Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy

AIMS

This study evaluates the incidence of local complications after immediate breast reconstruction (IBR) following mastectomy with a subpectorally placed silicone prosthesis, with emphasis on the effect of radiation treatment on IBR.

METHODS

The medical records of 100 women, who underwent a mastectomy followed by IBR with a subpectorally placed silicone prosthesis at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, between March 1990 and March 1995, were reviewed. Thirteen prostheses were implanted prior to radiation treatment, and 15 prostheses were implanted after irradiation of the chest wall.

RESULTS

Early complications were seen in 15% of the IBR and were more often in irradiated women. At long-term follow-up, the most common complication was capsular contracture (21%). This occurred significantly more around prostheses placed in a previously irradiated area (P<0.0005), or which were irradiated after IBR (P=0.001). Loss of prosthesis was seen in 11 cases, and was significantly (P<0.005) more in irradiated women (n=5; 18%) compared to women who were not irradiated (n=6; 7%).

CONCLUSIONS

Complications after IBR with a silicone prosthesis were more common in women who were treated with radiotherapy prior to or after IBR following mastectomy than in women who were not irradiated. In particular, capsular contracture around a prosthesis placed in a previously irradiated area was significantly increased. The use of musculocutaneous flaps, such as the transverse rectus abdominis muscle or latissimus dorsi flap, is preferable for reconstruction of previously irradiated breasts. There is no indication to remove the prosthesis before radiation therapy of the chest wall.

Value of estrogenic recruitment before chemotherapy: first randomized trial in primary breast cancer

PURPOSE

Several preclinical studies showed that short-term pretreatment of breast cancer cells with estrogens can increase the antitumor efficacy of different cytotoxic drugs. Some early clinical studies in patients with advanced breast cancer did seem to support these findings. Therefore, the efficacy of estrogenic recruitment followed by chemotherapy was compared with that of chemotherapy alone in a randomized phase III study in women with lymph node-positive primary breast cancer.

PATIENTS AND METHODS

Three hundred twenty-eight patients with stage II/IIIA breast cancer who were younger than 66 years of age were randomly allocated to chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide (FAC) or FAC plus pretreatment with ethinyl estradiol (EE(2)). FAC (500, 50, and 500 mg/m(2), respectively) was administered intravenously once every 4 weeks for four cycles. EE(2) (0.5 mg) was administered orally, both 24 hours and immediately preceding FAC chemotherapy.

RESULTS

Patient and tumor characteristics and chemotherapy dosages were comparable in both treatment groups. Of 318 assessable patients, with a median follow-up of 6.8 years, 177 patients had a relapse and 127 died. No significant differences were observed between the two treatment groups with respect to relapse-free, local recurrence-free, and overall survival according to univariate and multivariate analyses adjusted for age, menopausal status, tumor size, grade, number of positive nodes, and steroid-receptor status. The power for the detection of an increase of 50% in the median relapse-free survival was 80%.

CONCLUSION

Estrogenic recruitment of breast cancer cells before FAC chemotherapy did not influence the efficacy of adjuvant chemotherapy in stage II/IIIA breast cancer patients after a follow-up of 6.8 years.

[Second Opinion Consult Clinic for Surgical Oncology in the Daniel den Hoed Clinic: analysis of the first 245 patients]

OBJECTIVE

To determine the characteristics and outcome in patients visiting a surgical oncology outpatient clinic for a second opinion.

DESIGN

Prospective and descriptive.

METHOD

From October 1996 till December 1998, 245 patients visited the Second Opinion Outpatient Clinic of the department of Surgical Oncology of the University Hospital Rotterdam/Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands. The oncological data were recorded. The patient's satisfaction with their first physician and the hospital was scored in a standardized way. Cytological, histological and radiological material was revised and discrepancies with the results from elsewhere were recorded. The results of comparing the first and second opinion were retrospectively categorized as: identical; not identical without consequences for the prognosis but with implications for the quality of life; not identical with implications for the prognosis.

RESULTS

The primary tumour was breast cancer in 58% of the patients, 19% had a tumour of the digestive tract, and 23% presented with a variety of malignancies. The main problems for which the second opinion was asked were treatment (69%), diagnosis (17%) and adjuvant treatment (11%). Of all patients 53% was satisfied with the communication with the primary physician, 24% was moderately satisfied and 23% was unsatisfied. Revision of pathological and radiological material was done in 214 and 157 patients, respectively, resulting in 1% and 3% major discrepancies with therapeutical implications. The second opinion was identical to the first opinion in 53% of the patients. In 24% it was different without and in 7% with possible implications for the prognosis. In 16% a comparison of the second with the first opinion was not possible. Seventy-one per cent of the patients were referred to the primary physician, while for 21% further treatment or follow-up was done in the Cancer Centre and 8% chose to be referred to another hospital. Of patients who were satisfied or moderately satisfied with the communication with their primary physician 83% and 79% respectively were referred to the primary physician compared with 31% of those who were unsatisfied.

Histological determinants for different types of local recurrence after breast-conserving therapy of invasive breast cancer. Dutch Study Group on local Recurrence after Breast Conservation (BORST)

The purpose of this study was to determine which histological factors are associated with an increased risk for local recurrence in the breast after breast-conserving therapy for early breast cancer (TNM stage I and II) and whether risk patterns vary according to menopausal status and type of local recurrence. Through complete follow-up of the patients of eight regional radiation oncology departments, two cancer institutes and one surgical clinic in The Netherlands, 360 patients were identified with local recurrence in the breast after having received breast-conserving therapy (local tumour excision, axillary dissection and irradiation of the whole breast and a boost to the tumour bed) during the 1980s. For each case, two controls with a follow-up of similar duration without local recurrence were randomly selected. Histological slides of the primary tumour were reviewed. Among premenopausal patients the risk of recurrence for those younger than 35 years was significantly higher than that for premenopausal patients of 45 years or older (relative risk (RR) 2.9; 95% confidence interval (95% CI) 1.3-6.6, P < 0.05). The risk of recurrence at or near the site of the primary tumour was most significantly increased for patients with high grade extensive intraductal component (EIC) adjacent to the primary tumour (RR 4.1; 95% CI 1.7-9.8, P < 0.01). Microscopic margin involvement was an important risk indicator for diffuse recurrence and recurrence in the skin of the breast, especially in the presence of vascular invasion (RR 25; 95% CI 4.0-150, P < 0.001). To prevent local recurrence at or near the site of the primary tumour, local excision with a 1-2 cm margin of healthy tissue and a 15 Gy boost seemed adequate local treatment for patients with well differentiated EIC. In contrast, a wider surgical margin, a higher boost dose or mastectomy should be considered for patients with poorly differentiated EIC. Microscopic margin involvement in the presence of vascular invasion significantly increases the risk of diffuse recurrence or recurrence in the skin.

