The incidence of lung carcinoma after surgery for breast carcinoma with and without postoperative radiotherapy

BACKGROUND

In the current study, the authors compared the incidence of subsequent primary lung carcinoma in patients with breast carcinoma who received radiotherapy as part of their treatment and in those patients who did not. The patients were participants in two large National Surgical Adjuvant Breast and Bowel Project (NSABP) breast carcinoma trials, B-04 and B-06, which prospectively randomized women to either undergo surgery alone or to undergo surgery and postoperative radiotherapy.

METHODS

The NSABP trial B-04 (1971-1974) randomized patients to undergo radical mastectomy versus total (simple) mastectomy and radiotherapy to the chest wall, axilla, and supraclavicular and internal mammary lymph node areas. For patients with a clinically uninvolved axilla, there was a third randomization arm: total mastectomy without radiotherapy. The B-06 trial (1976-1984) randomized patients between those undergoing total mastectomy versus lumpectomy versus those undergoing lumpectomy and breast irradiation, with all patients undergoing an axillary lymph node dissection. The records of all patients who developed a recurrence in the lung or a new primary lung tumor were reviewed to determine the incidence and laterality of confirmed and probable primary lung carcinoma.

RESULTS

For the 1665 evaluable patients on the NSABP B-04 trial (mean follow-up of 21.4 years), there was a total of 23 subsequent confirmed and probable ipsilateral or contralateral primary lung carcinomas. In those patients who had received comprehensive postmastectomy radiotherapy, there was a statistically significant increase in the incidence of these new primary tumors (P = 0.029). With regard to the development of confirmed new primary ipsilateral lung carcinoma alone, the incidence was statistically significantly increased (P = 0.013) in those patients who had received radiotherapy as part of their treatment, and when confirmed and probable ipsilateral lung carcinomas were analyzed, there was a strong trend toward a statistically significant increase in those patients who had received radiotherapy (P = 0.066). For the 1850 evaluable patients on the NSABP trial B-06 (mean follow-up of 19.0 years), there was a total of 30 second primary lung carcinomas but no increase in either ipsilateral or contralateral primary tumors of the lung in those patients who had received radiotherapy.

CONCLUSIONS

Extensive postmastectomy irradiation of the chest wall and regional lymphatic node areas, with consequent exposure of a greater volume of lung to higher doses as administered in the NSABP B-04 trial compared with postlumpectomy breast irradiation in the NSABP B-06 trial, was associated with an increased incidence of subsequent primary lung tumors, both ipsilateral and contralateral.

Surface freezing in binary mixtures of chain molecules. I. Alkane mixtures

X-ray surface scattering and surface tension measurements are used to study surface freezing in molten mixtures of alkanes. These binary mixtures consist of protonated and deuterated alkanes, as well as of alkanes of different lengths. As for pure alkanes, a crystalline monolayer is formed at the surface a few degrees above the bulk freezing temperature. The structure of the monolayer has been determined on an angstrom scale. A simple theoretical approach is used to account for the thermodynamical observations at the surface and in the bulk. The model is based on a competition between entropic mixing and a repulsive interaction due to chain-length mismatch. The surface and bulk liquid phases are treated as ideal mixtures, while the solid phases are treated as regular mixtures. The theory is found to account well for all the mixtures studied, both hydrogenated-hydrogenated and hydrogenated-deuterated. The repulsive interaction and its dependence on the chain lengths of the components are determined from fits to the measured data.

Surface freezing in binary mixtures of chain molecules. II. Dry and hydrated alcohol mixtures

Surface freezing is studied in dry and hydrated alcohol mixtures by surface x-ray scattering and surface tension measurements. A crystalline bilayer is formed at the surface a few degrees above the bulk freezing temperature. The packing is hexagonal, with molecules aligned along the surface normal in all cases. The in-plane lattice constant reveals a qualitatively different behavior with composition for hydrated and dry mixtures. The simple theoretical approach used successfully for alkane and deuterated alkane mixtures accounts well also for the alcohol mixtures. The repulsive length-mismatch term opposing the mixing entropy term in the free energy of the mixtures is shown to have a universal behavior for all mixtures studied: protonated alkanes, deuterated alkanes, and dry and wet alcohols. This universality is somewhat counterintuitive in view of the different interactions (e.g., hydrogen bonding in alcohols) in the different mixtures.

