Weekly CAF chemotherapy for advanced breast cancer patients

BACKGROUND: Seromas and impaired shoulder function are well-known complications after modified radical mastectomy for breast cancer. Early postoperative physiotherapy is a common treatment to avoid shoulder dysfunction. The aim of this study was to evaluate if the frequency of postoperative seromas could be reduced, without increasing shoulder dysfunction, by delayed postoperative shoulder exercises. METHODS: In a prospective study 163 patients with breast cancer undergoing modified radical mastectomy were randomized to physiotherapy starting on postoperative day 1 or day 7. Patients were seen by the surgeons and the physiotherapists during hospital stay and in the outpatient department. Seromas and other complications were registered by the surgeons. The physiotherapists instructed the patients pre- and postoperatively and assessed shoulder function. RESULTS: There was a significantly higher incidence of postoperative seromas in the group of patients that started physiotherapy postoperative day 1 (38%) compared to the group that started physiotherapy postoperative day 7 (22%) (p < 0.05). There was no significant difference between the groups in the late outcome of shoulder function. CONCLUSION: The incidence of seromas after modified radical mastectomy for breast cancer is reduced by delaying shoulder exercises one week postoperatively. Earlier postoperative physiotherapy is not necessary to avoid impaired shoulder function.     

Experience with lymphatic mapping in breast cancer using isosulfan blue dye

Sentinel (first tumor-draining) lymph node (SLN) biopsy directed by the blue dye technique may be as accurate as complete axillary lymph node dissection (ALND) in determining whether breast cancer has metastasized to the lymph nodes and may have fewer surgical complications because it is less invasive. Breast cancer patients scheduled for ALND between February and June 1997 who did not have prior axillary surgery, prior radiation therapy, or preoperative chemotherapy were included. Isosulfan blue dye was injected around the primary tumor or the biopsy cavity just before ALND. Operations were performed in a tertiary breast center by two breast surgeons who did not have experience with the technique before this study. The results of blue stained nodes were compared to those of the ALND. Blue-stained nodes were identified in 35 of 40 patients (88%), and the results were concordant with ALND in 33 of 35 (94%), 7 patients were concordant for positive results and 26 for negative results. We identified SLNs in patients whose cancers were either in the medial or lateral halves of the breast. Average time for SLN dissection was 19 +/- 9 minutes, and there were no complications. The diagnostic accuracy of the isosulfan blue dye technique for SLN biopsy, 94%, is high enough to warrant further research. The lack of complications and the short time needed to perform the technique are attractive features. Broader experience with the technique is required to evaluate the reliability and reproducibility of this method.     

Overnight closed suction drainage after axillary lymphadenectomy for breast cancer

Axillary lymphadenectomy in breast conservation surgery is associated with substantial morbidity in either seroma formation or infection. Seroma formation in the axilla requiring aspiration occurs in up to 42 per cent of patients treated without drainage. Prolonged outpatient suction drainage reduces but does not eliminate the incidence of seroma formation, while increasing cost, discomfort, and possibly infection rates. We studied the efficacy of overnight closed suction drainage in patients undergoing breast conservation surgery. Fifty consecutive patients undergoing a standard axillary dissection for breast cancer were studied. The axilla was drained with a 7-French closed suction drain. All drains were removed within 23 hours of surgery and prior to discharge from the outpatient surgical center. Patients were examined by the operating surgeon 7 to 10 days after surgery. One patient (2%) experienced a seroma postoperatively. No infections were observed in all 50 patients, and the remaining 49 patients did not experience visible or symptomatic seromas. The number of lymph nodes removed ranged between 5 and 33 with a mean of 15.5 +/- 0.6. Nine out of 50 (18%) patients had metastatic breast cancer to the axillary lymph nodes. Patients undergoing breast conservation surgery benefit from overnight closed suction drainage of the axilla. This short-term method reduces the incidence and the inherent morbidity of axillary seroma formation.     