Survival in hereditary breast cancer associated with germline mutations of BRCA2

PURPOSE

Breast cancer in BRCA1 and BRCA2 gene-mutation carriers may differ from so-called sporadic breast cancer in clinical features and behavior. These potential differences may be of importance for the prevention, screening, and, ultimately, treatment of breast cancer in women with such germline mutations. Thus far, there have been very few studies on the survival of BRCA2-associated breast cancer patients.

PATIENTS AND METHODS

We determined the disease-free and overall survival of 28 breast cancer patients from 14 consecutive families with eight different BRCA2 germline mutations. These patients' survival and tumor characteristics were compared with those of a control group of 112 sporadic breast cancer patients matched to them by age and year of diagnosis.

RESULTS

The 5-year disease-free survival was 52% for each group (P =.91); the overall survival was 74% for BRCA2 carriers and 75% for sporadic cases (P =.50). At the time of diagnosis, tumors from the BRCA2 carriers were borderline significantly larger in comparison to the tumors in sporadic cases (P =.05), but axillary nodal status was not significantly different in the two groups (node-negativity, 63% v 52. 8%, respectively; P =.34). With respect to steroid receptor status, BRCA2-associated tumors were more likely to be steroid receptor-positive, especially regarding progesterone receptor status (100% v 76.7% positive, respectively; P =.06). Stage-adjusted recurrence and death rates were nonsignificantly better for BRCA2 cases (hazard ratios of 0.84 and 0.59 [P =.61 and P =.19], respectively). In contrast, after 5 years, the rate of metachronous contralateral breast cancer in BRCA2 patients was 12% (v 2% in controls; P =.02).

CONCLUSION

Patients with hereditary breast cancer due to BRCA2 have a similar prognosis when compared with age-matched sporadic breast cancer patients. Contrary to our previous observation regarding BRCA1-associated breast cancer, BRCA2 tumors tended to be steroid receptor-positive, instead of steroid receptor-negative.

Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer

BACKGROUND

Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy.

METHODS

One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection.

RESULTS

In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error.

CONCLUSION

In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.

Absence of severe systemic toxicity after leakage-controlled isolated limb perfusion with tumor necrosis factor-alpha and melphalan

BACKGROUND

Severe systemic toxicity and hemodynamic changes after isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF-alpha) and melphalan, with or without interferon-gamma, have been reported in several series. We studied whether these side effects could be precluded by preventing leakage from the isolated circuit into the systemic circulation.

METHODS

Clinical and pharmacokinetic data for 20 consecutive patients with recurrent melanoma of the limbs who were treated by ILP with TNF-alpha (3-4 mg) and melphalan, with or without interferon-gamma, were studied. Leakage rates and TNF-alpha levels were determined during and after ILP and were correlated with systemic toxicity and hemodynamic changes.

RESULTS

Only two patients experienced leaks (2% and 13%) during ILP. For 18 patients without leakage, the mean peak systemic TNF-alpha level was 2.8 ng/ml at 10 minutes after ILP. After leakage, the peak systemic TNF-alpha levels were 31.9 and 88.3 ng/ml at 5 minutes. Toxicity was mild and consisted mainly of fever (n = 17) and nausea/vomiting (n = 19) during the first day after ILP. Some patients developed tachycardia (n = 6), hypotension (n = 3; responding immediately to fluid challenge), a decrease in the WBC count (n = 3; grade I) or thrombocyte count (n = 11; grade I/II, no hemorrhage or therapeutic intervention), or hepatotoxicity [cytolysis (n = 15; 14 grade I/II and 1 grade IV) or hyperbilirubinemia (n = 7; grade I/II, all resolving spontaneously)]. Patients with tachycardia or hepatotoxicity exhibited significantly higher TNF-alpha levels after ILP, compared with other patients.

CONCLUSIONS

Systemic toxicity after ILP with TNF-alpha is minimal and does not differ from that after ILP with melphalan alone when leakage is adequately controlled.

The composition of serous fluid after axillary dissection

OBJECTIVE

To analyse the composition of the serous fluid formed after axillary dissection.

DESIGN

Descriptive study.

SETTING

University hospital and teaching hospital, The Netherlands.

SUBJECTS

16 patients whose axillas were dissected as part of a modified radical mastectomy for stage I or II breast cancer.

MAIN OUTCOME MEASURES

Chemical and cellular composition of axillary drainage fluid on the first, fifth, and tenth postoperative days compared with the same constituents in blood and with reported data on the composition of peripheral lymph.

RESULTS AND CONCLUSION

On the first postoperative day the drainage fluid contained blood contents and a high concentration of creatine phosphokinase (CPK). After day one it changed to a peripheral lymph-like fluid but containing different cells, more protein, and no fibrinogen, making coagulation impossible. The reduction in the fluid production must be caused by other wound healing processes, such as formation of scars and connective tissue.

Cost of care in a randomised trial of early hospital discharge after surgery for breast cancer

The aim of this study was to determine the effect of the reduction of the length of hospital stay after surgery for breast cancer on the rate of care consumption and the cost of care. Patients with operable breast cancer were randomised to a short or long postoperative hospital stay. Data on care consumption were collected for a period of 4 months in diaries administered by patients, and socioeconomic status was evaluated by questionnaires. A cost minimisation analysis using the 'societal' perspective was performed and savings were compared with the savings of hospital charges. The use of professional home care was higher for the short stay group during the first month (7.2 versus 1.3 h, P < 0.0001). The number of out-patient consultations, the intensity of informal home care and patient's expenses did not increase after early discharge. The total cost of care was reduced by US$1320 by introducing the short stay programme (P = 0.0007), but the savings were substantially lower than the savings in hospital charges (US$2680).

Median sternotomy: the preferred incision for resection of lung metastases

OBJECTIVE

To describe our experience with median sternotomy for resection of lung metastases and to assess whether computer tomography (CT) accurately predicts the number and extent of lung metastases.

DESIGN

Retrospective case record study.

SETTING

University hospital/Cancer Centre, The Netherlands.

SUBJECTS

78 patients with pulmonary metastases from various histological types of tumours who were operated on through a median sternotomy during the 10-year period January 1985-January 1995.

INTERVENTION

Median sternotomy for resection of lung metastases with the intention to cure. Extension of the incision in case of extended disease.

MAIN OUTCOME MEASURES

Presence of unilateral or bilateral metastases in relation to preoperative CT.

RESULTS

78 patients underwent a total of 82 sternotomies. CT did not accurately diagnose the extent of disease in 38 patients (49%). In 72 cases metastases were excised. In 58 patients (81%) histological examination showed tumour-free margins microscopically. 36 patients had bilateral metastases. CT showed unilateral disease in 49 patients. 14 (29%) had bilateral involvement. 4 patients required lobectomy and in two patients anterolateral extension of the sternotomy was necessary. Eleven patients (15%) developed minor complications. There was no operative mortality.

