The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis.

BACKGROUND: Following neoadjuvant chemotherapy (NAC), the optimal strategies for postmastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after breast-conserving surgery (BCS) are controversial. In this analysis, we evaluate the impact of these radiotherapy (RT) approaches for women with clinically node-positive breast cancer treated with NAC in the National Cancer Database (NCDB). PATIENTS AND METHODS: Women with cT1-3 cN1 M0 breast cancer treated with NAC were divided into four cohorts by surgery [Mastectomy (Mast) versus BCS] and post-chemotherapy pathologic nodal status (ypN0 versus ypN+). Overall survival (OS) was estimated using the Kaplan-Meier method and RT approaches were analyzed using the log-rank test, multivariate Cox models, and propensity score-matched analyses. RESULTS: From 2003 to 2011, 15 315 cases were identified including 3040 Mast-ypN0, 7243 Mast-ypN+, 2070 BCS-ypN0, and 2962 BCS-ypN+ patients. On univariate analysis, PMRT was associated with improved OS for both Mast-ypN0 (P = 0.019) and Mast-ypN+ (P < 0.001) patients. On multivariate analyses adjusted for factors including age, comorbidity score, cT stage, in-breast pathologic complete response, axillary surgery, ypN stage, estrogen receptor status and hormone therapy, PMRT remained independently associated with improved OS among Mast-ypN0 [hazard ratio (HR) = 0.729, 95% confidence interval (CI) 0.566-0.939, P = 0.015] and Mast-ypN+ patients (HR = 0.772, 95% CI 0.689-0.866, P < 0.001). No differences in OS were observed with the addition of RNI to breast RT for BCS-ypN0 or BCS-ypN+ patients. Propensity score-matched analyses demonstrated identical patterns of significance. On subset analysis, OS was improved with PMRT in each pathologic nodal subgroup (ypN0, ypN1, and ypN2-3) (all P < 0.05). CONCLUSIONS: In the largest reported analysis of RT for cN1 patients treated with NAC, PMRT was associated with improved OS for all pathologic nodal subgroups. No OS differences were observed with the addition of RNI to breast RT.

Patterns of failure following surgical resection of renal cell carcinoma: implications for adjuvant local and systemic therapy.

PURPOSE: This report is a patterns-of-failure analysis of resected renal cell carcinoma (RCC) performed to determine the relative incidences of local failure (LF) and distant failure, to identify the pathologic features predicting for each using a multivariate analysis, and to assess the relative impact of each form of failure on overall survival (OS). In this way, the potential value of and selection of patients for adjuvant local and/or systemic therapy can be better evaluated. MATERIALS AND METHODS: The records of 172 patients with unilateral, nonmetastatic RCC who were treated with definitive surgery between 1978 and 1988, and who had a minimum follow-up duration of 1 year, were identified through the Memorial Sloan-Kettering tumor registry. Distribution by stage included T1, 10 patients; T2, 102; T3a, 32; T3b, 27; and T4, one. The incidences of positive lymph nodes (LNs) and positive margins were 5.8% and 6.4%, respectively. RESULTS: LF developed in only six patients, yielding a 7-year actuarial incidence of 5%. In this subset, four patients developed distant metastases (DM), three occurring concurrently with or before LF. DM developed in 30 patients, yielding a 7-year actuarial incidence of 26%. Among the variables that had an impact on the development of DM according to univariate log-rank tests, only positive LNs (P = .026) and renal vein extension (P = .001) remained as significant independent prognosticators. The overall 7-year actuarial survival rate was 80%. Eleven patients died of RCC during follow-up, nine of whom (82%) died of metastatic disease. CONCLUSION: LF is rare following surgical management of RCC, and shows no clear causal relationship with the development of DM. Patients die of DM, and not LF. These data do not support the role of adjuvant radiation therapy in this disease. Patients with LN involvement or renal vein extension have a significantly increased risk for developing DM, and are therefore appropriate candidates for trials investigating systemic therapy.

Spontaneous regression of a postpartum pituitary mass demonstrated by computed tomography.

An 18-year-old woman had postpartum thyrotoxicosis, hypercalcemia, and secondary adrenocortical insufficiency. A pituitary mass with suprasellar extension was demonstrated on computed axial tomography (CT). The patient subsequently became hypothyroid and normocalcemic, and repeated CT scanning showed that the pituitary mass had undergone a spontaneous regression in size. Computed axial tomographic scanning is an important modality for the evaluation of postpartum pituitary masses and their natural history. This case suggests that some patients with postpartum hypopituitarism and a pituitary mass need not have early surgical intervention but may be closely observed and treated by hormone replacement alone.