Breast cancer surgery: Comparing surgical groups and determining individual differences in postoperative sexuality and body change stress.

Women diagnosed and surgically treated for regional breast cancer (N?=?190) were studied to determine the sexual and body change sequelae for women receiving modified radical mastectomy (MRM) with breast reconstruction in comparison with the sequelae for women receiving breast-conserving therapy (BCT) or MRM without breast reconstruction. The sexuality pattern for women receiving reconstructive surgery was one that was significantly different—with lower rates of activity and fewer signs of sexual responsiveness—than that for women in either of the other groups. Significantly higher levels of traumatic stress and situational distress regarding the breast changes were reported by the women receiving an MRM in contrast to the women treated with BCT. Using a model to predict sexual morbidity, regression analyses revealed that individual differences in sexual self-schema were related to both sexual and body change stress outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Time-dependent changes in CT-based dosimetry of I-125 prostate brachytherapy

OBJECTIVE: To determine if overnight hospital stay after carotid endarterectomy (CEA) is feasible and safe in the Australian setting. DESIGN: Case series with follow-up of 4-11 months (mean, 7 months). PATIENTS AND SETTING: All patients undergoing primary CEA performed by a vascular surgeon (BMB) between 30 May and 11 November 1996. Surgery was performed in one of four hospitals (a district general public hospital with about 400 beds and three private hospitals) in the Gosford area of New South Wales. INTERVENTIONS: CEA using regional anaesthesia and sedation, after diagnosis by duplex ultrasound scan, avoiding cerebral angiography and intensive care; planned discharge after overnight hospital stay; review at one month and duplex ultrasound scan at four months. OUTCOME MEASURES: Length of hospital stay and complications. RESULTS: 65 patients were admitted for CEA during the study period and 59 were scheduled for overnight stay (one had "re-do" surgery, two remained longer for reasons unrelated to carotid artery disease, and three had been scheduled before the change to overnight stay). 54 (92%) were discharged on the first postoperative day, and only three required readmission within 30 days (for urinary retention, angina and reperfusion syndrome). There were no deaths, no myocardial infarctions and no recognised instances of cerebral ischaemia during follow-up. CONCLUSION: CEA can be performed safely without cerebral angiography or intensive care, with over 90% expectation of a single night's stay in hospital.     

Combined laparoscopy and minilaparotomy for outpatient reversal of tubal sterilization

This retrospective study determines risks, outcomes, and cost savings in microscopic tubal sterilization reversal done by minilaparotomy. From January 1992 to December 1993, 40 women, as outpatients, had combined laparoscopy and minilaparotomy for tubal anastomosis. The mean operating time was 1.7 hours, mean blood loss was 20 mL, and mean recovery time was 3.2 hours. Thirty-seven patients (93%) were discharged on the same day, two stayed for 23 hours, and one patient required hospitalization for 2 nights. There were no immediate or postoperative complications. Early crude pregnancy rate was 60%, with an 8% ectopic rate. Tubal patency was confirmed in 39 (98%). The average total cost to the patient was $5,200. Microsurgical tubal anastomosis can be done safely and successfully on an outpatient basis, reducing costs and morbidity and accelerating the patient's return to activity.     

Skin-sparing mastectomy. Oncologic and reconstructive considerations

OBJECTIVE: The authors compared skin-sparing mastectomy and traditional mastectomy both followed by immediate reconstruction in the treatment of breast cancer. SUMMARY BACKGROUND DATA: Skin-sparing mastectomy is used increasingly in the treatment of breast cancer to improve the aesthetic results of immediate reconstruction. The oncologic and reconstructive outcomes of this procedure have never been analyzed closely. METHODS: Institutional experience with 435 consecutive patients who underwent total mastectomy and immediate reconstruction from January 1989 through December 1994 was examined. Mastectomies were stratified into skin-sparing (SSM) and non-skin-sparing (non-SSM) types. RESULTS: Three hundred twenty-seven SSMs and 188 non-SSMs were performed. The mean follow-up was 41.3 months (SSM, 37.5 months, non-SSM, 48.2 months). Local recurrences from invasive cancer occurred after 4.8% of SSMs versus 9.5% of non-SSMs. Sixty-five percent of patients who underwent SSMs had nothing performed on the opposite breast versus 45% in the group of patients who underwent non-SSM (p = 0.0002). Native skin flap necrosis occurred in 10.7% of patients who underwent SSMs versus 11.2% of patients who underwent non-SSMs. CONCLUSIONS: Skin-sparing mastectomy facilitates immediate breast reconstruction by reducing remedial surgery on the opposite breast. Native skin flap necrosis is not increased over that seen with non-SSM. Skin-sparing mastectomies can be used in the treatment of invasive cancer without compromising local control.     