CONCLUSION

Bilateral staging and finding of occult metastases, complete surgical clearance in a one stage procedure, and lower morbidity are the reasons that we suggest that median sternotomy is the procedure of choice of resection of pulmonary metastases. For eligible patients the choice of surgical approach should not be made conditional on the results of CT alone.

Hyperthermic isolated limb perfusion with tumour necrosis factor and melphalan as treatment of locally advanced or recurrent soft tissue sarcomas of the extremities

Hyperthermic isolated limb perfusion (HILP) with various chemotherapeutic agents has been used for the local treatment of high-grade soft tissue sarcomas (STS) of the extremities, but in most cases with a disappointing result. Most regimens should certainly not be considered superior to surgery plus radiotherapy. Although the majority of extremity STS can be resected locally, some have a very large size and are in close proximity to bones, nerves or blood vessels. In these cases, amputation is the only means of resecting the tumour. A new combination of drugs used in the set-up of HILP with tumour necrosis factor-alpha and melphalan has emerged as a very promising option for the limb-saving management of locally advanced STS. In recent studies, complete response rates of approximately 30% and partial remission rates of 50% have been achieved, while the overall limb-salvage rate is more than 80%.

Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial

OBJECTIVE

To assess the medical and psychosocial effects of early hospital discharge after surgery for breast cancer on complication rate, patient satisfaction, and psychosocial outcomes.

DESIGN

Randomised trial comparing discharge from hospital 4 days after surgery (with drain in situ) with discharge after drain removal (mean 9 days in hospital). Psychosocial measurements performed before surgery and 1 and 4 months after.

SETTING

General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population.

SUBJECTS

125 women with operable breast cancer.

MAIN OUTCOME MEASURES

Incidence of complications after surgery for breast cancer, patient satisfaction with treatment, and psychosocial effects of short stay or long stay in hospital.

RESULTS

Patient satisfaction with the short stay in hospital was high; only 4% (2/56 at 1 month after surgery and 2/52 at 4 months after surgery) of patients indicated that they would have preferred a longer stay. There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups (median 8 v 9 days respectively, P=0.45) or the incidence of wound complications (10 patients v 9 patients). The median number of seroma aspirations per patient was higher for the long stay group (1 v 3.5, P=0.04). Leakage along the drain occurred more frequently in short stay patients (21 v 10 patients, P=0.04). The two groups did not differ in scores for psychosocial problems (uncertainty, anxiety, loneliness, disturbed sleep, loss of control, threat to self esteem), physical or psychological complaints, or in the coping strategies used. Before surgery, short stay patients scored higher on scales of depression (P=0.03) and after surgery they were more likely to discuss their disease with their families (at 1 month P=0.004, at 4 months P=0.04).

CONCLUSIONS

Early discharge from hospital after surgery for breast cancer is safe and is well received by patients. Early discharge seems to enhance the opportunity for social support within the family.

Survival and tumour characteristics of breast-cancer patients with germline mutations of BRCA1

BACKGROUND

Hereditary breast cancer has been associated with mutations in the BRCA1 and BRCA2 genes and has a natural history different from sporadic breast cancer. We investigated disease-free and overall survival for patients with a proven BRCA1 alteration.

METHODS

We estimated disease-free and overall survival for 49 Dutch patients from 19 consecutive families with a proven specific BRCA1 mutation and one family with strong evidence for linkage to the BRCA1 gene. We compared clinical outcome and data on tumour size, histology, axillary nodal status, contralateral breast cancer, and oestrogen-receptor and progesterone-receptor status with those of 196 patients with sporadic breast cancer, matched for age and year of diagnosis.

FINDINGS

Disease-free survival for BRCA1 and sporadic patients at 5 years was 49% (95% CI 33-64) and 51% (43-59), respectively (p=0.98). Overall survival at 5 years was 63% (47-76) and 69% (62-76), respectively (p=0.88). Recurrence and death rates did not differ significantly between groups. Hazard ratios for recurrence and death among BRCA1 patients were 1.00 (0.65-1.55) and 1.04 (0.63-1.71) relative to sporadic patients (p=0.88), and these did not differ significantly after adjustment for prognostic factors. Patients with BRCA1-associated breast cancer had twice as many progesterone-receptor-negative tumours (p<0.005) and development of contralateral breast cancer was four to five times as frequent as in the sporadic group (p<0.001).

INTERPRETATION

We showed that disease-free and overall survival were similar for sporadic and hereditary breast cancer in the presence of different tumour characteristics, which has implications for screening prophylactic therapy, and different treatments of hereditary breast cancer.

[Women with hereditary risk of breast cancer: consensus of surgical representatives of study groups for hereditary tumors regarding intensive monitoring, diagnosis and preventive resection]

Women in whom a hereditary increased risk of breast cancer is established are often moved by anxiety to ask a surgeon for intensive periodical checking of the breasts or prophylactic resection breast tissue. This article contains a consensus on the relevant policy reached by surgeons from the two cancer centres and eight university hospitals in the Netherlands. Intensive follow-up is indicated only when the risk of breast cancer is twice as high as in women from the population in general. The age from which check-up examinations are carried out is from 25 years or from 5 years before the age at which the youngest relative developed breast cancer. For female gene carries from families with hereditary breast cancer, whether or not identified, the risk of death from breast cancer in spite of intensive follow-up is 7-20%. Preventive bilateral mastectomy is recommended only in case of a demonstrated gene mutation or a life-long risk of breast cancer in excess of 50%. Even after preventive surgical treatment, women should report annually for examination, because frequently a little mammary tissue remains behind.

[Multidisciplinary treatment of superior sulcus (Pancoast) tumors]

Ten patients with a Pancoast tumour, seven with pulmonary carcinoma, three with a soft tissue tumour, were treated surgically with or without preoperative chemotherapy or external radiotherapy, and with postoperative external radiotherapy mostly in combination with brachytherapy using a flexible intraoperative template. The results were highly variable, e.g. one patient died after three months, another was still alive without tumour after 36 months. Optimal treatment requires cooperation of experienced surgeons, radiotherapists and medical oncologists.

