Behavioural improvements with thalamic stimulation after severe traumatic brain injury.

Widespread loss of cerebral connectivity is assumed to underlie the failure of brain mechanisms that support communication and goal-directed behaviour following severe traumatic brain injury. Disorders of consciousness that persist for longer than 12 months after severe traumatic brain injury are generally considered to be immutable; no treatment has been shown to accelerate recovery or improve functional outcome in such cases. Recent studies have shown unexpected preservation of large-scale cerebral networks in patients in the minimally conscious state (MCS), a condition that is characterized by intermittent evidence of awareness of self or the environment. These findings indicate that there might be residual functional capacity in some patients that could be supported by therapeutic interventions. We hypothesize that further recovery in some patients in the MCS is limited by chronic underactivation of potentially recruitable large-scale networks. Here, in a 6-month double-blind alternating crossover study, we show that bilateral deep brain electrical stimulation (DBS) of the central thalamus modulates behavioural responsiveness in a patient who remained in MCS for 6 yr following traumatic brain injury before the intervention. The frequency of specific cognitively mediated behaviours (primary outcome measures) and functional limb control and oral feeding (secondary outcome measures) increased during periods in which DBS was on as compared with periods in which it was off. Logistic regression modelling shows a statistical linkage between the observed functional improvements and recent stimulation history. We interpret the DBS effects as compensating for a loss of arousal regulation that is normally controlled by the frontal lobe in the intact brain. These findings provide evidence that DBS can promote significant late functional recovery from severe traumatic brain injury. Our observations, years after the injury occurred, challenge the existing practice of early treatment discontinuation for patients with only inconsistent interactive behaviours and motivate further research to develop therapeutic interventions.

Thromboembolic Events Associated with Thalidomide and Multimodality Therapy for Soft Tissue Sarcomas: Results of RTOG 0330.

Introduction. RTOG 0330 was developed to address the toxicity of RTOG 9514 and to add thalidomide (THAL) to MAID chemoradiation for intermediate/high grade soft tissue sarcomas (STSs) and to preoperative radiation (XRT) for low-grade STS. Methods. Primary/locally recurrent extremity/trunk STS: ≥8 cm, intermediate/high grade (cohort A): >5 cm, low grade (cohort B). Cohort A: 3 cycles of neoadjuvant MAID, 2 cycles of interdigitated THAL (200 mg/day)/concurrent 22 Gy XRT, resection, 12 months of adjuvant THAL. Cohort B: neoadjuvant THAL/concurrent 50 Gy XRT, resection, 6 months of adjuvant THAL. Planned accrual 44 patients. Results. 22 primary STS patients (cohort A/B 15/7). Cohort A/B: median age of 49/47 years; median tumor size 12.8/10 cm. 100% preoperative THAL/XRT and surgical resection. Three cycles of MAID were delivered in 93% cohort A. Positive margins: 27% cohort A/29% cohort B. Adjuvant THAL: 60% cohort A/57% cohort B. Grade 3/4 venous thromboembolic (VTE) events: 40% cohort A (1 catheter thrombus and 5 DVT or PE) versus 0% cohort B. RTOG 0330 closed early due to cohort A VTE risk and cohort B poor accrual. Conclusion. Neoadjuvant MAID with THAL/XRT was associated with increased VTE events not seen with THAL/XRT alone or in RTOG 9514 with neoadjuvant MAID/XRT.

Selective disruption of the sarcotubular system in frog sartorius muscle. A quantitative study with exogenous peroxidase as a marker.

Skeletal muscles which have been soaked for 1 hr in a glycerol-Ringer solution and then returned to normal Ringer solution have a disrupted sarcotubular system. The effect is associated with the return to Ringer's since muscles have normal fine structure while still in glycerol-Ringer's. Karnovsky's peroxidase method was found to be a very reliable marker of extracellular space, filling 98.5% of the tubules in normal muscle. It was interesting to note that only 84.1% of the sarcomeres in normal muscle have transverse tubules. The sarcotubular system was essentially absent from glycerol-treated muscle fibers, only 2 % of the tubular system remaining connected to the extracellular space; the intact remnants were stumps extending only a few micra into the fiber. Thus, glycerol-treated muscle fibers provide a preparation of skeletal muscle with little sarcotubular system. Since the sarcoplasmic reticulum is not destroyed and the sarcolemma and myofilaments are intact in this preparation, of the properties of the sarcolemma may thus be separated from those of the tubular system.

