Post-treatment sarcoma in breast cancer patients

Background: Many patients treated for breast cancer with radiotherapy will survive their disease and be at risk for treatment-related sarcoma for many years. Methods: In order to identify patients with post-treatment sarcoma and define this disease, we examined the records of 99 patients treated for sarcoma with a history of antecedent breast carcinoma. Of these patients, 51 were felt to have a sarcoma unrelated to breast cancer treatment and 48 were felt to have a treatment-related sarcoma (secondary to lymphedema and/or radiation). Results: Lymphangiosarcoma of the extremity was the most common histologic subtype of post-treatment sarcoma, accounting for 22 of 48 cases (46%). Twenty-six patients (54%) developed nonlymphangiosarcoma post-treatment sarcoma; all of these were radiation-associated sarcomas. The median latency interval between the diagnosis of breast cancer and the development of sarcoma was 11 years (range 4–44) and was not different between the two groups. However, patients with nonlymphangiosarcoma were significantly younger when diagnosed with breast cancer than were those with lymphangiosarcoma of the extremity (median 43 vs. 51 years, p<0.001). The survival of all 48 patients was poor: 5-year survival was 29%. Five-year survival of patients with other types of post-treatment sarcoma was just as poor as those with lymphangiosarcoma of the extremity (30% vs. 28%, p=0.98). Conclusions: Patients who develop sarcoma after treatment for breast cancer have a poor prognosis whether it occurs as Stewart-Treves syndrome or other types of post-treatment sarcoma. Younger patients may be at higher risk than are older patients for the development of nonlymphangiosarcoma post-treatment sarcoma.Presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Lipomas where you least expect them.

Although lipomas are relatively common and found in most anatomical sites, we are not aware of any previous reports of lipomas arising between the two layers of the deep temporal fascia above the zygomatic arch. This is surprising because a fat pad is seen and used during surgery in this area to protect the frontal branch of the facial nerve. This case highlights the importance of understanding the anatomy of this region, because lipomas can potentially arise in any of three fat pads laying near the facial nerve in this area.     

Metastasising chordoma to the mandible from a rare vertebral site: the first reported case.

Chordoma is a rare tumor, arising from notochord remnants, which usually occurs in the axial skeleton and rarely metastasizes. Although there have been 3 previous reports of metastatic disease to the facial bones from sacrococcygeal chordoma, this is the first to describe spread to the mandible from a vertebral primary chordoma.     

Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.     

Noninvasive measurement of regional blood flow in man

Regional blood flow in man is ideally measured by techniques that are noninvasive, accurate, and can measure flow repetitively with comparative ease. Although numerous noninvasive techniques are available, no single method records blood flow accurately in every location. The neophyte investigator is often faced with a confusing array of methods and can spend considerable time searching for the ideal one. This paper presents current methods available to the clinical or metabolic researcher and comments on the strengths and limitations of each method. It is hoped that this will allow more rapid selection of a flow measurement method that is tailored to each individual's need.     

A double blind clinical trial to assess the value of aprotinin in third molar surgery.

The bovine derived polypeptide, aprotinin, inhibits the activation of certain chemical mediators of acute inflammation. These mediators are responsible for causing pain and swelling in traumatised tissue. The properties of aprotinin were assessed in patients requiring surgical removal of third molars, a procedure which often results in considerable postoperative pain and swelling. A double blind clinical trial compared the effects of local infiltration of 1 ml of saline on one side of the mouth and aprotinin (10,000 international units) on the other, in patients requiring extraction of both mandibular third molars. Pain scores were assessed with a visual analogue scale, and swelling was subjectively assessed. The results, when analysed statistically, showed that aprotinin significantly reduced postoperative pain and swelling on the side of the mouth on which it was used, as compared to the control side (0.01% significance).     

The effect of an on-site radiology facility on radiologic utilization in family practice

Family physicians around the world are increasing their use of diagnostic x-ray examinations at a time of controversy about radiologic overutilization. To explore the role of accessibility in utilization, a study was undertaken testing the hypothesis that on-site radiology facilities are an important determinant of usage. Using a historical cohort design with chart review, rates in selected groups of patients were compared between two teaching family medicine centers, one with an on-site radiology service and one without. After controlling for confounding variables, patients with chest-related diagnoses were 2.4 times more likely (P less than .05) to have a chest film in the presence of on-site facilities. Rates for the off-site examination, upper gastrointestinal series, in patients with abdominal-related diagnoses were similar (relative risk 1.34, P greater than .5) at both centers. Higher usage brought no short-term clinical benefit. It was also observed that residents overinterpreted one quarter of chest films when compared with radiologists' reports.