Ultrasound-guided aspiration biopsy for detection of nonpalpable axillary node metastases in breast cancer patients: new diagnostic method

This study was designed to evaluate the accuracy of ultrasonography alone and in combination with fine-needle aspiration biopsy (FNAB) for detection of axillary metastases of nonpalpable lymph nodes in breast cancer patients. Ultrasonography was carried out in 150 axillas of 148 patients (mean age 57 years, range 30-80 years); and in 93 axillas lymph nodes were detected. Nodes were described according to their dimension and echo patterns and were compared with histopathologic results. FNAB was carried out in 81 axillas (122 nodes). The sensitivity of ultrasonography was highest (87%) when size (length >5 mm) was used as criterion for malignancy, but the specificity was rather low (56%). When nodes with a malignant pattern (echo-poor or inhomogeneous) were visualized, specificity was 95%. Ultrasound-guided FNAB had a sensitivity of 80% and a specificity of 100% and detected metastases in 63% of node-positive patients. It is concluded that FNAB is an easy, reliable, inexpensive method for identifying patients with positive nodes. In the case of negative findings, other diagnostic procedures to exclude lymph node metastases, such as sentinel node mapping, could be performed.

Prognostic value of the TNM-classification for small bowel cancer

BACKGROUND/AIMS

To examine the relationship between the pathological stage and survival for adenocarcinoma of the small bowel.

MATERIALS AND METHODS

The medical records of 99 patients with small bowel cancer, diagnosed between January 1984 and December 1993, were reviewed retrospectively. Lymphomas and carcinomas of the ampulla of Vater were excluded from this study. All operated patients with adenocarcinomas were staged by the TNM-classification using pathological and surgical reports.

RESULTS

Sixty-four adenocarcinomas, 24 carcinoid tumours and 11 sarcomas were analysed. The cancer-specific 5-year survival rate for patients with adenocarcinoma, carcinoid tumours and sarcomas was 22%, 39% and 55%, respectively. Twenty-eight patients with adenocarcinoma underwent radical tumor resection: segmental resection in 20, pancreaticoduodenectomy in 7 and ileocoecal resection in one patient. In the remaining 34 patients "curative" resection was not feasible and none of them survived for more than 3 years. The 5-year survival rate of the curatively resected patients was 46%. Actuarial 3-year survival rate for stage I was 38%, 70% for stage II and 0% for stage III.

CONCLUSION

Our results demonstrate that survival is poor for patients with lymph node metastasis, despite apparently curative surgery.

A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer

BACKGROUND AND METHODS

The influence of negative pressure on fluid production and complication rates after axillary dissection for breast cancer was studied in a prospective randomized trial. Patients were randomized for either a high or a low vacuum drainage system. Drainage volumes and complication rates were recorded.

RESULTS

No statistically significant differences were found between the low vacuum group (n = 68) and the high vacuum group (n = 73) in volume (728 ml versus 780 ml) and duration (9.5 days versus 10 days) of seroma production, number of wound complications (5 versus 6), or infections (3 versus 2). There was a significant positive relationship between body mass index and seroma production, independent of the drainage system (P = 0.002). The drainage volume of the separately drained breast wound after mastectomy and lumpectomy was larger for the high vacuum system (55 ml versus 100 ml, P = 0.02). Vacuum loss was more frequent in the high vacuum drain group (11 versus 2, P = 0.01), where as leakage around the drain occurred more often in the low vacuum group (18 versus 6, P = 0.004).

CONCLUSION

There are no differences in axillary fluid production or wound complication rates after axillary dissection and subsequent drainage between high and low vacuum drainage systems.

Continuity of information for breast cancer patients: the development, use and evaluation of a multidisciplinary care-protocol

The multidisciplinary nature of much patient-care may lead to gaps in the continuity of information which they receive, as well as to different care-professionals giving them contradictory information. As a counter-measure, a protocol has been developed which integrates medical, nursing, and a variety of extramural events and activities into a comprehensive description of 15 'moments' in the care of breast cancer surgery-patients. Among innovations, the protocol includes information about psychosocial guidance following diagnosis, and about the discharge procedure and contact with fellow-sufferers. The protocol was implemented in Rotterdam in 1994, in two hospitals and in the community; and evaluated formatively on the basis of reactions from 53 patients and 81 care-professionals. Both groups found its form and content to be successful and informative.

Isolated limb perfusion with tumor necrosis factor and melphalan for limb salvage in 186 patients with locally advanced soft tissue extremity sarcomas. The cumulative multicenter European experience

OBJECTIVE

The objective of the study was to achieve limb salvage in patients with locally advanced soft tissue sarcomas that can only be treated by amputation or functionally mutilating surgery by performing an isolated limb perfusion (ILP) with tumor necrosis factor (TNF) + melphalan (M) as induction biochemotherapy to obtain local control and make limb-sparing surgery possible.

SUMMARY BACKGROUND DATA

To increase the number of limb-sparing resections in the treatment of locally advanced extremity soft tissue sarcoma, preoperative radiation therapy or chemotherapy or a combination of the two often are applied. The ILP with cytostatic agents alone is another option but rarely is used because of rather poor results. The efficacy of the application of TNF in ILP markedly has changed this situation.

METHODS

In 8 cancer centers, 186 patients were treated over a period of almost 4.5 years. There were 107 (57%) primary and 79 (43%) recurrent sarcomas, mostly high grade (110 grade III; 51 grade II; and 25 very large, recurrent, or multiple grade I sarcomas). The composition of this series of patients is unusual: 42 patients (23%) had multifocal primary or multiple recurrent tumors; median tumor size was very large (16 cm); 25 patients (13%) had known systemic metastases at the time of the ILP. Patients underwent a 90-minute ILP at 39 to 40 C with TNF + melphalan. The first 55 patients also received interferon-tau. A delayed marginal resection of the tumor remnant was done 2 to 4 months after ILP.

RESULTS

A major tumor response was seen in 82% of the patients rendering these large sarcomas resectable in most cases. Clinical response rates were: 33 complete response (CR) (18%), 106 partial response (PR) (57%), 42 no change (NC) (22%), and 5 progressive disease (PD) (3%). Final outcome was defined by clinical and pathologic response: 54 CR (29%), 99 PR (53%), 29 NC (16%), and 4 PD (2%). At a median follow-up of almost 2 years (22 months; range, 6-58 months), limb salvage was achieved in 82%. Regional toxicity was limited and systemic toxicity minimal to moderate, easily managed, with no toxic deaths.

CONCLUSIONS

In the setting of isolated limb perfusion, TNF is an active anticancer drug in patients. The ILP with TNF + melphalan can be performed safely in many centers and is an effective induction treatment with a high response rate that can achieve limb salvage in patients with locally advanced extremity soft tissue sarcoma.

Isolated limb perfusion with high-dose tumor necrosis factor-alpha in combination with interferon-gamma and melphalan for nonresectable extremity soft tissue sarcomas: a multicenter trial

PURPOSE

To determine the efficacy of isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF) in combination with interferon-gamma (IFN) and melphalan as induction therapy to render tumors resectable and avoid amputation in patients with nonresectable extremity soft tissue sarcomas (STS).