Myosin mRNA accumulation and myofibrillogenesis at the myotendinous junction of stretched muscle fibers.

Myofiber growth and myofibril assembly at the myotendinous junction (MTJ) of stretch-hypertrophied rabbit skeletal muscle was studied by in situ hybridization, immunofluorescence, and electron microscopy. In situ hybridization identified higher levels of myosin heavy chain (MHC) mRNA at the MTJ of fibers stretched for 4 d. Electron microscopy at the MTJ of these lengthening fibers revealed a large cytoplasmic space devoid of myofibrils, but containing polysomes, sarcoplasmic reticulum and T-membranes, mitochondria, Golgi complexes, and nascent filament assemblies. Tallies from electron micrographs indicate that myofibril assembly in stretched fibers followed a set sequence of events. (a) In stretched fiber ends almost the entire sarcolemmal membrane was electron dense but only a portion had attached myofibrils. Vinculin, detected by immunofluorescence, was greatly increased at the MTJ membrane of stretched muscles. (b) Thin filaments were anchored to the sarcolemma at the electron dense sites. (c) Thick filaments associated with these thin filaments in an unregistered manner. (d) Z-bodies splice into thin filaments and subsequently thin and thick filaments fall into sarcomeric register. Thus, the MTJ is a site of mRNA accumulation which sets up regional protein synthesis and myofibril assembly. Stretched muscles also lengthen by the addition of myotubes at their ends. After 6 d of stretch these myotubes make up the majority of fibers at the muscle ends. Essentially all these myotubes repeat the developmental program of primary myotubes and express slow MHC. MHC mRNA distribution in myotubes is disorganized as is the distribution of their myofibrils.

Incorporation of nascent myosin heavy chains into thick filaments of cardiac myocytes in thyroid-treated rabbits.

A monoclonal antibody (mAb 37) specific for alpha-myosin heavy chain (alpha-MHC) is used to follow the spatial and temporal incorporation of alpha-MHC into rabbit left ventricular myocytes. The expression of the two adult cardiac MHC genes, alpha and beta, is regulated by manipulating the thyroid hormone level of the animal. 10 wk on a propylthiouracil diet down-regulates expression of alpha-MHC to near 0%. alpha-MHC gene expression is up-regulated by injecting L-triiodothyronine (100 micrograms/kg per d) for 1-4 d. This protocol provides a means by which to follow the redistribution pattern of alpha-MHC within the myocyte in vivo. A uniform distribution of immunofluorescent signal is seen within every myocyte throughout the left ventricle. Ultracryomicrotomy without fixation is used to obtain sections for immunogold-electron microscopy. To quantify the immunogold method the density of gold-labeled antibody per unit of area tissue is determined for various regions of the sarcomere. Tissue from normal and 2-wk baby has a uniform distribution of gold density along the length of the A band. The average gold density of the A band increases with days of thyroid injection from 38 +/- 4 grains/micron 2 (n = 2 animals) (mean +/- SE) at day 1 to 182 +/- 59 grains (n = 2 animals) at day 4. There is a nonuniform incorporation of the newly synthesized alpha-MHC within the A band of thyroid-treated animals since 50% more of the alpha-MHC is found at the end of the A band while the center of the A band has 40% less than the average alpha-MHC content (grains/micron 2, n = 7 animals). These results support a thick filament assembly model that allows every myosin in a thick filament to be exchanged with new myosin. However, in the intact functioning myocyte, there is greater exchange of new myosin at the ends than in the central region of the thick filament.

Stereological analysis of mammalian skeletal muscle. I. Soleus muscle of the adult guinea pig.

