSIONS: These findings suggest that T-MRI is more sensitive than CECT in the preoperative predicting of the resectability of hepatic lesions. Despite T-MRI accurately correlating with intraoperative surgical findings, IOUS should be performed on all patients prior to a final decision to resect or ablate a focal liver lesion.

Is specimen mammography beneficial?

HYPOTHESIS: Specimen mammography is not beneficial in the management or outcome of patients undergoing image-guided needle-localized breast biopsies. DESIGN: A retrospective study of consecutive patients who underwent needle/dye-localized breast biopsies between January 1, 1993, and December 31, 1995. SETTING: National Cancer Institute (Bethesda, Md)-designated comprehensive cancer center. PATIENTS: One hundred sixty-four patients underwent 165 needle/dye-localized breast biopsies for suspicious mammographic abnormalities. RESULTS: In only 3 (1.8%) of 165 patients did the patient clearly benefit from specimen mammography. In no patient was a malignant neoplasm missed. The mean time for the specimen mammogram was 20 minutes, adding an additional 55 hours of operating room time. Specimen mammography cost an additional $60,522 and was incorrect in 41 (24.8%) of 165 patients. CONCLUSION: Specimen mammography added little to patient care, as only 3 (1.8%) of 165 patients benefited from the information.

Postoperative suppressive therapy for thyroid adenomas.

Thyroid adenoma is a common disease. If partial thyroidectomy is performed, postoperative suppression therapy is often given to avoid nodule development in the remaining thyroid. It is unclear whether this treatment is warranted. Patients who underwent a partial thyroidectomy with a histologic diagnosis of follicular thyroid adenoma from January 1985 until February 1998 were studied retrospectively. Patients were analyzed on the basis of postoperative therapy, new thyroid nodule growth, and costs. Seventy-six patients were identified with a recurrence rate of 4 per cent (3/76). Sixty-one per cent (46/76) were treated with postoperative thyroid suppression therapy, and no difference in new nodule development was noted with at least 6 months of follow-up (P = 0.274). No patients required reoperation. A large cost saving was shown for patients who were not treated with levothyroxine. We conclude that postoperative thyroid suppression may not be routinely indicated. A prospective, randomized study would be necessary to answer this question conclusively.

Contralateral prophylactic mastectomy improves the outcome of selected patients undergoing mastectomy for breast cancer.

BACKGROUND: Risk factors for contralateral breast cancer (CBC) may indicate a benefit for contralateral prophylactic mastectomy (CPM) at the time of unilateral mastectomy for breast cancer. The purpose of this study is to evaluate the efficacy of CPM in preventing CBC. METHODS: sixty-four patients undergoing CPM and a control group of 182 patients not undergoing CPM and matched for age, stage, surgery, chemotherapy, and hormonal therapy were retrospectively compared for CBC rate, disease-free survival, and overall survival. RESULTS: Thirty-six CBCs occurred in the control group. In the CPM group, 3 CBCs were found at the time of prophylactic mastectomy, but none occurred subsequently (P = 0.005). Disease-free survival at 15 years in the CPM group was 55% (95% confidence interval [CI] 38% to 69%) versus 28% (95% CI 19% to 36%) in the control group (P = 0.01). Overall survival at 15 years was 64% (95% CI 45% to 78%) CPM versus 48% (95% CI 39% to 58%) in controls (P = 0.26). CONCLUSION: CPM prevented CBC and significantly prolonged disease-free survival. Future studies will need to address risk assessment and contralateral breast cancer prevention in patients treated for early breast cancer.

Lung cancer found unresectable at thoracotomy: reappraisal of an old problem.

