Tubular carcinoma of the breast: an institutional experience and review of the literature

Tubular carcinoma of the breast is a variant of invasive ductal carcinoma that is well differentiated and characterized by an orderly tubular formation. Although often perceived to have a better prognosis, there continues to be questions regarding the extent of treatment required. A retrospective review of 44 patients diagnosed with tubular carcinoma of the breast from 1987 to 1999 was performed. All documented data regarding patient and tumor characteristics plus the extent of treatment were analyzed and compared. Lymph node metastases were present in 4 of 32 patients (13%) who had nodes examined. Tumor size correlated with axillary status, with tumors less than 15 mm having no axillary nodal involvement. No other factor influenced nodal status. In breast conservation patients without adjuvant radiation, 5% (1 of 20) had local recurrence versus 0% (0 of 13) of patients who received postoperative radiation. Ductal carcinoma in situ (DCIS) was associated with 52% of tubular cancers. Second breast cancers developed in 16% of cases. There was no difference in presentation or outcome for pure versus mixed tubular carcinoma. Overall mortality was 2%. Overall survival for patients with tubular carcinoma is quite good. Breast conservation treatment results in low rates of local recurrence for tubular carcinoma with or without the use of adjuvant radiation therapy. Pure tubular carcinomas had the same behavior and overall prognosis as mixed tubular carcinomas and should be classified together. Lymph node status did not influence disease-free or overall survival.     

Influence of thoracic epidural analgesia on cardiovascular autonomic control after thoracic surgery

Background. Thoracic epidural analgesia (TEA) is effective inalleviating pain after major thoracoabdominal surgery and mayalso reduce postoperative mortality and morbidity. This studyinvestigated cardiovascular autonomic control in patients undergoingelective thoracic surgery and its modulation by continuous TEA. Methods. Thirty-eight patients were randomly assigned to receivepatient-controlled analgesia (PCA group) or thoracic epiduralanalgesia (TEA group) with doses of bupivacaine (0.25% duringoperation, 0.125% after operation) and fentanyl (2 µg ml^–1).Heart rate variability (HRV), baroreflex function and pressureresponse to nitroglycerine and phenylephrine were assessed beforeoperation, 4 h after the end of surgery (POD 0) and on the firstand second postoperative days (POD 1 and POD 2). Results. Early after surgery, all HRV variables and baroreflexsensitivities were markedly decreased in both groups. In theTEA group, total HRV and its high-frequency components (HF)increased towards preoperative values at POD 1 and POD 2,whereas the ratio of low to high frequencies (LF/HF) was significantlyreduced (mean (SD), –44 (15)% at POD 0, –38 (17)%at POD 1, –37 (18%) at POD 2) and associatedwith blunting of the postoperative increase in heart rate andblood pressure. In the PCA group, the ratio of LF/HF remainedunchanged and the decrements in HRV variables persisted untilPOD 2. In the two groups, baroreflex sensitivities andpressure responses recovered preoperative values at POD 2. Conclusions. In contrast with PCA management, TEA using lowconcentrations of bupivacaine and fentanyl blunted cardiac sympatheticneural drive, resulting in vagal predominance, while HRV variableswere better restored after surgery. Br J Anaesth 2003; 91: 525–31     

Thoracic Lymphangioma

Thoracic lymphangioma is a benign congenital condition that may involve any organ within the chest. Here, a case of intra thoracic isolated extramediastinal lymphangioma is reported. The child had respiratory distress from neonatal period. Surgery completely cured the patient. However, it is only the 3rd reported case in English literature     

Brain metastases at the time of presentation of non-small cell lung cancer: a multi-centric AERIO analysis of prognostic factors

A multi-centre retrospective study involving 4 French university institutions has been conducted in order to identify routine pre-therapeutic prognostic factors of survival in patients with previously untreated non-small cell lung cancer and brain metastases at the time of presentation. A total of 231 patients were recorded regarding their clinical, radiological and biological characteristics at presentation. The accrual period was January 1991 to December 1998. Prognosis was analysed using both univariate and multivariate (Cox model) statistics. The median survival of the whole population was 28 weeks. Univariate analysis (log-rank), showed that patients affected by one of the following characteristics proved to have a shorter survival in comparison with the opposite status of each variable: male gender, age over 63 years, poor performance status, neurological symptoms, serum neuron-specific enolase (NSE) level higher than 12.5 ng ml(-1), high serum alkaline phosphatase level, high serum LDH level and serum sodium level below 132 mmol l(-1). In the Cox's model, the following variables were independent determinants of a poor outcome: male gender: hazard ratio (95% confidence interval): 2.29 (1.26-4.16), poor performance status: 1.73 (1.15-2.62), age: 1.02 (1.003-1.043), a high serum NSE level: 1.72 (1.11-2.68), neurological symptoms: 1.63 (1.05-2.54), and a low serum sodium level: 2.99 (1.17-7.62). Apart from 4 prognostic factors shared in common with other stage IV NSCLC patients, whatever the metastatic site (namely sex, age, gender, performance status and serum sodium level) this study discloses 2 determinants specifically resulting from brain metastasis: i.e. the presence of neurological symptoms and a high serum NSE level. The latter factor could be in relationship with the extent of normal brain tissue damage caused by the tumour as has been demonstrated after strokes. Additionally, the observation of a high NSE level as a prognostic determinant in NSCLC might reflect tumour heterogeneity and understimated neuroendocrine differentiation.     