A quantitative analysis of the volumes, surface areas, and dimensions of the ultrastructural components in the soleus muscle fibers of the guinea pig was made by using point counting methods of stereology. Muscle fibers have structural orientation (anisotropy) and have spatial gradients of the structures within the fiber; therefore the standard stereological methods were modified where necessary. The entire analysis was repeated at two section orientations to test the modifications and identical results obtained from both. The volume of lipid droplets was 0.20 +/- 0.06% (mean +/- standard error, n = 5 animals) and the nuclei volume was 0.86 +/- 0.20% of the fiber volume. The total mitochondrial volume was 4.85 +/- 0.66% of the fiber volume with about one-third being found in an annulus within 1 microm of the sarcolemma. The mitochondrial volume in the remaining core of the fiber was 3.6 +/- 0.4%. The T system has a volume of 0.14 +/- 0.01% and a surface area of 0.064 +/- 0.005 microm(2)/microm(3) of the fiber volume. The surface area of the sarcolemma is 0.116 +/- 0.013 microm(2)/microm(3) which is twice the T system surface area. The volume of the entire sarcoplasmic reticulum is 3.52 +/- 0.33% and the surface area is 0.97 +/- 0.09 microm(2)/microm(3). The sarcoplasmic reticulum is composed of the terminal cisternae whose volume is 1.04 +/- 0.19% and surface area is 0.24 +/- 0.05 microm(2)/microm(3). The tubules of the sarcoplasmic reticulum in the I band and A band have volumes of 1.97 +/- 0.24% and 0.51 +/- 0.08%, and the surface areas of the I and A band reticulum are 0.56 +/- 0.07 microm(2)/microm(3) and 0.16 +/- 0.04 microm(2)/microm(3), respectively. The Z line width, myofibril and fiber diameters were measured.

Transverse tubular system in glycerol-treated skeletal muscle.

Horseradish peroxidase used as an extracellular marker fills 98.5 percent of the central triadic elements (tubules) in normal muscle and 97.2 percent in muscle soaked in Ringer solution to which 400-millimolar glycerol is added. A glycerol-soaked muscle rapidly returned to normal Ringer solution has a disrupted transverse tubular system and has only 3.2 percent of triads filled with peroxidase.

Metabolic characterization of human soft tissue sarcomas in vivo and in vitro using proton-decoupled phosphorus magnetic resonance spectroscopy.

We applied 1H-decoupling and nuclear Overhauser enhancement to obtain well-resolved 31P magnetic resonance spectra accurately localized to 20 soft tissue sarcomas in vivo, using three-dimensional chemical shift imaging. Fifteen spectra had large phosphomonoester signals (21% of total phosphorus) that contained high amounts of phosphoethanolamine (compared to those of phosphocholine) but no signals from glycerophosphoethanolamine, and glycerophosphocholine was detected in only four cases. Prominent nucleoside triphosphates (52% of phosphorus) and low inorganic phosphate (10% of phosphorus) indicated that a large fraction of these 15 sarcomas contained viable cells, and this impression was confirmed histologically in 13 of the sarcomas. High-resolution in vitro 31P spectra of extracts of surgical specimens of four of the sarcomas studied in vivo and six additional sarcomas confirmed the in vivo assignments of metabolites and revealed considerable inter- and intratumoral variations of metabolite concentrations associated with histological variations in the relative amounts of cells and of matrix materials or spontaneous necrosis. Seven sarcomas, all high grade with pleomorphic or round cells rather than spindle cells, contained an unidentified phosphodiester signal in vivo; its absence in the extract spectra indicates that it may be from an abnormally mobile membrane component. We have documented a means to obtain new information about in vivo metabolism in human sarcomas and to provide a basis on which to examine the uses of 31P magnetic resonance spectroscopy in the clinical management of sarcomas.

Sizes of components in frog skeletal muscle measured by methods of stereology.

Stereological techniques of point and intersection counting were used to measure morphological parameters from light and electron micrographs of frog skeletal muscle. Results for sartorius muscle are as follows: myofibrils comprise 83% of fiber volume; their surface to volume ratio is 3.8 mum-1. Mitochondria comprise 1.6% of fiber volume. Transverse tubules comprise 0.32% of fiber volume, and their surface area per volume of fiber is 0.22 mum-1. Terminal cisternae of the sarcoplasmic reticulum comprise 4.1% of fiber volume; their surface area per volume of fiber is 0.54 mum-1. Longitudinal sarcoplasmic reticullum comprises 5.0% of fiber volume, and its surface area per volume of fiber is 1.48 mum-1. Longitudinal bridges between terminal cisternae on either side of a Z disk were observed infrequently; they make up only 0.035% of fiber volume and their surface area per volume of fiber is 0.009 mum-1. T-SR junction occurs over 67% of the surface of transverse tubules and over 27% of the surface of terminal cisternae. The surface to volume ratio of the caveolae is 48 mum-1; caveolae may increase the sarcolemmal surface area by 47%. Essentially the same results were obtained from semitendinosus fibers.