We review our experience with unresectable non-small cell lung cancer, after adoption of a more aggressive surgical approach, including mediastinal lymph node dissection. Cases with enlarged mediastinal lymph nodes (MLNs, cN2) that were predicted to be resectable were included. Our objective was to identify preoperative findings to prevent unnecessary thoracotomy. In 1988-1997, 192 patients had thoracotomy for non-small cell lung cancer. Fifteen cases (7.7%) were found unresectable at thoracotomy. CT scans demonstrated enlarged MLNs in 7 of 15 and enlarged hilar lymph nodes in 6 of 15 cases. The tumor abutted the hilum in 5 of 15, chest wall in 2 of 15, and mediastinal structures in 7 of 15 cases. Atelectasis was seen in 3 of 15 cases. During the same period, 63 patients with stage III disease, including 39 patients with enlarged MLNs, were resected. The unresectability rate for cN2 patients was 15.2 per cent. Five (33%) patients were physiologically unable to tolerate the required pneumonectomy [forced expiratory volume in 1 second, 1.65 liters (range, 1.15-2.07)]. There were three (20%) esophageal invasions, two (13.3%) mediastinal invasions, two (13.3%) aortic invasions, two (13.3%) metastases to the diaphragm, and one (6.6%) invasion of proximal pulmonary artery. Median survival was 4 months. Two-year actuarial survival was 8 per cent. We conclude that careful palpation and dissection were required to establish unresectability. Preliminary thoracoscopy would have prevented thoracotomy in two cases (13.3%) of diaphragmatic metastases but would not reliably establish unresectable invasion of mediastinal structures.

Beyond palliative mastectomy in inflammatory breast cancer--a reassessment of margin status.

BACKGROUND: Inflammatory breast cancer is a locally advanced tumor with an aggressive local and systemic course. Treatment of this disease has been evolving over the last several decades. The aim of this study was to assess whether current therapies, both surgical and chemotherapeutic, are providing better local control (LC) and overall survival (OS). We also attempted to identify clinical and pathologic factors that may be associated with improved OS, disease-free survival (DFS), and LC. METHODS: A 25-year retrospective review performed at the City of Hope National Medical Center identified 90 patients with the diagnosis of inflammatory breast cancer. RESULTS: Of the 90 patients identified with inflammatory breast cancer, 33 received neoadjuvant therapy (NEO) consisting of chemotherapy followed by surgery with radiation (n = 26) and without radiation (n = 7). Fifty-seven patients received other therapies (nonNEO). Treatments received by the nonNEO group consisted of chemotherapy, radiation, mastectomy, adrenalectomy, and oophorectomy, alone or in combination. The median follow-up was 28.9 months for the NEO group and 17.6 months for the nonNEO group. Borderline significant differences in the OS distributions between the two groups were found (P = .10), with 3- and 5-year OS for the NEO group of 40.0% and 29.9% and for the nonNEO group of 24.7% and 16.5%, respectively. DFS and LC were comparable in the two groups. Lower stage was associated with an improved OS (P < .05). The 5-year OS for stage IIIB was 30.9%, compared to 7.8% for stage IV. In those patients with stage III disease who were treated with mastectomy and rendered free of disease, margin status was identified by univariate analysis to be a prognostic indicator for OS (P < .05). The 3-year OS, DFS, and LC for patients with negative margins were 47.4%, 37.5%, and 60.3%, respectively, compared to 0%, 16.7%, and 31.3% in patients with positive margins. CONCLUSIONS: This study suggests that in patients with inflammatory breast cancer and nonmetastatic disease, an aggressive surgical approach may be justified with the goal of a negative surgical margin. Achievement of this local control is associated with a better overall outcome for this subset of patients. The ability to obtain negative margins may further identify a group of patients with a less aggressive tumor biology that may be more responsive to other modalities of therapy.

Ethnic differences in the behavior of hepatocellular carcinoma.