PATIENTS AND METHODS

Among 55 patients with 30 primary and 25 recurrent sarcomas, there were 48 high-grade and seven grade 1 sarcomas (very large, recurrent, or multiple). The composition of this series of patients is unusual: 13 patients (24%) had multifocal primary sarcomas or multiple recurrent tumors; tumors were very large (median, 18 cm); and nine patients (16%) had known systemic metastases. IFN was administered subcutaneously on the 2 days before ILP with TNF, IFN, and melphalan. A delayed marginal resection of the tumor remnant was usually performed 2 to 3 months after ILP.

RESULTS

A major tumor response was seen in 87% of patients and rendered the sarcomas resectable in most cases. Clinical response rates were as follows: 10 (18%) completes responses (CRs), 35 (64%) partial responses (PRs), and 10 (18%) no change (NC). Final outcome was defined as follows by clinical and pathologic response: 20 (36%) CRs, 28 (51%) PRs, and seven (13%) NC. Limb salvage was achieved in 84% (follow-up duration, 20+ to 50+ months). In 39 patients, resection of the tumor remnant (n = 31) or of two to eight tumors (n = 8) after ILP was performed; local recurrence developed in five (13%). When no resection was performed (multiple tumors or systemic metastases), local recurrences were frequent (five of 16), but limb salvage was often achieved as patients died of systemic disease. Regional toxicity was limited and systemic toxicity minimal to moderate with no toxic deaths. Histology showed hemorrhagic necrosis; angiographies showed selective destruction of tumor-associated vessels.

CONCLUSION

ILP with TNF, IFN, and melphalan is a safe and highly effective induction biochemotherapy procedure that can achieve limb salvage in patients with nonresectable extremity STS. TNF is an active anticancer drug in humans in the setting of ILP.

The pedicled omentoplasty and split skin graft (POSSG) for reconstruction of large chest wall defects. A validity study of 34 patients

The aim of this study was to evaluate retrospectively the results of pedicled omentoplasty and split skin graft (POSSG) in reconstructing (full thickness) chest wall defects, and to define its role as a palliative procedure for local symptom control. Thirty-four patients with recurrent breast cancer (n = 25), radiation-induced necrosis (n = 5) or sarcoma (n = 4) of the chest wall were selected for the study. All patients underwent curative or palliative chest wall resection with reconstruction by pedicled omentoplasty and split skin graft (POSSG), between 1986 and 1994. Reconstructive outcome, complications, local tumour and symptom control following surgery was measured. The most common complication was shown to be partial necrosis of the omental flap (35%), followed by respiratory problems (26%), facial hernia (26%) and thoracic wound problems (15%), which were mostly treated in a conservative way (68%). The 3-year local tumour-free interval after POSSG in patients curatively treated for breast cancer is 16%. Seventy per cent of the patients who underwent palliative resection had longstanding relief of local pain, bleeding or foetor due to local tumour growth. It can be concluded that large (full thickness) chest wall defects after resection of local recurrence, primary malignancy or osteoradionecrosis of the chest wall can successfully be reconstructed by POSSG. Chest wall resection in patients treated with palliative intention is effective in local symptom control.

Surgical treatment of lung metastases: The European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group study of 255 patients

BACKGROUND

Several reports have shown a prolonged survival after surgical treatment of pulmonary metastases from soft tissue sarcomas. However, it is still unclear which prognostic factors predict a favorable outcome. Series are not comparable and the data are conflicting. Therefore, a multi-institutional study was undertaken to analyze prognostic factors in selecting patients for resection of pulmonary metastases from soft tissue sarcomas.

METHODS

This report is a retrospective study of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group. Two hundred fifty-five patients underwent complete resection of lung metastases from soft tissue sarcomas. Cases with chondrosarcoma and small round cell sarcomas like Ewing sarcoma were excluded.

RESULTS

The 3 year and 5 year overall postmetastasectomy survival rates were 54% and 38%, respectively. The disease free postmetastasectomy survival rates were 42% and 35%, respectively. Analysis of prognostic factors for a more favorable outcome revealed disease free intervals of 2.5 years or more, following a resection with microscopically free margins, age less than 40 years, and Grade I and II tumors. These prognostic factors have an independent influence on overall survival, using a multivariate Cox regression model.

CONCLUSIONS

Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicates that complete clearance of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.

Pulmonary resection for metastases of colorectal origin

STUDY OBJECTIVE

To develop selection criteria for pulmonary metastasectomy in patients with metastases of colorectal cancer confined to the lungs.

DESIGN

A retrospective study.

SETTING

Medical records of all patients operated on for this condition in the Netherlands in the period 1982 to 1992 (n = 38).

INTERVENTION

Evaluation by means of Cox's proportional hazards regression analysis of factors, which might relate to postthoracotomy disease-free survival and/or postthoracotomy survival.

MEASUREMENTS AND RESULTS

The 5-year disease-free survival was 31%, and the overall 5-year survival was 43% (Kaplan-Meyer). Multivariately, a number of three or fewer metastases (p = 0.012) and a short delay between detection of pulmonary metastases and resection (p = 0.05) related to a longer postthoracotomy disease-free interval. A longer interval between resection of the primary tumor and detection of lung metastases related to a longer postthoracotomy survival (p = 0.021).

CONCLUSIONS

Patients with three or less pulmonary metastases of colorectal origin may benefit from resection; once metastases have been detected, resection should not be postponed.

[Initial Dutch results with a presymptomatic DNA tests in familial breast/ovarian carcinoma. Rotterdamse Werkgroep voor Erfelijke Tumoren]

Recent discoveries in the field of molecular-genetic research make it possible to detect an increased genetic risk of tumours, because several genes are linked to hereditary forms of breast cancer. The breast cancer gene BRCA1, located on chromosome 17q, is quantitatively the most important gene so far. A BRCA1 gene mutation is estimated to occur in 1-3 per 1000 women in the general population, i.e. in about 10,000 women among the 4 million Dutch women aged 25-55 years. In this study experiences are described concerning oncologic, clinical-genetic and psychologic aspects in the first Dutch family in which a BRCA1-gene defect was detected with the corresponding hereditary breast/ovarian cancer syndrome. Of the relatives 88% participated in the genetic family study and 76% wished to be informed on the individual DNA-test results. From the first-degree relatives of the breast cancer patients 54% appeared to be gene mutation carrier. The detection of a gene mutation in a woman could make her decide to undergo preventive mastectomy and (or) ovariectomy, besides regular breast examination and mammography. Surgeons and radiotherapists, the group of doctors who treat primary breast cancer, have to anticipate more radical operations with regard to breasts in this selected group of (future) patients. Detection of the gene may also have consequences for family planning. Identification of carriers of the gene mutation can lead to a selection of women with increased risk of breast cancer. Primary or secondary preventive measures, early diagnostic management and regular examination may lead to a decrease in death from breast cancer.