Structural changes in single muscle fibers after stimulation at a low frequency.

Direct stimulation of single muscle fibers from Xenopus laevis at a frequency of 1 Hz results in a decline of the peak isometric twitch tension after about 200 twitches. Fibers were chemically fixed in glutaraldehyde after a varying number of twitches and at several fatigue levels, and the ultrastructural appearance was compared with that of resting fibers treated by identical fixation methods. No gross structural abnormalities were observed but subtle changes occurred. The mitochondria of stimulated fibers contain granules of normal size and number. The inner crista width is constant but the matrix width is increased on stimulation. These changes would not compromise ATP production. The myofibrils are normal except for a slight swelling in the myosin lattice. The transverse system (T system) and sarcoplasmic reticulum are intact. The minor diameter of the transverse tubule (T tubule) is increased slightly in stimulated fibers. The gap between the T-TC membranes stays constant at about 110 A, but tiny connecting pillars are seen to cross this gap more frequently in stimulated fibers (21 +/- 5% triads) than in resting fibers (8 +/- 6%). In stimulated fibers there is a marked increase in the electron dense content of the terminal cisternae (TC). Inasmuch as the observed structural changes correlate with the number of twitches but not with the fatigue level, it is concluded that TC density and T-TC pillar formation are related to the normal mechanisms of excitation-contraction coupling.

The T-SR junction in contracting single skeletal muscle fibers.

The junction between the T system and sarcoplasmic reticulum (SR) of frog skeletal muscle was examined in resting and contracting muscles. Pillars, defined as pairs of electron-opaque lines bounding an electron-lucent interior, were seen spanning the gap between T membrane and SR. Feet, defined previously in images of heavily stained preparations, appear with electron-opaque interiors and as such are distinct from the pillars studied here. Amorphous material was often present in the gap between T membrane and SR. Sometimes the amorphous material appeared as a thin line parallel to the membranes; sometimes it seemed loosely organized at the sites where feet have been reported. Resting single fibers contained 39 +/- 14.3 (mean +/- SD; n = 9 fibers) pillars/micrometer2 of tubule membrane. Single fibers, activated by a potassium-rich solution at 4 degrees C, contained 66 +/- 12.9 pillars/micrometer2 (n = 8) but fibers contracting in response to 2 mM caffeine contained 33 +/- 8.6/micrometer2 (n = 5). Pillar formation occurs when fibers are activated electrically, but not when calcium is released directly from the SR; and so we postulate that pillar formation is a step in excitation-contraction coupling.

Aerosolized gamma-interferon and lipopolysaccharide enhances cytotoxicity of murine pulmonary alveolar macrophages.

In vivo stimulation of pulmonary alveolar macrophages (PAMs) may enhance tumor cell cytotoxicity. A model using aerosolized gamma-interferon (gamma-IFN) and lipopolysaccharide (LPS) was developed to induce enhanced PAM activation in vivo in C57BL/6 mice. Mice received four doses of aerosol (2 doses/day) consisting of gamma-IFN (10(4) microU/mouse) and LPS (100 micrograms/mouse). Other groups received either gamma-IFN alone, LPS alone, or saline (control). Cells were harvested by bronchoalveolar lavage. Macrophage cell count demonstrated an increase in macrophage recruitment in the gamma-IFN and LPS group. PAMs were evaluated for in vitro cytotoxicity against B16-F10 melanoma cells. Treatment groups demonstrated enhanced cytotoxicity over controls, and the combination (gamma-IFN plus LPS) was significantly better in cell killing than either treatment modality alone (p less than or equal to 0.02). Activated PAMs selectively killed tumor cells, but did not kill the 3T3 fibroblast cell line. Peritoneal macrophages from mice treated by inhalational gamma-IFN + LPS were enhanced (indicating a systemic effect), but not to the same extent as PAMs. These studies suggest that inhalation of gamma-IFN + LPS can selectively enhance in vivo cytotoxicity of murine PAMs. This may potentially be applicable to human tumor management.