Intensive chemotherapy for progressive chronic lymphocytic leukemia administered early after a nonmyeloablative allograft.

A 51-year-old patient with refractory CLL elected to participate in a trial of nonmyeloablative trans- plantation from an HLA-matched unrelated donor. He received low-dose fludarabine/TBI, with infusion of donor PBPC and cyclosporin (CsA)/MMF. Early post transplant he experienced explosive tumor growth with respiratory insufficiency. After immunosuppression discontinuation and rituximab administration, no response was observed. This prompted treatment with cyclophosphamide (2 g/m(2)/day x 2), paclitaxel (250 mg/m(2) over 24 h), doxorubicin (50 mg/m(2)), solumedrol (500 mg/day), and a second dose of rituximab, from days +11 to +14. A rapid response was achieved. Chemotherapy did not cause an obvious compromise of donor stem cell engraftment or establishment of stable donor chimerism.

Bacterial infections in a hospital-based skilled nursing facility.

The incidence of bacterial infections occurring in 132 residents in a Veterans Administration hospital-based nursing home care unit (VA NHCU) was studied retrospectively over a 1 yr period. There were a total of 35 non-Foley-catheter-related bacterial infections documented during this time, occurring in 21 residents. Of these infections, 14 were pulmonary, 18 urinary and 3 of the integument. Of the 23 residents having indwelling urinary catheters, 47.8% became clinically symptomatic due to a urinary infection at least one time during the year. Thirty-six per cent of these infections were due to Pseudomonas aeruginosa and 48% were due to E. coli and Proteus mirabilis. Eighteen of 23 residents (78.3%) with Foley catheters had more than one predominant organism cultured from their urine during the year, making the practice of monthly cultures not very useful in considering treatment. If one grouped all urinary tract infections on the NHCU, the major pathogens were Pseudomonas (19.5%), Klebsiella (17.1%). Proteus (17.1%) and E. coli (14.6%). Documented pulmonary infections were predominantly due to Streptococcus pneumonia (50.0%) and Hemophilus influenza (35.7%). Our data suggest that the location of the institutional setting must be considered in caring for the elderly resident in a skilled nursing facility. Future plans to establish hospital based nursing home units must consider the benefits resulting from easy access to acute health care and educational programs against problems of hospital bacterial flora.

Relationships between alternative complement pathway activation, C-reactive protein, and pneumococcal infection.

In the absence of specific antibody, opsonization of Streptococcus pneumoniae may be mediated by the alternative complement pathway (AP) or by C-reactive protein (CRP) via C1 binding. To determine the role of these mechanisms in pneumococcal (PNC) disease, we studied 19 patients with differing severities of PNC infection. C4 and CRP levels and zymosan-induced consumption of 50% hemolytic complement (CH50) were measured in specimens obtained acutely and then weekly. In patients with complicated illness, the modified mean CH50 in acute sera was 178 +/- 57 U/ml, significantly lower than the mean CH50 of 331 +/- 80 U/ml in patients with uncomplicated illness (P less than 0.05). The values of the two groups on a given day approximated each other on days 7, 14, and 23. Consumption of complement by zymosan was also lower in acute sera of patients with complicated illness, with a mean value of 19 +/- 18 U/ml compared with 58 +/- 30 U/ml in those with uncomplicated illness (P less than 0.05). This difference was also seen on day 7 (P less than 0.05). Disease involving lower-numbered PNC serotypes (less than 10) correlated with reduced availability of AP factors in acute sera, independent of illness severity. Mean CRP levels were inversely related to zymosan-induced complement activation in patients with complicated illness. These data suggest that in vivo depletion of AP factors is significantly greater in patients with complicated illness and is associated with high CRP levels. CRP may enhance AP activation via C3 convertase generation and function with it as a preantibody host defense mechanism.

Chlamydia trachomatis in the pharynx and rectum of heterosexual patients at risk for genital infection.

Although urogenital infections with Chlamydia trachomatis are well recognized, less is known about infection at other body sites in adults. Pharyngeal specimens obtained from 706 heterosexual men and 686 women, and rectal specimens obtained from 1223 women who were at risk for chlamydia infection were cultured for C. trachomatis. Urogenital specimens were obtained from all patients. Chlamydia trachomatis was isolated from the pharynx in 3.7% of men and 3.2% of women. Recovery of chlamydiae was not associated with the presence of pharyngeal symptoms, but in women, but not men, it was associated with a history of oral-genital sex. The organism was also recovered from the rectum of 5.2% of the women. Rectal isolation did not correlate with a history of rectal symptoms or rectal sex but did correlate with concurrent genital infection. Infection at these sites may be important in the transmission or persistence of C. trachomatis infections.