Patient characteristics and treatment factors affecting cosmesis following lumpectomy and breast irradiation

Compared to a mastectomy, lumpectomy and breast irradiation provide an obvious cosmetic advantage. The majority of patients will have a good or excellent outcome with breast conservation therapy. However, poor or fair cosmetic results are reported in about 10% to 20% of patients. To evaluate factors influencing cosmetic outcome in women following lumpectomy and breast irradiation, all women (265) who presented for follow-up in a 6-month period after having previously been treated with postlumpectomy breast irradiation were thoroughly examined and assessed for cosmetic outcome factors including skin pigmentation changes, distortion of the breast, asymmetry, and differences in size between the two breasts. By multivariate analysis, skin pigmentation changes significantly correlated with axillary dissection (p = 0.0049) and black race (p = 0.001). An increased interval from surgery was associated with a decreased incidence of pigmentation changes (p = 0.0058). Smaller size of the treated breast was associated with a longer interval from surgery (p < 0.0001) and an increased separation between opposed tangential fields (p < 0.0001). One hundred twenty-eight women (48.3%) had an excellent cosmetic result (no skin changes or deformity and very slight, if any, difference in size). An additional 110 patients (41.5%) had a good result (no skin changes and just a noticeable difference in size between the two breasts or skin changes with no difference in size between the two breasts). An excellent or good cosmetic result versus a fair or poor result was associated with white race (p = 0.0056), smaller separation between the tangential fields (p = 0.01), the use of a boost (p = 0.0025), and no use of tamoxifen (p = 0.025).

Fulminant Mycoplasma pneumoniae infection with multi-organ involvement: a case report

A 50-year-old man with no medical history was admitted because of progressive respiratory distress, aseptic meningitis, disseminated intravascular coagulation, cholestatic hepatitis, and renal failure. Mycoplasma pneumoniae infection was confirmed serologically. The patient was treated with erythromycin and showed a favorable recovery. Although M. pneumoniae infection is usually a benign, self-limited acute respiratory disease, on rare occasions it can manifest itself with a fulminant course and multi-organ involvement, even in normal healthy individuals.

Radiotherapy for symptomatic metastases to the mandible in adults

Since 1996, seven patients from six radiotherapy facilities that treat more than 2,000 patients per year were treated with radiotherapy for symptomatic metastases to the mandible from primary carcinoma of the prostate (3 patients), carcinoma of the breast (2 patients), adenocarcinoma of the ethmoid sinuses (1 patient), and multiple myeloma (1 patient). All patients presented with pain of several weeks' duration and had radiographic confirmation of a destructive lesion in the mandible. Administered radiotherapy doses ranged from 400 cGy/1 fraction to 4,000 cGy/20 fractions. All patients experienced excellent palliation with complete or almost complete resolution of all symptoms within 1 month. The authors suggest short courses of radiotherapy for symptomatic metastases to the mandible.

Arm edema after lumpectomy and breast irradiation

Ipsilateral arm edema can be a troublesome adverse sequel of breast conservation therapy. We carried out a prospective study of arm edema in every patient (265) seen during a 6-month period for follow-up after radiotherapy postlumpectomy for unilateral primary breast cancer. One hundred eighty-one (181) women (68.3%) had an axillary dissection. All had radiotherapy to the breast via parallel opposed tangential beams. Only eight (3%) had additional separate portals for irradiation of nodal areas. Adjuvant systemic therapy consisted of tamoxifen alone in 127 patients (47.9%) and chemotherapy with or without tamoxifen in 60 (22.6%). Ipsilateral arm edema developed in 19 patients (7.2%). Edema was mild (1+) in 16 patients, and moderate in 3 (2+). Multivariate analysis revealed that the risk of arm edema was significantly increased in heavier women (p = 0.0016), women who had an axillary dissection (p = 0.0446), and women who received tamoxifen (p = 0.0385).

