The treatment of operable breast cancer in the elderly female.

The treatment of operable breast cancer in eighty-two patients older than seventy years was analyzed. The cancers were treated at an advanced stage and the axilla was involved as frequently as in younger women. The factors influencing survival differ because of competing mortalities from heart disease and stroke. The risks are discussed in relation to life expectancy and treatment method.     

Carcinoma of the lip.

(1) Carcinoma of the lip occurs predominantly in men in their seventh and eighth decades of life. (2) Epidermoid carcinoma is the most common malignant lip tumor. (3) Metastases to cervical lymph nodes are uncommon. (4) Elective neck dissection is not indicated. (5) Therapeutic radical neck dissection can benefit the patient in the presence of proved suprahyoid lymph node metastases. (6) The five year survival rate for epidermoid carcinoma of the lip is higher than the rate for epidermoid carcinoma of other sites in the oral cavity or pharynx. (7) Local recurrence does not correlate with the size of the primary tumor. (8) Initial treatment failures can frequently be salvaged surgically.     

Books received for reviewSurgery,Creighton University School of Medicine,

The eighth reported case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.     

Carcinoma of the hypopharynx

The data in this study suggest that radical surgical treatment offers the best chance for control of disease in patients with cancer of the hypopharynx. The cervical lymph nodes are at a very high risk for early involvement by metastatic disease. Elective treatment of cervical lymph nodes must be considered in initial treatment planning to obtain better control of regional disease.     

Renal circulation during hypotension

The partial pressures of canine aortic and renal parenchymal oxygen and carbon dioxide were measured spectrometrically in vivo. Renal parenchymal hypoxia and hypercapnia, disproportionate to aortic controls, were found to occur in systemic hypotension and to persist after a return of normotension. This argues for the existence of a vasoconstrictive mechanism in renal vasculature.     

Three year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage

Polytetrafluoroethylene grafts were used for 175 femoropopliteal reconstructions with a cumulative 3 year life table patency rate of 77 percent. Reoperation for early or late failure was required in 27 patients to achieve this patency rate. If these 27 failures were calculated as nonpatent grafts, 3 year patency would be 62 percent. Thirty month life table patency rates were 94 and 91 percent for polytetrafluoroethylene axillofemoral and femorofemoral bypasses, respectively. Twenty-two polytetrafluoroethylene axillopopliteal bypasses were performed because of infection in the groin, previously failed reconstructions or unavailability of femoral vessels due to disease. The 2 year life table patency rate was 69 percent, with nine of the grafts patent for more than 1 year. Forty polytetrafluoroethylene bypasses to arteries at the ankle or in the foot resulted in a 2 year life table patency rate of 48 percent. Thus, polytetrafluoroethylene grafts show early promise as a vascular prosthesis. Although further study will be required to define the exact role of this new arterial substitute, it already can facilitate the performance of otherwise difficult or impossible limb salvage procedures.     

Anorectal crohn's disease: Definitive surgery for fistulas and recurrent abscesses

Twenty patients with anorectal Crohn's disease manifested by anal fistulas or recurrent perirectal abscesses underwent attempted definitive surgical eradication of that pathologic process. The role of Parks' partial internal anal sphincterectomy is discussed. The results are presented and correlated with the activity of the underlying Crohn's disease. The excellent results recommend this approach for re-current perirectal abscess and intersphincteric abscess, even when occurring for the first time.     

Nonhuman primate animals for research in gastrointestinal problems

Problems of husbandry, anesthesia, tranquilization, physical restraint while awake, prevention of disease transmission, fluid and electrolyte balance, and postoperative care have now been overcome enabling one to make a choice of primate animal subject based on the scientific merit of the species available.The Laboratory for Experimental Medicine and Surgery in Primates (LEMSIP) was planned to fill the need for nonhuman primate animals and appropriate related facilities in a large biomedical research community (Greater New York). Innovative methods of husbandry, caging, cost accounting, and space utilization have reduced dramatically the cost of experimentation with primates, making them competitive with other animals. A program of simultaneous and sequential utilization of animals by more than one investigator has resulted in an average utilization of each animal for 6.5 programs per year. The Laboratory now functions as a truly interinstitutional program providing a unique resource and a possible prototype for shared facilities elsewhere.     