Randomised controlled trial of effects of early discharge after surgery for breast cancer

OBJECTIVE: To determine the effect of early discharge from hospital after surgery for breast cancer on physical and psychological illness. DESIGN: Randomised controlled trial comparing discharge two days after surgery (before removal of drain) with standard management (discharge after removal of drain). SETTING: Regional breast unit. SUBJECTS: 100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80). MAIN OUTCOME MEASURES: Physical illness (infection, seroma formation, shoulder movement) and psychological illness (checklist of concerns, Rotterdam symptom questionnaire, hospital anxiety and depression scale) preoperatively and at one month and three months postoperatively. RESULTS: Women discharged early had greater shoulder movement (odds ratio 0.28 (95% confidence interval 0.08 to 0.95); P = 0.042) and less wound pain (odds ratio 0.28 (0.10 to 0.79); P = 0.016) three months after surgery compared with women given standard management. One month after surgery scores were significantly lower on the Rotterdam symptom questionnaire in patients who were discharged early (ratio of geometric mean scores 0.73 (0.55 to 0.98) P = 0.035), but rates of psychological illness generally did not differ between groups. CONCLUSIONS: Increased rates of physical or psychological illness did not result from early discharge after surgery for breast cancer. This policy can be recommended for patients with support at home.     

Surgical considerations and approach to thyroid cancer

Patients with thyroid cancer can be safely treated by an experienced endocrine surgeon. More extensive initial surgery such as total or near-total thyroidectomy seems to decrease tumor recurrence and prolong life. When such operations can be done with minimal complications, we believe it is the treatment of choice because even low-risk patients have a 4% or 5% risk of eventually dying of thyroid cancer. If this risk of death from thyroid cancer can be decreased to 1% or 2% and the rate of serious complications is 1% or 2%, the authors believe total thyroidectomy is indicated. Most patients can be discharged within 1 day of total thyroidectomy.     

DNA/genetic vaccination (minireview)

Surgery remains the primary treatment for early stage breast cancer. Modified radical mastectomy and lumpectomy with axillary dissection continue to be the two procedures most commonly performed. Changes in the healthcare system and advances in medical research in cancer treatment affect the nursing care of these patients. The introduction of the sentinel node biopsy may change certain aspects of surgical treatment, as some patients may not require an axillary dissection. The challenge for nurses is to provide quality care and maintain established standards for patients with breast cancer as their hospitalizations are shortened to same day or overnight stays. The purpose of this article is to review the standard surgical treatments and related nursing care and discuss the impact of the sentinel node biopsy and the impact of changes in the length of hospital stay on the care of women with breast cancer.     

Outpatient vaginal hysterectomy in a community hospital

From Sept 1, 1992 to Dec 31, 1993, 38 outpatient vaginal hysterectomy patients were evaluated for identification of complications after discharge, adequacy of pain relief at home, return to baseline lifestyle, and costs. No complications that would have necessitated an overnight or longer stay were identified. All patients reported adequate pain relief and a more rapid return to activity than they had expected. The hospital cost of outpatient vaginal hysterectomy was about half that of inpatient, and additional significant savings were realized in the cost of postoperative medication. Patients were positive about returning home the day of surgery and would recommend the protocol to others who qualified.     