The influence of different cultivating conditions on polymorphonuclear leukocyte apoptotic processes in vitro, I: the morphological characteristics of PMN spontaneous apoptosis

Polymorphonuclear leukocyte (PMN) populations incubated in vitro with normal human serum are save-regulated systems of spontaneous apoptosis. Light microscopy (LM), transmission (TEM), and scanning (SEM) electron microscopes were used for the evalution of PMN apoptopic alteration. Twelve-hour PMN populations were represented by optimal number of normal and different apoptotic forms. Their ultrastructural analysis showed that on this background, 3 apoptotic cell lines (code named "first," "second," and "third") were predominated. The following characteristics were featured: "first"--vacuolization of same organelles, release of their content outside, increase of general cytoplasmic density, nuclear filling with condensed chromatin, and formation of PMNs mainly into small, round, dense forms; "second"--involvement of micronuclei or nuclei in apoptosis, their displacement to the cytoplasmic membrane and separation from the cells, and cytoplasm had numerous intact granules almost until the completion of apoptosis; "third"--synchronous apoptotic process of the nuclei and cytoplasm, moderate electronic density of cytoplasm, and granular translocation to the cell surface. Secondary necrosis was completed mainly in the apoptotic process of the "second" and "third" lines. SEM surfaces confirmed the results of TEM. This research showed that neutrophil spontaneous apoptosis is a complicated process. The 3 apoptotic cell lines reflect different pathways characteristic for the studied systems under certain conditions of cultivation.

Structure of a Langmuir film on a liquid metal surface

The structure of organic monolayers on liquid surfaces depends sensitively on the details of the molecular interactions. The structure of a stearic acid film on a mercury surface was measured as a function of coverage with angstrom resolution. Unlike monolayers on water, the molecules were found here to undergo a transition from surface-parallel to surface-normal orientation with increasing coverage. At high coverage, two condensed hexatic phases of standing-up molecules were found. At low coverage, a two-dimensional (2D) gas phase and condensed single- and double-layered phases of flat-lying molecular dimers were revealed, exhibiting a 1D longitudinal positional order. This system should provide a broader tunability range for nanostructure construction than solid-supported self-assembled monolayers.

Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer

BACKGROUND

In 1976, we initiated a randomized trial to determine whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer.

METHODS

A total of 1851 women for whom follow-up data were available and nodal status was known underwent randomly assigned treatment consisting of total mastectomy, lumpectomy alone, or lumpectomy and breast irradiation. Kaplan-Meier and cumulative-incidence estimates of the outcome were obtained.

RESULTS

The cumulative incidence of recurrent tumor in the ipsilateral breast was 14.3 percent in the women who underwent lumpectomy and breast irradiation, as compared with 39.2 percent in the women who underwent lumpectomy without irradiation (P<0.001). No significant differences were observed among the three groups of women with respect to disease-free survival, distant-disease-free survival, or overall survival. The hazard ratio for death among the women who underwent lumpectomy alone, as compared with those who underwent total mastectomy, was 1.05 (95 percent confidence interval, 0.90 to 1.23; P=0.51). The hazard ratio for death among the women who underwent lumpectomy followed by breast irradiation, as compared with those who underwent total mastectomy, was 0.97 (95 percent confidence interval, 0.83 to 1.14; P=0.74). Among the lumpectomy-treated women whose surgical specimens had tumor-free margins, the hazard ratio for death among the women who underwent postoperative breast irradiation, as compared with those who did not, was 0.91 (95 percent confidence interval, 0.77 to 1.06; P=0.23). Radiation therapy was associated with a marginally significant decrease in deaths due to breast cancer. This decrease was partially offset by an increase in deaths from other causes.