FDG-PET sensitivity for melanoma lymph node metastases is dependent on tumor volume

BACKGROUND AND OBJECTIVES: The purpose of this study is to determine the tumor volume threshold for successful positron emission tomography (PET) imaging of melanoma nodal metastases. METHODS: Review of a clinical series of patients who had FDG-PET imaging of regional lymph node basins followed by lymphadenectomy. Lymph node tumor volumes were calculated from direct measurements of metastatic nodule(s) in formalin fixed specimens. PET scan interpretations were correlated with histology to determine sensitivity. Sensitivity was correlated with the aggregate lymph node tumor volume in the nodal basin and with AJCC stage group. RESULTS: Forty-five patients with 49 pathologically positive regional nodal basins comprised the study group. Median total basin tumor volume was 28.3 mm(3)(range 0.004-22,879 mm(3)). FDG-PET sensitivity for detection of all tumor volumes was 0.49. The observed 90% sensitivity threshold for detection of nodal metastases was > or = 78 mm(3). PET sensitivity was 0.14 for detection of tumor volumes < 78 mm(3). PET sensitivity differed by prescan AJCC stage: I-0.0; II-0.24; III-0.81; IV-1.0 (P < 0.001). CONCLUSIONS: FDG-PET reliably detects lymph node tumor deposits greater than approximately 80 mm(3) volume, but sensitivity falls rapidly below this. This amount of tumor is most likely to occur in patients with AJCC stage III or IV disease.     

Lack of Evidence of Osteo-medullary Metastases at Diagnosis in Patients with High Grade Gliomas

Journal of Neuro-Oncology - High grade gliomas usually show a transient response to standard therapy by radiation. A local evolution leads to patient death in most of the cases. Necropsic series...     

Fractionated Radiosurgery for Brain Metastases in 43 Patients with Breast Carcinoma

About 15% of metastatic breast carcinoma patients are diagnosed with brain metastases. Historically, the majority are treated with palliative external whole-brain radiation with a median survival of 4 months. We examined stereotactic radiosurgery's effect on treatment outcome in such patients. Four hundred and fifty four consecutive patients with brain metastases were treated with stereotactic radiosurgery at Staten Island University Hospital, NY, between 1991 and 1999. The medical records of 60 women with histologically confirmed breast cancer were retrospectively reviewed. Forty-three patients (71%) received fractionated radiosurgery (4×600cGy) and form the core of this report. Sixty five percentage had been previously unsuccessfully treated by whole-brain radiation or had recurrence after craniotomy. Survival was calculated by the Kaplan–Meier method. The median age at diagnosis of brain metastases was 52 years, with median interval of 49 months following the diagnosis of tumor primary. Median survival from brain diagnosis reached 13.6 months. Overall median survival from radiosurgery treatment was 7.5 months. Fifteen patients with one or two brain lesions survived a median of 11.5 months. For the fractionated cohort of patients 1- and 2-year actuarial survival was 28.2% and 12.8%, respectively. Three patients are alive at 32, 34 and 64 months, respectively. We conclude that fractionated radiosurgery improves survival of patients with brain metastases from breast cancer, especially those with small lesions, good functional status and no other metastatic disease. These patients should be encouraged to consider radiosurgery, possibly before WBRT. Considering our 7.5 months overall survival including patients with multiple metastases, and patients with progressive brain metastases despite extensive standard therapy and often systemic disease, these results suggest that radiosurgery could benefit breast cancer patients with brain metastases and extend life.     

Effects of sodium bicarbonate supplementation on axial and peripheral bone mass in rats on strenuous treadmill training exercise

We observed the effects of sodium bicarbonate supplement on bone mass in rats on strenuous treadmill training. Sixty female Wistar rats (93-days-old; mean initial weight 261 ± 16 g) were studied. One group of 15 rats was killed at the beginning of the experiments (basal control group), while another group of 15 rats was not manipulated (Exer−NaB−). Another group of 15 rats was exercised but did not receive sodium bicarbonate (Exer+NaB−), while the final group of 15 rats exercised and received sodium bicarbonate (Exer+NaB+) at a dose of 0.05 mg/kg/day, administered by esophageal catheter on exercise days. These rats were killed at the end of 11 weeks. Femoral and vertebral length, weight, and bone mineral content (BMC) and density (BMD) were measured. According to anova with the Tukey–Kramer test, femur length and weight, vertebral weight, femur BMC and BMD, vertebral BMC and BMD and the ratio between femur and vertebral BMC and final body weight, and plasma bicarbonate were lower in the basal control and Exer+NaB− groups than in the two other groups (P < 0.005–0.0001). Overall, there was a positive correlation between femur and vertebral BMC and femur BMC and length (P < 0.0001 for all). Only in the Exer+NaB− group was there a positive association between plasma bicarbonate levels and femur length (r = 0.78; P < 0.0005). Our study demonstrates the adverse effects of strenuous exercise on bone, and the usefulness of sodium bicarbonate supplements in preventing and minimized these effects. Received: May 1, 2000 / Accepted: August 11, 2000     

Instant Vertebral Assessment: A Noninvasive Dual X-ray Absorptiometry Technique to Avoid Misclassification and Clinical Mismanagement of Osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.