Limited surgical management for primary breast cancer: A commentary on the NSABP reports

This report presents an overview of findings from 2 interrelated studies carried out during the past 15 years by the National Surgical Adjuvant Breast and Bowel Project to determine the efficacy of alternative local and regional treatments of primary breast cancer. Findings from the first clinical trial, begun in 1971 involving 1,665 women, indicate that after 10 years of follow-up there are no significant differences in disease-free survival, distant disease-free survival, or survival among patients treated by radical mastectomy or total mastectomy with and without radiation. The findings also indicate that radiation of internal mammary nodes in patients with inner quadrant lesions does not improve survival and that results obtained at 5 years accurately predict the outcome through 10 years. The second clinical trial, implemented in 1976 and accruing 1,843 women, demonstrates that after 5 years, treatment by segmental mastectomy (lumpectomy) with or without radiation results in disease-free, distant disease-free, and overall survival at least equivalent to, and in certain aspects better than, that achieved after total breast removal. Whereas 92% of those treated with radiation remained free of breast tumor at 5 years, when breast radiation was not employed, 72% (p<0.001) were without tumor reoccurrence. In positive-node patients, 98% of those radiated remained tumor free, whereas only 64% of those receiving no radiation were free of tumor although both groups received chemotherapy. While the clinical significance of these findings is obvious, their biological importance has received less attention. When considered in conjunction with other laboratory and clinical investigations, they lend no support for the anatomic and mechanistic precepts that have dictated thinking relative to metastasis production and have influenced surgical thinking. Clinical issues have arisen as a consequence of the 2 studies, particularly the second. Should a mastectomy be performed when lumpectomy specimen margins are involved with tumor? How should tumor reoccurrence in the ipsilateral breast following lumpectomy be managed? Can lumpectomy be employed for subareolar tumors or for tumors ≥4 cm? How extensive need radiation therapy be following lumpectomy? We have commented on all of these issues and have presented our current thinking regarding the management of patients in whom they arise.     

MR technology: effect of even-echo rephasing on calculated T2 values and T2 images

In multiple spin-echo image sequences of blood flow, the "even-echo" phenomenon produces an absolute increase in signal magnitude from first- to second-echo images of normal vessels harboring slow flow. Distinguishing this from the apparent relatively high signal intensity seen on second-echo images in pathologic foci of stationary tissue is important to the diagnostician. Selected case material containing two tissue types was reviewed retrospectively: tissues known to harbor slow flow, such as normal veins and venous sinuses and vascular malformations, and tissues that have long transverse (T2) relaxation times and appear as intense structures on second-echo images, such as neoplasms, infarcts, and regions of demyelination. Calculations of T2 parameters were made by computer for defined regions of interest. T2 images were also generated. Visual inspection of the acquired images did not reliably distinguish increased intensity due to even-echo rephasing from the relative changes between adjacent tissues seen on second-echo images. More definitive differentiation of the even-echo phenomenon was provided by calculated values of T2 and computer-synthesized T2 images representing acquired intensity data of two-echo sequences. The synthesized images were especially useful when stationary tissue with lengthened T2 values was adjacent to or in proximity to vessels or vascular lesions. A five spin-echo image sequence was valuable for separating slow flow from stationary tissue by a technique of synthesizing T2-difference images using three consecutive echoes.     

Fractures of the hook of hamate: radiographic signs

Isolated fractures of the hamulus, formerly considered rare, are being seen more frequently. Many of these injuries are sports related, particularly in golf, tennis, racquetball and baseball players. Failure to make an early diagnosis can result in severe pain and sometimes incapacitating disability. We studied the clinical and radiological findings in 12 patients who had fracture of the hook of the hamate. We propose three radiographic signs of fracture that are readily seen on routine PA projections: "absence" of the hook of the hamate; "sclerosis" of the hook; and lack of cortical density, i.e., a barely visible outline, of the hamulus.     

Iatrogenic oesopha-geal perforation due to tracheal or naso-gastric intubation

Oesophageal perforation, due to a difficult endotracheal or nasogastric intubation occurred in a 49-year-old female. Perforation of the oesophagus is a rare complication of intubation of the trachea or oesophagus. Endotracheal intubation alone is most often blamed for iatrogenic oesophageal trauma following surgery. The incidence of iatrogenic oesophageal trauma is similar after nasogastric or endotracheal intubation. Iatrogenic oesophageal perforation occurs principally over the crico-pharyngeus muscle on the posterior wall of the oesophagus. Here the oesophagus is thin and is markedly narrowed. Contamination of the perioesophageal space with gastric contents leads to diffuse cellulitis and infection. Diagnosis is made by evidence of cervical subcutaneous emphysema, cervical pain, dysphagia, temperature elevation and leukocytosis. Plain roentenograms of the neck and a contrast media swallow will confirm the diagnosis. Treatment consists of massive antibiotic therapy followed by surgical repair and drainage of the area. Mortality ranges from 10-15 per cent with early diagnosis to 50 per cent if surgery is delayed.     