CONCLUSIONS

Lumpectomy followed by breast irradiation continues to be appropriate therapy for women with breast cancer, provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained.

External beam irradiation of craniopharyngiomas: long-term analysis of tumor control and morbidity

PURPOSE

To delineate the long-term control and morbidity with external beam radiotherapy (EBRT) of craniopharyngiomas.

METHODS AND MATERIALS

Between 1971 and 1992, 24 craniopharyngioma patients underwent EBRT at the University of Pittsburgh. Most (19 of 24) were treated within 1-3 months after subtotal resection. The other prior surgical procedures were biopsy (n = 2) and gross total resection (n = 1); 2 patients did not undergo any surgical procedure. The median follow-up was 12.1 years. The median patient age was 29 years (range 5-69). The total radiation doses varied from 36 to 70 Gy (median 59.75). The normalized total dose (NTD, biologically equivalent dose given in 2 Gy/fraction [alpha/beta ratio = 2]) varied from 28 to 83 Gy (median 55.35).

RESULTS

The actuarial survival rate at 10 and 20 years was 100% and 92.3%, respectively. The actuarial local control rate at 10 and 20 years was 89.1% and 54.0%, respectively. No local failures occurred with doses >or=60 Gy (n = 12) or NTDs >or=55 Gy. The complication-free survival rate at 10 and 20 years was 80.1% and 72.1%, respectively. No complications were noted with an NTD of <or=55 Gy. The actuarial survival free from any adverse outcome (recurrence or complication) was 70.1% and 31.8% at 10 and 20 years, respectively. The adverse outcome-free survival appeared optimized (at 73%) with an NTD of 55-63 Gy. Multivariate analysis found that tumor control correlated significantly with the total dose (p = 0.02), treatment complications with NTD (p = 0.008), and adverse outcome with hypopituitarism on presentation (p = 0.03).

CONCLUSION

We recommend treating craniopharyngioma with 1.6-1.7-Gy dose fractions to 60 Gy to optimize outcome from EBRT.

Demixing transition in a quasi-two-dimensional surface-frozen layer

A thin/thick transition was observed by x-ray reflectivity in a surface-frozen crystalline bilayer on the surface of a molten binary mixture of long alcohols. This rare example of a solid-solid phase transition in a quasi-2D system is shown to result from an abrupt temperature-driven change in the layer's composition, kinetically enabled by the layer's ability to exchange molecules with the underlying 3D liquid bulk. Mean-field thermodynamics yields a Gibbs-adsorption-like expression which accounts very well for the transition.

The Brain Tumor Cooperative Group NIH Trial 87-01: A Randomized Comparison of Surgery, External Radiotherapy, and Carmustine versus Surgery, Interstitial Radiotherapy Boost, External Radiation Therapy, and Carmustine

OBJECTIVE

The objective of the Brain Tumor Cooperative Group NIH Trial 87-01 trial was to investigate the effect of additional implanted radiation therapy in newly diagnosed patients with pathologically confirmed malignant gliomas.

METHODS

The study involved a randomized comparison of surgery, external beam radiotherapy, and carmustine (BCNU) versus surgery, external beam therapy, interstitial radiotherapy boost, and BCNU in newly diagnosed malignant gliomas. 125I was chosen as best suited for this effort because it allowed preimplantation planning and postimplantation quality assurance review. Two hundred ninety-nine patients met the eligibility criteria and were randomized into the two arms of the study between December 1987 and April 1994. Follow-up continued for an additional 3 years. Twenty-nine patients were identified as having committed protocol violations and were excluded, resulting in 270 subjects in the Valid Study Group. One hundred thirty-seven patients received external beam radiation and BCNU, and 133 underwent the 125I implantation plus external beam radiation and BCNU therapy.