BACKGROUND: The purpose of this study was to examine the clinical presentation, prognostic factors, and survival rates of patients with hepatocellular carcinoma (HCC) and to examine differences between Asian and non-Asian patients with HCC. METHODS: A review of the clinical characteristics and laboratory evaluations for 76 patients in two different broad ethnic groups (Asians [Group 1] and non-Asians [Group 2]) who underwent treatment for HCC from 1977-1995 was performed. Chi-square and Cox regression analyses were performed to assess factor interaction and association with survival. RESULTS: A total of 24 patients in Group 1 and 52 patients in Group 2 were reviewed. Of the clinical variables examined, a higher rate of a history of hepatitis B positivity was observed in Group 1 compared with Group 2 (32% vs. 6%; P=0.001). Among the 76 patients with HCC, a 1-year survival estimate of 41.4% was found. There was a borderline significant difference in survival between Group 1 and Group 2 with a 1-year survival estimate of 29.5% versus 46.9%, respectively (P=0.08). Better overall survival was found in patients who had tumors that were resectable (P=0.0001), had an alpha-fetoprotein level <10 ng/mL (P=0.02), or were a younger age at the time of diagnosis (P=0.01). There was a trend for Asian race (P=0.08) to be associated with poorer survival. When these risk factors were entered into a multivariate analysis, tumor resectability and non-Asian race were most predictive of improved survival (model P value = 0.007). When controlling for the multiple variables most often reported to be associated with HCC, Asians had a significantly lower survival than non-Asians (P<0.01). CONCLUSIONS: In this study it appears that the outcome for Asian patients with hepatoma is worse than for non-Asian patients, even when controlling for factors commonly associated with HCC. Biologic or social factors that are not appreciated currently may be involved in Asian patients with HCC, contributing to a poorer clinical outcome.

Resection with external beam and intraoperative radiotherapy for recurrent colon cancer.

OBJECTIVE: To review treatment outcomes for patients with locoregional recurrent colon cancer who underwent resection, intraoperative radiotherapy (IORT), and external beam radiotherapy (EBRT). DESIGN: Retrospective study of patients treated between January 1990 and June 1994. SETTING: Tertiary care cancer center. PATIENTS: Eleven patients with bulky recurrent colon cancer extending to adjacent organs or structures signed informed consent forms to receive IORT. INTERVENTION: Of 10 patients who underwent exploratory laparotomy, 5 had no metastatic disease and underwent resection, IORT, and EBRT. Complete resection was accomplished in 4 patients. Doses of IORT ranged from 13 to 20 Gy depending on residual tumor burden; EBRT was typically delivered postoperatively to a dose of 45 Gy. MAIN OUTCOME MEASURES: Survival and locoregional tumor control. RESULTS: All 4 patients who underwent complete resection, IORT, and EBRT are alive without locoregional recurrence 53 to 77 months after treatment. Of these, only 1 patient developed distant metastases. The fifth patient, who had gross residual tumor, developed local recurrence 5 months after IORT. One patient developed an IORT complication-ureteral fibrosis leading to ipsilateral nephrectomy. CONCLUSION: Long-term disease-free survival can be achieved in selected patients with bulky regional recurrence of colon cancer with complete tumor resection, IORT, and EBRT.

Phase I trial of intraperitoneal iododeoxyuridine with and without intravenous high-dose folinic acid in the treatment of advanced malignancies primarily confined to the peritoneal cavity: flow cytometric and pharmacokinetic analysis.

In this Phase I study, the maximally tolerated doses (MTDs) of i.p. iododeoxyuridine (IdUrd) alone and in combination with i.v. calcium leucovorin (LV) were determined. The pharmacokinetics and pharmacological advantage of IdUrd were evaluated, and flow cytometric analysis allowed examination of the extent of incorporation of IdUrd into tumor cells with and without the addition of i.v. LV. Thirty-nine patients with advanced neoplasms primarily confined to the peritoneal space were enrolled in a dose-escalation trial using 4-h dwells of IdUrd administered i.p. daily for 4 days with and without an i.v. infusion of LV 500 mg/m2/day for 4.5 days. Twenty-three patients received single-agent therapy, and 13 patients received i.p. IdUrd in combination with i.v. LV. The MTD of single-agent IdUrd administered on this schedule was 4125 mg/m2/day for 4 days; and that of the IdUrd in combination was 3438 mg/m2/day. Dose-limiting toxicities were myelosuppression and stomatitis. During the period of the dwell, the peritoneal AUC (area under the curve) of IdUrd exceeded the plasma AUC of IdUrd by one or two orders of magnitude in all patients at all doses tested; there was a possible effect of LV on peritoneal AUC. The geometric mean pharmacological advantage (AUCperitoneal/ AUCplasma) was 181 at 625 mg/m2/day and 90 at 4538 mg/m2/day. Flow cytometric analysis suggests saturation of IdUrd measured in DNA at the 2500-3125 mg/m2 dose level, without an increase after the addition of LV. Twelve patients received 4-12 courses of therapy. One patient with recurrent ovarian cancer who received 16 courses of therapy experienced complete resolution of her ascites, near normalization of CA-125 levels, and improved quality of life; two patients with high-risk tumors receiving "adjuvant" therapy are disease-free at 3 and 6 years after treatment; other patients experienced transient clearing of ascites. The recommended Phase II dose of i.p. IdUrd using a 4-h dwell daily for 4 days is 3750 mg/m2/day alone or 3125 mg/m2/day in combination with continuous i.v. LV at 500 mg/m2/day for 4.5 days. Although flow cytometric data suggest that DNA incorporation of IdUrd is not affected by the addition of LV, the cytotoxicity of the combination regimen may be increased due to LV-enhanced, IdUrd-related inhibition of thymidylate synthase. For this reason, we recommend that efficacy studies of the combination continue in parallel with studies of IdUrd alone.