A retrospective comparative study evaluating the results of mild hyperthermic versus controlled normothermic perfusion for recurrent melanoma of the extremities

The aim of this study was to investigate the role of mild hyperthermia (39-40 degrees C) in isolated cytostatic perfusion for patients with recurrent melanoma of the extremities. A total of 218 patients treated with mild hyperthermic perfusion was compared to 166 patients perfused under controlled normothermic conditions (37-38 degrees C). Only patients whose lesions had been excised before or at the moment of perfusion were eligible for this study. A variety of prognostic factors was controlled for in a Cox proportional hazards analysis. The application of mild hyperthermia did not influence limb recurrence-free interval nor survival (corrected P values 0.46 and 0.18, respectively). In this retrospective comparative study, no benefit for mild hyperthermia in regional isolated perfusion could be identified.

The pedicled omentoplasty, a simple and effective surgical technique to acquire a safe pelvic radiation field; theoretical and practical aspects

A substantial number of patients need radiotherapy after surgery for pelvic malignancy. Approximately 15% of them will experience radiation enteritis. After omentoplasty, reduction of irradiated bowel volume may be obtained. We evaluated the pedicled omentoplasty during gynaecologic surgery as a technique to improve safe irradiation of the pelvic region.

[Initial results of immediate reconstruction of the breast following mastectomy]

OBJECTIVE

Evaluation of the results of immediate reconstruction after mastectomy for breast cancer by means of a silicone implant.

DESIGN

Retrospective analysis.

SETTING

Department of Surgical Oncology of the Dr Daniël den Hoed Cancer Centre and Department of Surgery of the Zuiderziekenhuis, Rotterdam, the Netherlands.

METHOD

From September 1990 till July 1993, 37 immediate reconstructions of the breast after mastectomy were performed in 35 patients by means of a silicone implant. Indications for the treatment, consequences for further oncological treatment, additional plastic surgery, and complications of the reconstruction were evaluated.

RESULTS

The indications for mastectomy and immediate reconstruction were local recurrence after breast conservative treatment (6 operations), multifocal disease (8), extensive in situ carcinoma (8), non-radically removed tumour at lumpectomy (5), anticipated poor cosmetics after breast conservative treatment (6), prophylactic ablation of the breast (2), and patient preference (1). 5 patients received adjuvant systemic chemotherapy, which could be administered without delay, and without negative influence on the result of the breast reconstruction. Additional plastic surgical treatment consisting of reconstruction of the areolar complex and correction of the breast symmetry, was performed in 5 and 3 patients respectively. In 8 of the 37 reconstructions (22%) complications were encountered. The main complications were haematoma (2), infection (4), implant removal (3), capsular contracture (2), skin necrosis (2), and luxation of the implant (1).

CONCLUSION

Immediate reconstruction after mastectomy is a valuable treatment modality in breast cancer.

Repeated resection of recurrent pulmonary metastatic soft tissue sarcoma

A series of nine patients who presented with recurrent lung metastases from soft tissue sarcoma after pulmonary surgery were treated with a second or further thoracotomy. There were no postoperative deaths. The median interval between the first and second thoracotomy was 23 months. Four patients underwent three or more operations. Post-thoracotomy survival was 24-209 months after the first thoracotomy. Five patients are alive after repeated thoracotomies more than 10 years after initial treatment of the primary STS. It is concluded that in cases of recurrent lung metastases from STS repeated thoracotomy is the best therapy if all metastases can be removed completely.

Surgical treatment of pulmonary metastases from soft tissue sarcomas: a retrospective study in The Netherlands

Sixty-seven of 87 patients with soft tissue sarcoma underwent complete resection of the metastases in the lung. In this retrospective study, follow-up was for a median of 24 months. The 5-year overall, crude and disease-free survival was 38%, 45%, and 41%, respectively. Twenty-seven (40%) patients developed a recurrence in the lung. Of the six prognostic variables, the only factor significantly related to disease-free survival was grade. It is concluded that surgery for lung metastases of soft tissue sarcoma should be considered as standard therapy when preoperative evaluation predicts a complete resection. By adding chemotherapy to surgery, an improvement of prognosis probably can be achieved.

Limb recurrence-free interval and survival in patients with recurrent melanoma of the extremities treated with normothermic isolated perfusion

To date, little is known about prognostic factors for limb recurrence-free interval and survival in patients with recurrent melanoma of the limbs treated with regional isolated perfusion. Therefore, 216 such patients treated with normothermic perfusion using melphalan during the period 1978 to 1990 were analyzed for patient and tumor related variables using a Cox proportional hazard model. The five year limb recurrence-free interval was 52 percent. For stage II (n = 67), IIIA (n = 71) and IIIAB and IIIB (n = 78) disease separately, these percentages were 53, 56 and 47 percent. In stage II disease, patients with a local recurrence adjacent to scar or skin graft had a significantly better five year limb recurrence-free interval than patients with satellites (75 versus 33 percent; p = 0.0009). Prognostic factors for limb recurrence-free interval were--in order of importance--tumor tissue left in situ, number of previous limb recurrences and total tumor surface area. The overall five year survival rate was 42 percent. For stages II, IIIA and IIIAB and IIIB disease, these percentages were 57, 45 and 25 percent, respectively. There was no survival benefit for patients with a local recurrence. Prognostic factors for survival were, in order of importance, stage of disease, gender, age, Breslow thickness, Clark level of infiltration of the primary melanoma and the number of lesions forming the indication for perfusion. The results of this study will eventually further delineate indications for perfusion.

Results of regional isolated perfusion for locally inoperable melanoma of the limbs

In the period 1978-1990, 49 patients with locally inoperable melanoma of the limbs were treated with regional isolated perfusion according to four different perfusion schedules. Perfusion resulted in a complete remission in 28 patients (57%), with a median duration of 10 (1-55+) months, and a partial remission in 10 (21%), with a median duration of 3 (1-9) months. In patients treated with a double (normothermic or sequential hyperthermic) perfusion schedule the complete remission rate was higher. Regional lymph node involvement reduced the chance of achieving complete remission. Twelve patients with complete remission (43%) showed a relapse in the perfused area. The corresponding 3-year limb recurrence-free interval was 46%. This interval was mainly influenced by the number of lesions at the moment of perfusion. Three of the patients who failed to respond eventually required amputation of the affected limb. The median follow-up of the surviving patients was 23 (5-142) months. At the time of analysis 23 patients were still alive, 12 of whom had no evidence of disease. Patients with complete remission had a slightly, though statistically not significant better 3-year survival rate than patients without complete remission (49% vs 33%). Regional isolated perfusion halted progression in all of these 49 patients and resulted in a complete remission for 57%. It is, therefore, an important modality in the management of patients with locally inoperable melanoma and provides a valuable alternative to amputation.