A reassessment of ticarcillin/clavulanic acid dose recommendations for infants, children and adults

Breast reconstruction is frequently performed for and requested by women with breast cancer. There are continued concerns about the safety of this procedure. We reviewed the Medical College of Georgia experience with immediate breast reconstruction to determine overall morbidity and whether premorbid risk factors could predict complications. Patients were reviewed with attention to epidemiologic characteristics, comorbid medical conditions, and risk factors; hospital and operative course; immediate wound complications; and patient survival. t test and chi-square analysis were performed to determine risk factors for developing wound complications. Between October 1990 and December 1996, 55 patients underwent 62 mastectomies and immediate reconstruction for breast cancer or contralateral prophylaxis. There were 13 stage 0, 23 stage I, 16 stage II, 4 stage III, and 1 stage IV tumors. There were 19 prosthetic and 43 autologous tissue reconstructions. Eighteen patients had 24 wound complications. Major complications occurred in eight patients and required reoperation for implant removal (two bilateral), ventral herniorrhaphy, and split thickness skin grafting for tissue loss. Patients who were obese were statistically more likely to develop surgical wound complications. Tobacco use, age, comorbid medical illness, operative blood loss, length of operation, and length of hospital stay did not predict for the development of wound complications. Patients who underwent prosthetic reconstruction had a significantly higher rate of major wound complications when compared with those who had autologous reconstruction. There was a single case of delay of chemotherapy secondary to surgical wound complication. There were no cases of autologous flap loss or local recurrence. Median survival is 23 months (1-72 months). At last follow-up, 53 patients are alive and without evidence of local recurrence. Breast reconstruction may be performed safely for most breast cancer patients. Autologous tissue reconstruction is preferred and carries significantly less major morbidity. Reconstruction should not delay adjuvant chemotherapy.     

Immediate, bilateral transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction after mastectomy

Although breast reconstruction has been shown to provide psychological benefits in mastectomy patients, there is reluctance to perform immediate, bilateral TRAM flap reconstruction because of concerns regarding magnitude of the procedure, length of hospitalization, potential complications, and long-term recovery. Between June, 1990 and March 1992, 15 patients underwent immediate, bilateral TRAM flap reconstruction following bilateral mastectomy at the University of Michigan Hospitals. Diagnoses included lobular carcinoma in situ (nine patients), strong family history of breast cancer (five), or bilateral breast cancer (one). Invasive breast cancer was present in three patients. Three modified radical mastectomies and 27 simple mastectomies were performed. Bilateral pedicle TRAM flap reconstruction was carried out at the same time in all patients (30 flaps total). Marginal loss occurred in one flap (3%). Additional complications included marginal necrosis of the abdominal donor site wound (one), wound infection (two), and abdominal donor site hernia (one). Median hospital stay was 7 days. Median follow-up was 13 months (range 4-25 months). All patients have resumed their accustomed pre-operative activity patterns. These findings demonstrate that immediate, bilateral TRAM flap reconstruction is a safe and effective option for breast reconstruction after mastectomy.     

A phase II trial and pharmacokinetic analysis of 96-hour infusional paclitaxel in patients with metastatic colorectal cancer

AIMS: To carry out a retrospective study of male breast cancer over a 22-year experience. METHODS: Data from 121 male patients with breast cancer treated between the years 1972 and 1994 at the Surgical Clinic of Ankara Oncology Hospital were reviewed. Distribution of cases according to stage was: 2.5% stage I, 28.9% stage II, 55.4% stage III and 13.2% stage IV (AJCC staging method). The surgical treatment for 23 of the patients (19%) was Halsted's radical mastectomy or modified radical mastectomy. Seventy-three cases (60.3%) had total mastectomy without axillary node dissection and 25 (20.7%) had local tumour excision only. Seventy-two of 121 patients had adjuvant treatment. RESULTS: In general the prognosis of men with breast cancer was worse than for women. In the analysis of patients in stages I, II and III-A (operable disease group), the 5-year survival rates were 73% in axillary node-negative patients and 77% in those with tumours sized under 5 cm (P<0.001). In these patients, univariate analysis demonstrated that axillary status (relative risk of death in positive status vs. negative=3.6), tumour size (relative risk in T3 vs. T1-2=2), surgical treatment type (relative risk in simple mastectomy vs. radical mastectomy=1.9) and adjuvant chemotherapy (relative risk if no chemotherapy=1.4) were statistically significant factors associated with survival. CONCLUSIONS: Cox's regression model revealed that axillary status, tumour size and type of surgical treatment were the most important independent prognostic factors (P<0.001).     