Surgical management of thyroid cancer invading the airway.

BACKGROUND: Locally advanced thyroid cancer invading the tracheal cartilage represents a difficult treatment dilemma during thyroidectomy. METHODS: A retrospective chart review was performed to determine the results of laryngotracheal resection or tracheal cartilage shave with adjuvant radiotherapy in patients with locally advanced thyroid cancer invading the upper airway. RESULTS: Of 597 patients undergoing thyroidectomy for thyroid cancer, 40 were found to have laryngotracheal invasion. Thirty-five patients with superficial invasion underwent cartilage shave procedures with adjuvant radiotherapy; five with full-thickness invasion underwent radical resection, including tracheal sleeve resection (n = 3) or total laryngectomy (n = 2). Histologic subtypes included papillary (n = 32), follicular (n = 2), Hurthle cell (n = 1), medullary (n = 3), and anaplastic (n = 2). Of the cartilage shave group, 25 are currently alive with no evidence of disease at a mean follow-up of 81 months (range 1-290). Six developed isolated local/regional recurrence and were managed with total laryngectomy (n = 1), tracheal resection (n = 1), cervical lymphadenectomy (n = 1), or repeat radiotherapy (n = 3). All six patients remain free of disease at a mean follow-up of 5 years. Of those who underwent initial laryngotracheal resection, four remain free of disease at a mean follow-up of 5 years. The rates of 10-year disease-free survival and overall survival for all patients were 47.9% (95% confidence interval [CI] 24.8, 71.0) and 83.9% (95% CI 70.3, 97.5), respectively. CONCLUSIONS: These data suggest that adequate management of thyroid cancer with laryngotracheal invasion can be achieved with a more conservative surgical approach and adjuvant radiotherapy, reserving more radical resections for extensive primary lesions or locally recurrent disease.

Local recurrence in breast cancer: implications for systemic disease.

BACKGROUND: Recurrence in breast carcinoma follows a pattern of growth marked by local, regional, or widespread dissemination. Local recurrence may be the harbinger of systemic disease or failure of local control. Delineation of these processes may have implications in treatment. METHODS: A retrospective review found 1,171 patients with stages I and II breast cancer from 1978 to 1990 treated at the City of Hope Medical Center. RESULTS: Twenty-seven percent (n = 313) of patients developed recurrences. These were classified as local, including chest wall and regional nodes (n = 40), local and distant (n = 63), and distant (n = 210). Mean follow-up was 60 months. Multivariate analysis demonstrates tumor size was not different between the three groups, but the presence of positive lymph nodes was: local = 51%, local and distant = 78%, and distant = 64%. The disease-free interval was longest in the local group (42 months) versus the local and distant group (23 months) and distant group (39 months). Median survival was calculated from the time of recurrence: local = 90 months, local and distant = 26 months, and distant = 16 months. CONCLUSIONS: A group of patients with local recurrence have improved survival and do not develop distant disease. This group may benefit from aggressive surgical treatment to control local disease. These data suggest that a subset of breast tumors can act locally aggressive without metastatic potential.