Racism,stress and health in Asian Americans: A structural equation analysis of mediation and social support group differences

The buffering effect of social support on the negative effects of racism exposure on health outcomes has been mixed in prior studies regarding Asian Americans. Based on the stress-coping framework and using structural equation modelling (SEM) methods, we tested a theoretical model portraying simultaneous mediational paths from racism exposure to general physical and mental health through racism-related stress. Bootstrap analysis was used to test the indirect effects present in the model. Additionally, multi-group SEM analysis was conducted to investigate the moderation effect of social support from family and friends on the paths in the model. The sample consisted of 310 Asian American adults who completed an online survey. The results from the two-step SEM analysis and bootstrap analysis supported the theoretical model—racism exposure can simultaneously have a negative indirect effect on Asian Americans' physical and mental health via racism-related stress. Multi-group SEM analysis showed that there were no differences in model path coefficients based on having varying levels of social support from friends or family.     

Involvement of leukocytes and cytokines in the ovulatory process and corpus luteum function

The role of leukocytes and cytokines in ovarian physiology isnow established, although the function of each cell type andcytokine remains to be determined in detail. Current knowledgeof these effects on follicle development, ovulation, luteinizationand luteotrophic process and luteolysis is reviewed. It is possiblethat further research will help to unravel some of the clinicalmysteries in ovarian function, including polycystic ovary syndrome,premature menopause, ovulatory disorders, and luteal phase defect.Furthermore, the increasing use of cytokines and their antagonistsin clinical practice may have significant effects upon reproductivefunction.     

Immune Adherence of Platelets to Sensitized Leukocytes: a Model of Hyperacute Rejection

Specifically hypersensitized recipients of canine renal allotransplants demonstrate an accumulation of host platelets in the transplanted kidney within minutes following implantation. Transplant function is ra,idly lost. The present work describes an in vitro model of this hyperacute rejection mechanism. Renal donor leukocytes sensitized with host serum are incubated with donor platelets. Within a few minutes the platelets adhere to the sensitized leukocytes to form rosettes. Serum complement is required for platelet rosette formation. Platelets act as indicators in this reaction and they may be obtained from any dog. Donor platelets were used to avoid the transfer of specific antibody to the test mixture. The in vitro model supports the view that hyperacute rejection in the dog is a specific example of the immune adherence reaction in which platelets bind to antigen-antibody-complement complexes.     

Fusarium endocarditis involving aortic valve following coronary artery surgery

This article describes a case of infective aortic valve endocarditisdue to Fusarium oxysporum occurring 4 years after coronary arterybypass grafting. It is the first reported case of endocarditiscaused by Fusarium.     

USE OF POST-TETANIC COUNT IN ASSESSMENT OF A REPETITIVE VECURONIUM-INDUCED NEUROMUSCULAR BLOCK

In order to evaluate the use of the post-tetanic count (PTC)method during repetitive administration of vecuronium, we studied20 patients allocated randomly to one of two groups: 10 patientsreceived droperidol-fentanyl anaesthesia (control group); 10other patients were given droperidol-fentanyl anaesthesia modifiedsubsequently by addition of 0.5% isoflurane (isoflurane group).Before tracheal intubation, a bolus dose of vecuronium 0.08mg kg^–1 was given i. v. followed by repeated doses of0.03 mg kg^–1. The twitch response of adductor polliciswas recorded after supramaximal stimulation of the ulnar nerveat the wrist using a Myograph 2000 neuromuscular transmissionanalyser. In the control group, a close correlation was foundbetween PTC and time to first reaction to train-of-four (TOF)nerve stimulation. This relationship was unchanged when comparingthe bolus dose and each of eight consecutive maintenance doses.Further, the degree and the duration of intense block were unchangedafter each of the eight maintenance doses. In the isofluranegroup, the relationship between PTC and time to first reactionto TOF stimulation remained unchanged after addition of isoflurane.However, isoflurane caused a significant prolongation of theduration of intense block and a corresponding lower PTC in allpatients. We conclude that PTC is a reliable method to evaluateintense neuromuscular block caused by vecuronium, even afterrepetitive administration of the drug and in combination with0.5% isoflurane. Presented in part at the annual meeting of the American Societyof Anesthesiologists, San Francisco, October 1988.