Disruption of the perineurium in amphibian peripheral nerve: morphology and physiology.

Removal of a small piece of perineurium in amphibian nerve causes a lesion consistent with the presence of extensive demyelination. Conduction velocity is reduced by 30 to 40%, and most of the fibers that still conduct are labile, with abnormally low blocking temperatures and unusual susceptibility to conduction block induced by changes in extracellular electrolytes. Application of drugs that inhibit the delayed K+ conductance restores conduction to fibers blocked by temperature elevation and ionic changes. This preparation may prove useful in studies of the pathophysiology of demyelinating diseases.

Surgical management of recurrent liver tumors.

Hepatic resection remains the only potentially curative treatment modality for patients with primary and secondary malignant hepatic tumors. Unfortunately, most patients undergoing resection will develop recurrent disease. Aggressive local treatment of recurrent disease should be considered for patients with recurrence limited to the liver after an initial "curative" hepatic resection. In these patients, repeat hepatic resection can be performed safely and may result in long-term DFS. The decision to perform a repeat hepatic resection must currently be based on the same guidelines as used in selecting a patient for an initial hepatic resection: a limited number of metastases, the technical ability to resect all gross disease, satisfactory general medical condition of the patient, and adequate functional hepatic reserve. Cryotherapy is presently the only alternative to resection that may offer patients with intrahepatic recurrence a chance for long-term disease control. Although many questions remain regarding the ultimate role of cryotherapy and because current technology limits the size of lesions that can be successfully treated, experience to date indicates that it may be comparable to resection for some patients. Combinations of resection, cryotherapy, and regional chemotherapy may expand the population of patients with recurrent hepatic disease that may be managed surgically. Further evaluation of these treatment modalities in clinical trials will establish their ultimate role in the management of recurrent primary and secondary hepatic malignancies.

Diagnosis and surgical management of locally recurrent soft-tissue sarcomas of the extremity.

The patient who presents with evidence of a recurrent soft-tissue sarcoma of the extremity should have a complete history and physical examination. A diagnostic biopsy, either fine-needle or open biopsy, should be performed to confirm recurrence. Liver-function tests, complete blood cell count, electrolytes, and chest X-ray should be performed. If preliminary evaluation confirms local recurrence and is negative for regional or distant disease, a CT scan of the chest to better exclude metastases, as well as a CT or MRI of the local recurrence, should be performed. If neurovascular structures appear at risk on noninvasive scanning, an arteriogram is performed to exclude major vascular involvement. In selected circumstances, arterial and/or venous reconstruction may be indicated to allow complete gross removal of tumor. Complete removal of tumor should be combined with radiotherapy for all sarcomas with close margins and for any high-grade lesion regardless of margin status. Brachytherapy can often be used even when the patient has had prior teletherapy to the site. Complete tumor removal combined with adjuvant radiotherapy is the best way to prevent subsequent local recurrence and provide long-term survival.

Transforming growth factor alpha expression as a potential survival prognosticator in patients with esophageal adenocarcinoma receiving high-dose radiation and chemotherapy.

PURPOSE: Transforming growth factor alpha (TGFA) stimulates the growth and proliferation of cells, and its overexpression has been correlated with patient survival in a variety of tumors, including squamous carcinoma of the esophagus. This study was performed to investigate the influence of TGFA in patients with esophageal adenocarcinoma (EA) receiving high-dose radiation and chemotherapy (HDRCT). METHODS AND MATERIALS: Thirty-one patients with localized esophageal adenocarcinoma were enrolled in a Phase II study involving high dose radiation and concurrent 5-fluorouracil (5-FU)/mitomycin-C with or without esophagectomy. Twenty-seven pretreatment (tumor not available in 4) and 11 posttreatment (insufficient tumor in 20) specimens were immunostained using the avidin-biotin-peroxidase technique. RESULTS: Fifteen of 27 (56%) pretreatment and 4 out of 11 (36%) postchemoradiation specimens had intense TGFA staining. Eight patients with intense and seven with little or no staining on pretreatment biopsy underwent esophagectomy. Median survival for the eight patients was 28 months, and for the seven patients 19 months (p = 0.4). Transforming growth factor alpha staining of posttreatment specimens that contained residual tumor also did not correlate with overall (p = 0.36) or disease-free (p = 0.17) survival. Among the 10 patients with both pre and posttreatment TGFA specimens, decreasing or negative TGFA expression was associated with a better median disease-free survival (32 vs. 13 months, p = 0.04) than persistently positive or increasing TGFA expression. CONCLUSION: There is frequent overexpression of TGFA in EA. Although pretreatment TGFA expression was not associated with survival, patients with tumors that persistently expressed or that increased TGFA expression had a worse prognosis. Posttreatment TGFA expression may serve as a prognostic marker in patients with EA treated with HDRCT.