Survey of physicians' attitudes relative to the field of surgical oncology.

BACKGROUND: Surgical oncology as a distinct field of expertise is fairly young. The current study was designed to gain a better understanding of the attitude of practicing physicians toward the field of surgical oncology. METHODS: Three hundred twenty-seven physicians in the San Gabriel Valley (a suburban area adjacent to Los Angeles) responded to an anonymous survey of opinions regarding surgical oncology. Responses were placed into a computerized database. RESULTS: Of those responding, 179 were primary care physicians, 52 were general surgeons, 78 were gynecologists, and 18 were medical oncologists. Overall, 89% of physicians were familiar with the field of surgical oncology, but only 47% had ever heard of The Society of Surgical Oncology (SSO). Ninety-four percent of the respondents felt that a surgical oncologist should care for patients with complex cancer, and 63% of respondents felt that surgical oncologists should care only for patients with complex cancer. Familiarity with the field of surgical oncology and with the SSO correlated with the percentage of the physicians practice that was cancer related. Only 22% of physicians felt that the field of surgical oncology is redundant to the general surgical specialties. CONCLUSIONS: Results of the survey indicate that there is considerable recognition of the unique expertise of the surgical oncologist by the medical community. Unfortunately, many physicians are not familiar with the SSO. Educating physicians in the community about the SSO may help to further expand the role of the surgical oncologist in the care of the patient with cancer, standardize the expectations of the skills and training of a surgical oncologist, and set a benchmark for the surgical subspecialty.

Cancer of the male breast: a review.

A review of 20 cases of male breast cancer in 17 patients from 1959 to 1990 was performed. The median age at presentation was 53.3 years (range: 29 to 79). At the time of diagnosis, 30% (6) patients were stage I, 65% (13) stage II, and 5% (1) stage IV. Surgery was the initial form of therapy in all cases either as a radical mastectomy, modified radical mastectomy, or total mastectomy. The median disease-free survival was 4.8 years with a 5-year disease-free survival of 41%, and with a 5-year overall survival of 47%. Seven patients are alive with no evidence of disease, two are alive with disease, five have died of disease, and two died of other causes. Estrogen receptor (ER) and progesterone receptor (PR) assays were performed on the tumors of 10 patients, with 80% being ER positive and 70% PR positive. The median disease-free survival for ER positive patients was 6 months with a 5-year disease-free survival of 12.5%. The overall median survival for this group was 2.9 years with an overall 5-year survival of 25%. In this review there was a high percentage of patients who were ER positive. The positive receptor status had value in predicting decreased survival.

Repair of a complex body wall defect using polytetrafluorethylene patches.

Techniques for repair of chest wall, abdominal wall, and diaphragm have been well described, but simultaneous repair of defects involving each of these three areas after tumor ablation provides the surgeon with a difficult technical problem. Repair of a large defect with two polytetrafluorethylene patches after resection of an osteosarcoma invading the lower chest wall, abdominal wall, and diaphragm is described.

Restoration of oral function after maxillectomy with osseous integrated implant retained maxillary obturators.

This study assesses the success rate of osseous integrated implantation in assisting the prosthetic obturation of maxillectomy defects. Twenty-three patients received a total of 85 osseous integrated implants used for retaining maxillary obturators between 1985 and 1993. Defects include 13 radical maxillectomies, 5 premaxillary resections, 4 subtotal maxillectomies, and 1 soft-palate resection. Thirteen patients (50 implants) received a radiation dose ranging from 5,040 to 7,940 cGy. Implants can be placed at the time of ablation or subsequently. Efforts were made to spare uninvolved segments of the maxilla, especially premaxillary segments and tuberosities, at the time of ablation. Following a 6-month period of integration, implants were uncovered and utilized in prosthetic rehabilitation. Specific implant sites reveal variable success rates, with the anterior maxilla being 86% successful compared with the posterior maxilla being 57% successful. Radiation reduces the success rate from 80% to 55%, although it does not eliminate a patient from being a candidate for implantation. Prosthetic rehabilitation of large maxillary defects can be greatly facilitated with the use of osseous integrated implants in the remaining midfacial skeleton.