Is there an indication for a double perfusion schedule with melphalan for patients with recurrent melanoma of the limbs?

It has been reported that a double perfusion schedule shows a better complete remission rate than does the single procedure for recurrent melanoma of the limb. As more perfusion strategies approach the ideal of a 100% complete remission rate, the main issue now is to prolong the period of disease control in the limb, ie to reduce the limb recurrence rate. The follow up of 42 patients treated with a double perfusion schedule and of 45 patients treated with a single perfusion procedure was updated to compare the duration of limb disease control. Both treatment groups were well balanced with respect to patient and tumour characteristics. For patients treated with a double schedule, the dose of melphalan given in the first perfusion was low (6 mg/l limb volume; 1 h; normothermic) in order to make it possible to carry out a second perfusion (9 mg/l; 1 h; normothermic) with a planned short interval of 3-4 weeks. In the single perfusion group a normothermic perfusion with 10 mg melphalan/l was carried out. The acute tissue reactions and long-term side effects did not differ between the two treatment modalities. The response rate was significantly higher in the double perfusion group owing to a higher complete remission rate (76% vs 48%; P = 0.006). However, no significant difference was seen in limb disease control rates 3 years after perfusion (double schedule, 36%; single schedule, 30%), nor in overall 3-year survival (double schedule, 52%; single schedule, 45%). When evaluating perfusion regimens with equally high complete remission rates, attention should be focused on the duration of limb disease control.

Prognostic factors for tumor response and limb recurrence-free interval in patients with advanced melanoma of the limbs treated with regional isolated perfusion with melphalan

BACKGROUND

At this time little is known about prognostic factors for tumor response and subsequent limb recurrence-free interval in patients suffering from advanced melanoma of the limbs who were treated with regional isolated perfusion.

METHODS

A retrospective analysis was done, with a logistic regression model and a Cox proportional hazard analysis, looking at possible patient-, tumor-, and treatment-related prognostic factors in all 120 patients with advanced melanoma of the limbs who were treated with regional isolated perfusion with melphalan in the period 1978 to 1990 at our institutions.

RESULTS

Complete remission was achieved in 65 patients (54%) with a median duration of 9+ months (range, 1 to 97+ months), and partial remission was seen in 30 patients (25%). Prognostic factors for complete remission were multiple versus single perfusion schedule, the absence of regional node involvement, and leg versus other tumor sites. The 3-year limb recurrence-free interval was 38%. Factors associated with this interval were one as opposed to more than one lesion, complete remission after perfusion, and female sex. Patients exhibiting complete remission after perfusion had a better overall 3-year survival rate than had patients without complete remission (60% vs 35%; p = 0.0012).

CONCLUSIONS

In the present study prognostic factors for tumor response and limb recurrence-free interval could be determined. A multiple perfusion schedule may be more effective in providing complete remission in patients undergoing regional isolated perfusion than single perfusions are.

Systemic leakage during isolated limb perfusion for melanoma

A hazard of regional perfusion for melanoma is incomplete isolation, resulting in leakage of the cytostatic drug into the systemic circulation. Data were analysed retrospectively on 438 melphalan perfusions performed for melanoma of the extremities during the period 1978-1990; continuous isotopic measurement of systemic leakage was carried out. The cumulative systemic leakage after 60 min perfusion was 0.9 per cent (95 per cent confidence interval 0.7-1.1 per cent). Systemic leakage of > or = 1 per cent was detected in 12.6 per cent of perfusions, > or = 5 per cent in 6.2 per cent and > or = 10 per cent in 1.4 per cent. In 2.3 per cent of patients, systemic side-effects in the form of mild transient bone marrow depression occurred. Six variables related to the perfusion technique were assessed by multivariate analysis for their influence on systemic leakage. The level of isolation and diameter of the venous cannula emerged as significant factors. In addition, ligation of the internal iliac vein provided optimal isolation during iliac perfusion.

A retrospective comparative study evaluating the results of a single-perfusion versus double-perfusion schedule with melphalan in patients with recurrent melanoma of the lower limb

BACKGROUND

Forty-two patients with measurable recurrent melanoma of the lower limb were treated according to a double-perfusion schedule.

METHODS

To assess the advantage of this schedule compared with that of a single-perfusion treatment, a retrospective study was done comparing the 42 patients with 45 patients who had undergone a single-perfusion procedure. Both groups were well balanced with respect to patient and tumor characteristics. For patients treated with a double schedule, the dose of melphalan given in the first perfusion was low (6 mg/l; 1 hour; normothermic conditions) to make it possible to perform a second perfusion (9 mg/l; 1 hour; normothermic conditions) with a planned short interval of 3-4 weeks. In the single-perfusion group, a normothermic perfusion with 10 mg melphalan/l was performed.

RESULTS

The toxicity did not differ between the two treatment modalities. The response rate was significantly higher in the double-perfusion group (90% versus 68%; P = 0.007) because of a higher complete remission rate (76% versus 48%; P = 0.006). In both groups, approximately half of the patients with complete remission experienced disease recurrence in the perfused area (50% versus 52%). No significant differences were seen in the two groups in the regional node recurrence rate (33% in the double-perfusion group versus 20% in the single-perfusion group), distant recurrence rate (50% in the double-perfusion group versus 58% in the single-perfusion group), and their corresponding recurrence-free intervals. The overall 3-year survival rate was 46% in both groups.

CONCLUSION

In the patient groups studied, the double-perfusion schedule shows a better complete remission benefit than does the single-perfusion procedure. No differences are seen in limb, regional node, and distant recurrence rates in the two groups. Thus, additional improvement of the perfusion methodology is warranted.