T-cell deficiency in patients with squamous cell cancer of the head and neck

Cellular immunity was assessed in patients with operable squamous cell cancer of the head and neck using in vivo skin tests and in vitro lymphocyte stimulation tests. An expansion of a previous study continued to show that 30 per cent of patients with T₁N₀M₀ lesions were DNCB-negative and that with more advanced lesions there was further impairment. A similar finding was observed in the blastogenic response to phytohemagglutinin and conconavalin A but not pokeweed mitogen. Overall, 40 per cent of patients with resectable cancer had a significant depression of the blastogenic responses to conconavalin A and phytohemagglutinin. This depression ranged from 15 per cent in patients with T₁N₀M₀ lesions to 71 per cent in those with T₃N₀M₀ lesions. Although this depression was more severe in patients with palpable cervical node metastases, it was related more to the size of the primary tumor than to the nodes per se. An exception occurred in patients with large fixed nodes in whom the depression of lymphocyte stimulation was most severe. The absolute T-cell count was also depressed in patients with head and neck cancer. This depression parallelled the lymphocyte stimulation results with phytohemagglutinin and conconavalin A and was progressive with increasing stage of disease.A correlation exists between DNCB negativity and early recurrence and shortened survival. Clinical follow-up study is too short to assess the correlation of in vitro immune function with these clinical prognostic factors.     

Acute anal fissure: Treatment by lateral subcutaneous internal anal sphincterotomy

Lateral subcutaneous internal anal sphincterotomy in the management of chronic anal fissures is well established. Its role in the management of the acute severely painful fissure is reported and the technic described.     

Immediate breast reconstruction after modified mastectomy for carcinoma of the breast

With the increased knowledge of breast cancer and its implications, many women are unwilling to accept the deformity that results from the surgical treatment of this disease. The acceptance of modified mastectomy as the procedure of choice in carcinoma of the breast has resulted in selected patients being offered rehabilitation by restoration of the breast contour at the time of definitive surgery or 6 months later. We believe that an immediate breast prosthesis after modified mastectomy for carcinoma of the breast is an acceptable procedure in selected patients. The two-team approach to this procedure as advocated by Halsted will provide the patient with a maximal cancer preventive operation with a minimum of mental and emotional anxiety.     

Locally invasive,well-differentiated thyroid cancer: 22 Years' experience at Memorial Sloan-Kettering Cancer Center

Our experience with 32 cases of locally invasive well-differentiated thyroid carcinoma suggests the following: (1) Thyroidectomy may be limited to the area of gross tumor involvement with little risk of recurrence in the normal opposite lobe. (2) Elective neck dissection should be considered in patients with locally invasive tumors since the incidence of nodal metastases is high. As observed in this study, occult metastases were present in five of six patients dissected electively, and nodal metastases developed later in four of eight patients observed. (3) Surgical procedures for the primary tumor should remove all gross disease. This is possible with conservative operations in most patients; the only deaths from uncontrolled local disease occurred in two patients in whom gross disease was left at the first procedure. Most deaths were caused by distant metastases, and the 5, 10 and 15 year survival rates were 86, 64 and 64 percent, respectively.     

Anastomotic failure complicating total gastrectomy and esophagogastrectomy for cancer of the stomach.

Anastomotic failure complicated the postoperative course of 11 per cent of 350 gastric cancer patients who underwent total gastrectomy and esophagogastrectomy and was responsible for 33 per cent of all operative deaths. The extent of disease and the presence of tumor at the margin of resection did not prove to be significant factors in regard to the incidence of anastomotic failure. Gastrectomy combined with resection of other organs was associated with a significantly higher risk of failure. End-to-end esophagogastrectomy and esophagoduodenostomy appeared to be prone to failure, while Roux-en Y, jejunal pouch, and jejunal loop reconstructions were safer. Patients with severe intraabdominal or intrathoracic sepsis had a poor prognosis, and their management with surgical or conservative methods was ineffective. On the basis of these findings, alternatives to manual methods of visceral suturing should be considered.