The role of mastectomy in patients with stage I-II breast cancer presenting with gross multifocal or multicentric disease or diffuse microcalcifications.

PURPOSE: Women with Stage I-II invasive breast cancer who present with gross multicentric disease or diffuse microcalcifications have a significant risk of breast recurrence when treated with conservative surgery and radiation. The purpose of this report is to present the results of mastectomy in this group of patients. METHODS AND MATERIALS: Between 1982 and 1989, 88 patients with clinical Stage I-II breast cancer who presented with clinical and mammographic evidence of gross multicentric disease or diffuse microcalcifications underwent modified radical mastectomy. Median followup was 4 years for the 57 patients with gross multicentric disease and 5.6 years for 31 patients with diffuse microcalcifications. At the time of mastectomy, 42% of patients were found to have positive axillary nodes. Following mastectomy, 15 patients received post mastectomy radiation and 35 patients received adjuvant systemic chemotherapy. RESULTS: When compared to a group of 1295 patients with unifocal, Stage I-II breast cancer, treated with conservative surgery and radiation during the same time period, patients with gross multicentric disease and diffuse microcalcifications had a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease had a lower incidence of positive resection margins following mastectomy and patients with diffuse microcalcifications were younger. The 5-year actuarial risk of an isolated local-regional recurrence was 8% for patients with gross multicentric disease or diffuse microcalcifications and 7% for patients with unifocal disease. Patients with gross multicentric disease or diffuse microcalcifications and > or = 4 positive axillary nodes who did not receive post mastectomy radiation had an increased risk for local regional recurrence. There were no significant differences in the 5-year actuarial overall or relapse-free survival (88% and 73% gross multicentric disease, 97% and 86% diffuse microcalcifications and 90% and 79% unifocal disease), freedom from distant metastasis (76% gross multicentric disease, 90% diffuse microcalcifications, 86% unifocal disease) or incidence of contralateral breast cancer (10% gross multicentric disease, 13% diffuse microcalcifications, 8% unifocal disease) among the three groups. CONCLUSION: The present study demonstrates no increased risk of local-regional recurrence in patients with gross multicentric disease or diffuse microcalcifications undergoing mastectomy in contrast to the increased risk of breast recurrence in patients with gross multicentric disease undergoing conservative surgery and radiation. Indications for post mastectomy radiation include > or = 4 positive nodes or close or positive surgical margins. Despite a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease and diffuse microcalcifications have a 5-year actuarial overall and relapse-free survival comparable to a group of patients with unifocal disease treated with conservative surgery and radiation.

Preoperative chemoradiation for adenocarcinoma of the pancreas and duodenum.