RESULTS

The overall median survival for the Valid Study Group was 64.3 weeks. The median survival for patients receiving additional therapy of 125I was 68.1 weeks, and median survival for those receiving only external beam radiation and BCNU was 58.8 weeks. The cumulative proportion surviving between the two treatment groups was not statistically significantly different (log-rank test, P = 0.101). As in other studies in the literature, age, Karnofsky score, and pathology were predictors of mortality. Additional analyses incorporating an adjustment for these prognostic variables, either in a stratified analysis or Cox proportional hazards model, did not result in statistically significant differences in the cumulative proportion of patients surviving between the two treatment groups.

CONCLUSION

We conclude that there is no long-term survival advantage of increased radiation dose with 125I seeds in newly diagnosed glioma patients.

Tetra point wetting at the free surface of liquid Ga-Bi

A continuous surface wetting transition, pinned to a solid-liquid-liquid-vapor tetra coexistence point, is studied by x-ray reflectivity in liquid Ga-Bi binary alloys. The short-range surface potential is determined from the measured temperature evolution of the wetting film. The thermal fluctuations are shown to be insufficient to induce a noticeable breakdown of mean-field behavior, expected in short-range-interacting systems due to their d(u) = 3 upper critical dimensionality.

Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation

PURPOSE

To determine whether excision of an in-breast tumor recurrence (IBTR) plus 5000 cGy in 25 fractions to the new operative area is both tolerated and effective as treatment for an IBTR after previous lumpectomy and whole breast irradiation.

METHODS AND MATERIALS

Thirty-nine women with an IBTR after lumpectomy and breast irradiation for invasive carcinoma (n = 31) or ductal carcinoma in situ (n = 8) were treated with excision of the IBTR and radiotherapy (RT), 5000 cGy in 25 fractions, to the operative area using electrons of appropriate energy. The interval from completion of the first course of RT to diagnosis of the IBTR ranged from 16 to 291 months (median 63).

RESULTS

The repeat course of RT to the new operative area was well tolerated in all patients, and no late sequelae occurred other than skin pigmentation changes. Eight patients, including 2 with suspicious bone scans at the time of IBTR, developed distant metastases, and 7 died 21-71 months (median 48) after retreatment. One patient was alive with distant metastases at 27 months after retreatment. Four of the 8 patients who developed distant metastases also had a second IBTR, and 3 died with persistent disease in the breast. An additional 4 patients, for a total of 8, had a second IBTR. Three were alive and free of disease after mastectomy, and 1 was alive and free of disease after mastectomy and additional RT for chest wall recurrence. An additional patient developed recurrence in the axilla 9 months after reirradiation and was treated with surgery; she died free of disease at 63 months. One patient underwent mastectomy for suspected persistent disease 2 months after completion of repeat RT; no evidence of recurrent tumor was found in the removed breast. Thus, 30 women (76.9%) had an intact breast free of tumor at death or at last follow-up 1-180 months (median 51.5) after reirradiation. Using the Kaplan-Meier life table analysis, the estimated overall and disease-free 5-year survival rate for the 39 patients was 77.9% and 68.5%, respectively.

CONCLUSION

For select patients with an IBTR after lumpectomy and breast irradiation, excision of the IBTR followed by repeat external beam RT to the operative area may be an acceptable alternative to mastectomy.

Differential aspects in ratio measurements of [Ca(2+)](i) relaxation in cardiomyocyte contraction following various drug treatments

This study is concerned with the analysis of the time dependency of [Ca(2+)](i), monitored by indo-1-AM, via the ratiometric time response curve R(t) as measured during contractions of spontaneous or electrical stimulated cardiomyocytes (in culture). A mathematical formulation which describes the relaxation phase of R(t) was developed. By fitting formulation to the measured data of R(t), the extraction of characteristic parameters is feasible, which may reflect the factors regulating intracellular Ca concentration. The usefulness of the suggested formulation was examined by monitoring changes induced in those parameters following the exposure of the myocytes to different drugs, among which are: caffeine, ryanodine, thapsigargin db, cyclic AMP, isoprenaline, doxorubicin, and Cl-IB-MECA.