The role of regional isolated perfusion in the eradication of melanoma micrometastases in the inguinal nodes: a comparison between an iliac and femoral perfusion procedure

Regional perfusion therapy of melanoma is followed by an apparent decrease in lymph node metastases. When regional isolated perfusion is performed by cannulating the blood vessels at the iliac level, at least the middle and distal parts of the inguinal nodal zone are included. This is not the case with femoral perfusion. These two types of perfusion were therefore compared to determine whether iliac perfusion eradicates micrometastases present in the inguinal nodes. The regional node recurrence rate and time to regional node relapse of 97 patients treated with iliac perfusion were compared with those of 20 patients who received femoral perfusion. Prognostic factors such as sex, MD Anderson stage of disease, Breslow thickness and Clark level of the primary melanoma, and number of nodules of those with recurrent melanoma were equivalent in both groups. All patients were perfused with melphalan under normothermic conditions during the period 1978-1990. Five of 20 patients (25%) receiving femoral perfusion and 31 of 97 patients (32%) receiving iliac perfusion (P = 0.7, chi 2 test) developed inguinal node metastases after a median period of 25 (8-40) and 19 (2-71) months, respectively (Mann-Whitney U test, P = 0.9). There was no statistically significant difference in the 5-year survival rate (55% versus 62%, respectively; log rank test P = 0.5). Since no advantage could be seen in terms of reduction of inguinal node relapse for iliac perfusion, it is concluded that perfusion of the distal nodes is not the major cause of reduction of regional node metastases.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate versus delayed shoulder exercises after axillary lymph node dissection

A total of 144 evaluable patients with breast cancer were enrolled in a multicenter, randomized, prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection. Patients in group 1 (n = 78) started active shoulder exercises 1 day postoperatively. Patients in group 2 (n = 66) started on the eight postoperative day, following 1 week of immobilization of the arm. Patients in group 2 had 14% less wound drainage volume than those in group 1 (600 +/- 436 mL versus 701 +/- 398 mL); this difference, however, was not significant. Also, no differences could be established between the two groups when duration and volume of wound drainage, number and volume of seroma aspirations, wound complication rates, and shoulder function were compared 6 months after surgery.

Treatment of manifest and impending pathologic fractures of the femoral neck by cemented hemiarthroplasty

Thirty-four patients with manifest or impending pathologic fractures of the femoral neck were treated between 1971 and 1987. Breast carcinoma was the primary tumor in the majority of patients. All patients were treated with cemented hemiarthroplasty. Twenty-seven patients (79%) could walk at an average of nine days postoperatively. All patients experienced relief of pain. Two superficial wound dehiscences, one loosening of the prosthesis, and two prosthetic dislocations were encountered. Mean survival was 17.6 months overall (12 months for manifest fractures and 40 months for impending fractures). These results indicate that cemented hemiarthroplasty for pathologic fractures is a safe procedure resulting in long-lasting palliation without necessitating postoperative irradiation. The importance of tumor excochleation and the advantages of bone cement are emphasized.

Results of regional isolation perfusion with cytostatics in patients with soft tissue tumors of the extremities

From 1975 to 1986, 26 patients with soft tissue tumors of the extremities underwent a total of 29 perfusions. The cytostatics used were doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH) (19 perfusions), melphalan (two perfusions), and a combination of these agents (eight perfusions). Before perfusion most patients had been treated by surgical excision(s), radiotherapy, or systemic chemotherapy. Of 17 patients perfused because of local inoperable tumor, four showed prolonged complete remission of the tumor mass, stable disease was seen in three, and ten showed progression. The complete remissions observed in three patients with aggressive fibromatosis and in one with lymphangiosarcoma occurred after perfusion with doxorubicin combined with melphalan. Doxorubicin added to the perfusate as the sole cytostatic was not effective. Local recurrence was observed in five of nine patients treated by adjuvant perfusion, always after dubiously radical tumor excision. Toxicity was high, especially in the first few years. Tissue necrosis necessitated amputation in three cases (in two after perfusion with doxorubicin and melphalan and in one after repeated perfusion with doxorubicin only). This complication was no longer seen after adjustment of the dosage and dose distribution of doxorubicin, but the morbidity after perfusion with doxorubicin remained considerable.

Thymoma: a clinico pathological study of 21 cases and assessment of prognostic features

This is a retrospective and comprehensive study of 21 cases of thymoma treated during a period of 30 years (1954-1984). The tumors were staged into 3 categories: stage 1 for encapsulated completely resectable tumor, stage 2 for nonresectable intrathoracic tumor and stage 3 for tumor with extrathoracic spread. According to their lymphocytic content tumors were separated into 3 groups: 1) predominantly epithelioid (PE); 2) mixed cellular (MC) and predominantly lymphocytic (PL). Incidence of recurrence and survival were correlated with various treatment modalities. The tumor occurred in all age groups with highest incidence in the fourth decade. Six cases were asymptomatic. Myasthenia gravis was present only in one case. The most important prognostic factor was the stage of the tumor. Five-year survival was 69% for stage 2 and 0% for stage 3. All 12 patients who died with evidence of residual disease had PE tumors. Lymphocytic participation might be indicative of a residual functional competence and appears to confer a more favourable prognosis. This is a tumor of uncertain malignant potential which should be excised or debulked, and staged. Post-operative radiotherapy appears to prevent recurrence and improve the prognosis in stage 2. No therapeutic benefits were seen in the stage 3 cases. The value of chemotherapy is uncertain.

Post-irradiation angiosarcoma of the greater omentum

A case of angiosarcoma of the greater omentum is reported. This angiosarcoma developed 8 years after irradiation for cervical carcinoma and presented with an intra-abdominal hemorrhage. We describe her clinical course, treatment and follow-up. Although several other locations of irradiation-induced sarcomas have been published, this is the first report in literature of a postirradiation angiosarcoma in the greater omentum.

Functional morbidity after regional isolated perfusion of the limb for melanoma

A series of 57 patients still in follow-up after regional isolated perfusion (RIP) of Stage I-II high-risk melanoma is described. Functional morbidity of the perfused limb was investigated. Median interval after RIP was 5 years. With no regard to recurrent disease subjectively only one patient had severe complaints of the perfused limb. Objective investigation showed no edema or atrophy in 80% of the upper limbs and in 64% of the lower limbs. Concerning the mobility of the joints in the upper limb we found in four cases a disturbed function in several movements. More restriction were observed in the lower leg. Especially the ankle showed severe functional restrictions in more than 25%.

Cancer of the breast with nipple involvement

In the absence of gross deformity of the nipple, such as its retraction or Paget's disease, histological examination of this area is often neglected, or at best confined to a cursory look at a single sagittal section. The inadequacy of this approach is illustrated by this study of 33 consecutive cases of carcinoma of the breast treated with mastectomy. Multiple transverse sections showed tumour in 19 nipples (58%) involving one or more levels. Of these, 17 showed non-invasive tumour, either ductal or lobular type. Invasive tumour was seen in only two nipples, one of which was metastatic extension from the underlying breast tumour. Paget's cells were seen in two cases. The most significant finding was the eccentric location of tumour in 14 nipples. A single central sagittal section would have detected only five cases involving the centrally situated duct. An inexplicable finding was a preponderance of right nipple with tumour. No statistically significant correlation between nipple involvement and the size, location, multicentricity, type of tumour in the breast and metastases in axillary lymph nodes could be found. It became evident from this study that malignant changes in the nipple occur more commonly than is realised, and that it is also one of the sites of multicentric origin of the tumour. This factor will have to be taken into account in planning conservative therapeutic programmes.