PURPOSE: This study was designed to evaluate the effects of preoperative chemoradiation on resectability, response, local control, and survival in patients with local or local-regional involvement from carcinoma of the pancreas or cancer of the duodenum and to assess the associated toxicity of such treatment. METHODS AND MATERIALS: This prospective pilot study of preoperative chemoradiation was initiated in 1986 for patients with clinical evidence of adenocarcinoma of the pancreas or duodenum without evidence of distant metastases. Radiation was given at 1.8 Gy per day to a total dose of 50.4 Gy. Two cycles of chemotherapy were given concurrent with radiation. On days 2-5 and 29-32, 5-fluorouracil (1 gm/m2/24 h x 4 days) was given, while mitomycin-C (10 mg/m2) was given on day 2 only. Surgical resection was 4-6 weeks following completion of chemoradiation. Thirty-one patients (17 male and 14 female) were entered on the protocol with a median potential follow-up of 4.5 years (range 6 months to 7.5 years). The median age was 64 years (range 32-73 years). Twenty-seven patients had pancreatic cancer (25 head, two body), while four patients had carcinoma arising from the duodenum. Twenty-one patients were initially judged to be unresectable and ten potentially resectable prior to chemoradiation. RESULTS: Twenty-nine of 31 patients completed the entire course of radiation and both cycles of chemotherapy. Acute toxicity from chemoradiation consisted of nausea, vomiting, diarrhea, stomatitis, or hematologic suppression which was moderate to severe (Grade 3 or 4) in seven patients (23%). One patient died of sepsis following the first week of therapy. Seventeen patients (55%) underwent curative resection with subtotal or total pancreatectomy or Whipple resection (four duodenum, 13 pancreas) and two (2/17) had pathologic nodal involvement, while (0/17) none had involved margins. A complete pathologic response was seen in all four (4/4) patients with duodenal cancer and in none (0/13) with pancreatic cancer who underwent resection. The median postoperative hospitalization stay was 22 days (range 4-144 days). Of 17 patients who underwent curative resection, there were two postoperative mortalities (12%). Late complications have included abscess, one; and nonmalignant ascites, five. Ten of the 31 patients are alive. For patients with pancreatic cancer the median survival is 9 months, while survival at 1 year and 3 years are 36% and 19% overall and 60% and 43% at 1 and 3 years for those undergoing resection. Six of the 27 patients (22%) with pancreatic cancer are alive without recurrence. All four patients with duodenal cancer are alive without recurrence (12 months, 23 months, 35 months, 90 months). CONCLUSION: Preoperative chemoradiation for cancer of the pancreas and duodenal region was relatively well-tolerated and enhanced resectability and downstaging of nodal metastases were suggested. The 3-year survival, particularly in patients who underwent resection, was high. For these reasons the applicability of this treatment regimen for pancreatic cancer is presently being studied in a group-wide multi-institutional Phase II trial. Chemoradiation for duodenal cancer has produced a complete pathologic response in all patients and survival has been excellent, suggesting efficacy of this regimen for duodenal cancer.

Does the placement of surgical clips within the excision cavity influence local control for patients treated with breast-conserving surgery and irradiation.

PURPOSE: A number of authors have demonstrated the importance of using surgical clips to define the tumor bed in the treatment planning of early-stage breast cancer. The clips have been useful in delineating the borders of the tangential fields, especially for very medial and very lateral lesions as the boost volume. If surgical clips better define the tumor bed, then a reduction in true or marginal recurrences should be appreciated. We sought to compare the incidence of breast recurrence in women with and without surgical clips, controlling for other recognized prognostic factors. METHODS AND MATERIALS: Between 1980 and 1992, 1364 women with clinical Stage I or II invasive breast cancer underwent excisional biopsy, axillary dissection, and definitive irradiation. Median follow-up was 60 months. Median age was 55 years. Seventy-one percent of patients were path NO, 22% had one to three nodes, and 7% had > than four nodes. Sixty-one percent were ER positive and 44% PR positive. Margin status was negative in 62%, positive in 10%, close in 9%, and unknown in 19%. Fifty-seven percent of women underwent a reexcision. Adjuvant chemotherapy + tamoxifen was administered in 29%, and tamoxifen alone in 17%. Surgical clips were placed in the excision cavity in 556 patients, while the other 808 did not have clips placed. All patients had a boost of the tumor bed. Patients had their boost planned with CT scanning or stereo shift radiographs. No significant differences between the two groups were noted for median age, T stage, nodal status, race, ER/PR receptor status, region irradiated, or tumor location. Patients without clips had negative margins less often, a higher rate of unknown or positive margins and more often received no adjuvant therapy compared to patients with surgical clips. RESULTS: Twenty-five and 27 patients with and without surgical clips, respectively, developed a true or marginal recurrence in the treated breast. The actuarial probability of a breast recurrence was 2% at 5 years and 5% at 10 years for patients without clips compared to 5 and 11%, respectively, for patients with clips (p=0.01). Comparing the breast recurrence rates for patients with and without clips there was no significant difference for the following factors: chemotherapy, tamoxifen, negative, positive or close margins, reexcision, N1, and central or inner primary. Increased rates of breast recurrence were noted for patients with clips for the following variables: no adjuvant treatment (p < 0.001), unknown margins (p < 0.001), a single excision (p = 0.003), path NO (p = 0.001), and outer location (p= 0.02). A forward stepwise multivariate analysis for all 1364 patients was performed using the aforementioned variables as well as the presence or absence of surgical clips and the primary surgeon. The surgeon (p = 0.03) and no adjuvant treatment (p = 0.01) significantly influenced breast recurrence. For patients with surgical clips the 10 year isolated breast recurrence rate was 21% for a single surgeon vs. 6% in the remainder of the group (p = 0.01). For patients with clips, this surgeon had unknown margins in 48% of cases compared to 10% overall (p = 0.001). Excluding this surgeon from analysis the isolated breast recurrence for patients with clips was 6 vs. 5% for patients without clips (p = 0.18). CONCLUSIONS: Overall, there was a significant difference in the 10-year breast recurrence rate favoring women without clips despite more adverse prognostic factors. There was no difference in the breast recurrence rate for patients with or without surgical clips if careful attention to margin status was addressed. Failure to ink the surgical specimen resulting in unknown margins cannot be compensated for with the placement of .