Early-stage bilateral breast cancer treated with breast-conserving surgery and definitive irradiation: the University of Pennsylvania experience

PURPOSE: To determine whether patients with early-stage bilateral breast cancer can be treated with definitive irradiation following breast-conserving surgery with acceptable survival, local control, complications, and cosmesis. METHODS AND MATERIALS: During the period 1977-1992, 55 women with Stage 0, I, or II concurrent (n = 12) or sequential (n = 43) bilateral breast cancer were treated with definitive irradiation following breast-conserving surgery. The records of these 55 patients with 110 treated breasts were reviewed for tumor size, histology, pathologic axillary lymph node status, first and overall site(s) of failure, and adjuvant chemotherapy or hormonal therapy. Curves for survival, local control, and regional control were determined. Cosmetic outcome, complication rates, and matching technique were analyzed. The median total radiation dose delivered was 64 Gy (range 42-72) using tangential whole-breast irradiation followed by an electron or iridium implant boost. The tangential fields were matched with no overlap in 40 patients (73%); there was overlap on skin of up to 4 cm in 14 patients (25%); and the matching technique was unknown in 1 patient (2%). The median follow-up for the 12 women with concurrent bilateral breast cancer was 4.0 years. The median follow-up for the other 43 women with sequential cancer was 9.3 and 4.9 years, respectively, after the first and second cancers. RESULTS: For the overall group of 55 patients, the 5- and 10-year overall survival rates were 96% and 94%, respectively, after treatment of the first cancer, and 96% and 92%, respectively, after treatment of the second cancer. The 5- and 10-year actuarial relapse-free survival rates were 90% and 75%, respectively, after treatment of the first cancer, and 83% and 72%, respectively, after treatment of the second cancer. For the 110 treated breast cancers, the 5- and 10-year actuarial local failure rates were 5% and 15%, respectively. Complication rates were: 28% breast edema, 8% arm edema, 4% pneumonitis, 3% cellulitis, 1% rib fracture, and 1% brachial plexopathy; no patient developed matchline fibrosis. For patients with a minimum of 3 years of relapse-free follow-up, the rate of excellent or good cosmetic outcome for 104 treated breasts was 85%. CONCLUSION: Definitive irradiation after breast-conserving surgery is technically feasible for selected patients with concurrent or sequential early-stage bilateral breast cancer. Survival, local control, complication rates, and cosmetic outcomes appear comparable to historical reports of breast conservation treatment for unilateral disease. Bilateral definitive breast irradiation after breast-conservation surgery should be considered an acceptable alternative treatment to bilateral mastectomy for selected patients with concurrent or sequential early-stage bilateral breast cancer.     

Dose and dose intensity as determinants of outcome in the adjuvant treatment of breast cancer. The Cancer and Leukemia Group B