The impact of tamoxifen on breast recurrence, cosmesis, complications, and survival in estrogen receptor-positive early-stage breast cancer.

PURPOSE: To evaluate the impact of tamoxifen on breast recurrence, cosmesis, complications, overall and cause-specific survival in women with Stage I-II breast cancer and estrogen receptor positive tumors undergoing conservative surgery and radiation. METHODS AND MATERIALS: From 1982 to 1991, 491 women with estrogen receptor positive Stage I-II breast cancer underwent excisional biopsy, axillary dissection, and radiation. The median age of patient population was 60 years with 21% < 50 years of age. The median follow-up was 5.3 years (range 0.1 to 12.8). Sixty-nine percent had T1 tumors and 83% had histologically negative axillary nodes. Re-excision was performed in 49% and the final margin of resection was negative in 64%. One hundred fifty-four patients received tamoxifen and 337 patients received no adjuvant therapy. None of the patients received adjuvant chemotherapy. RESULTS: There were no significant differences between the two groups for age, race, clinical tumor size, histology, the use of re-excision, or median total dose to the primary. Patients who received tamoxifen were more often axillary node positive (44% tamoxifen vs. 5% no tamoxifen), and, therefore, a greater percentage received treatment to the breast and regional nodes. The tamoxifen patients less often had unknown margins of resection (9% tamoxifen vs. 22% no tamoxifen). The 5-year actuarial breast recurrence rate was 4% for the tamoxifen patients compared to 7% for patients not receiving tamoxifen (p = 0.21). Tamoxifen resulted in a modest decrease in the 5-year actuarial risk of a breast recurrence in axillary node-negative patients, in those with unknown or close margins of resection, and in those who underwent a single excision. Axillary node-positive patients had a clinically significant decrease in the 5-year actuarial breast recurrence rate (21 vs. 4%; p = 0.08). The 5-year actuarial rate of distant metastasis was not significantly decreased by the addition of adjuvant tamoxifen in all patients or pathologic node-negative patients. Pathologically node-positive patients had a significant decrease in distant metastasis (35 vs. 11%; p = 0.02). There were no significant differences in cause-specific survival for patients receiving tamoxifen when compared to observation (95% no tamoxifen vs. 89% tamoxifen; p = 0.24). Similar findings were noted for pathologically node-negative patients. However, axillary node-positive patients receiving tamoxifen had an improvement in 5-year actuarial cause-specific survival (90% tamoxifen vs. 70% no tamoxifen; p = 0.10). Cosmesis (physician assessment) was good to excellent in 85% of the tamoxifen patients compared to 88% of the patients who did not receive tamoxifen. CONCLUSION: The addition of tamoxifen to conservative surgery and radiation in women with Stage I-II breast cancer and estrogen receptor positive tumors resulted in a modest but not statistically significant decrease in the 5-year actuarial risk of a breast recurrence. Tamoxifen significantly decreased the 5-year actuarial risk of distant metastasis in axillary node-positive patients and there was a trend towards improvement in cause-specific survival that was not statistically significant. Tamoxifen did not decrease the 5-year actuarial rate of distant metastasis in axillary node negative, patients and in this group, there was no improvement in cause-specific survival. Tamoxifen did not have an adverse effect on cosmesis or complications.