BACKGROUND: Both total dose and dose intensity of adjuvant chemotherapy are postulated to be important variables in the outcome for patients with operable breast cancer. The Cancer and Leukemia Group B study 8541 examined the effects of adjuvant treatment using conventional-range dose and dose intensity in female patients with stage II (axillary lymph node-positive) breast cancer. METHODS: Within 6 weeks of surgery (radical mastectomy, modified radical mastectomy, or lumpectomy), 1550 patients with unilateral breast cancer were randomly assigned to one of three treatment arms: high-, moderate-, or low-dose intensity. The patients received cyclophosphamide, doxorubicin, and 5-fluorouracil on day 1 of each chemotherapy cycle, with 5-fluorouracil administration repeated on day 8. The high-dose arm had twice the dose intensity and twice the drug dose as the low-dose arm. The moderate-dose arm had two thirds the dose intensity as the high-dose arm but the same total drug dose. Disease-free survival and overall survival were primary end points of the study. RESULTS: At a median follow-up of 9 years, disease-free survival and overall survival for patients on the moderate- and high-dose arms are superior to the corresponding survival measures for patients on the low-dose arm (two-sided P<.0001 and two-sided P = .004, respectively), with no difference in disease-free or overall survival between the moderate- and the high-dose arms. At 5 years, overall survival (average +/- standard error) is 79% +/- 2% for patients on the high-dose arm, 77% +/- 2% for the patients on the moderate-dose arm, and 72% +/- 2% for patients on the low-dose arm; disease-free survival is 66% +/- 2%, 61% +/- 2%, and 56% +/- 2%, respectively. CONCLUSION: Within the conventional dose range for this chemotherapy regimen, a higher dose is associated with better disease-free survival and overall survival.     

Target volume and indications of radiotherapy in breast carcinoma

Breast-conserving surgery is now commonly used to treat breast cancer. While mastectomy has been the traditional treatment for ductal carcinoma in situ, it is felt to be excessive in most cases. A great effort has been made to identify pathobiological characteristics of DCIS that can be used to identify patients best suited for wide local excision vs. wide local excision and breast irradiation. Mastectomy and conservative surgery plus irradiation offer a similar outcome in patients with early stage invasive breast cancer. Radiotherapy has not been shown to improve survival but is able to reduce significantly the rate of local recurrence, which is regarded as a very undesirable outcome. There is still controversy concerning the necessity of irradiation of the breast in all patients. Analysis of predictors of outcome cannot identify a subgroup of patients with a very low risk for local breast recurrence who might not require radiation therapy. In premenopausal, node-positive breast cancer patients XRT has a beneficial effect not only on locoregional but also on systemic recurrences. Radiotherapy has to be integrated for a pre- or postoperative consolidation in new treatment concepts for locally advanced breast cancer which use primary chemotherapy and immediate or subsequent breast radiation. Radiation of internal mammary chain and supraclavicular fossa after conservative surgery does not lead to an increase in clinically important skin or pulmonary complications. Its role is being evaluated in current multicentre studies.     

Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast

BACKGROUND: Few women with locally advanced breast cancer remain disease-free, even for 2 years. Response to induction chemotherapy may be associated with longer disease-free and overall survival rates. The role of breast conservation in selected patients with response to induction chemotherapy was evaluated. METHODS: Since 1979, patients with Stages IIB and III breast cancer have undergone induction chemotherapy; patients with response continued chemotherapy until a plateau of regression was achieved. Before 1983, all patients having a response to chemotherapy underwent mastectomy; since 1983, selected patients have undergone breast conservation. Outcomes were tallied comparing these two groups of patients. RESULTS: The study group included 189 women, who were followed up for 12-159 months (median, 46 months) after diagnosis. Of the patients, 85% had a response to induction chemotherapy. Patients with no response were excluded from additional consideration in this study. One hundred three (64%) women underwent mastectomy; 55 (36%) were treated with breast conservation. The disease-free 5-year survival rate was 61% for all patients with a response to chemotherapy; 56% for those having mastectomy and 77% for those having breast conservation. The overall 5-year survival rate was 69% for all patients with a response to chemotherapy, 67% for those undergoing mastectomy and 80% for those having breast conservation. CONCLUSIONS: Induction chemotherapy achieves significant tumor regression in most women with locally advanced breast cancer, permitting subsequent breast conservation or mastectomy with a greater expectation of long-term success. Breast conservation is used more frequently with the same expectation of success as mastectomy, presuming careful selection based on response to chemotherapy.