Breast-conserving surgery and radiation therapy: are they underused?
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Breast Neoplasms↗
Biomedical subjects
J A van Heerden
Publications and source records attributed to J A van Heerden.
The clinical significance of nuclear DNA ploidy pattern in 184 patients with pheochromocytoma.
Flow cytometric nuclear DNA analysis was performed on paraffin-embedded tissue samples taken from 184 patients with pheochromocytoma and paraganglioma treated between 1960 and 1987. The Hedley technique was used for measurement of nuclear DNA content. Thirty-five percent of the tumors were DNA diploid, 33% showed a DNA tetraploid pattern, and 32% had DNA aneuploid pattern. Familial pheochromocytoma and associated endocrine or neoplastic disorders were more common among patients with DNA nondiploid tumors. Eighty-four percent of the tumors that invaded blood vessels and all patients with regional or distant metastases had tumors classified as DNA tetraploid or DNA aneuploid. Of 22 patients who had disease progression, 21 (95%) had tumors with abnormal DNA ploidy pattern (P less than 0.001). All 12 patients who died of cancer-related disease had abnormal DNA ploidy; none of the patients with DNA diploid tumor (n = 64) have died of pheochromocytoma (P less than 0.01). These results suggest that nuclear DNA ploidy pattern is an important and independent prognostic variable for patients with pheochromocytoma and paraganglioma.
Adrenal Gland Neoplasms↗
Parathyroid autotransplantation.
Although rare following initial cervical exploration, reoperative parathyroid surgery may cause permanent hypoparathyroidism in 15% to 30% of patients. Immediate fresh or delayed cryopreserved parathyroid autotransplantation is the principal surgical option to resolve this complication. Between 1980 and 1990, 18 and 12 patients underwent immediate and cryopreserved autotransplantation, respectively. With a mean follow-up of nearly 5 years, 61% of the immediate and 42% of the cryopreserved tissue showed evidence of function. However, only 10 (55%) and two (17%) of the respective patients had completely discontinued treatment with calcium supplementation. Graft-dependent hypercalcemia can occur with either technique. We conclude that until cryopreserved tissue can be transplanted with more reliable success and if the excised abnormal parathyroid likely represents the only remaining gland, we would advise immediate autotransplantation. In the reoperative setting, unless a residual normal parathyroid gland is confirmed, a portion of the excised parathyroid tissue should be cryopreserved for possible autotransplantation in case hypoparathyroidism develops subsequently.
Cryopreservation↗
Complications following pancreaticoduodenectomy. Current management.
From 1980 to 1989, 279 patients underwent pancreaticoduodenectomy at a single institution with a postoperative mortality of 4%. The aim of this study was to determine incidence, origin, and present management strategy of early complications following this operation. Significant morbidity occurred in 46% of the patients, including delayed gastric emptying (23%), pancreaticojejunal anastomotic leak (17%), intra-abdominal sepsis (10%), biliary-enteric anastomotic leak (9%), gastrointestinal tract bleeding (5%), and intra-abdominal hemorrhage (3%). Complications were associated with advanced age, prolonged operations, and increased operative blood loss. Most complications were managed nonoperatively. Mortality was increased when a reoperation was required, a biliary-enteric leak occurred, or an intra-abdominal abscess developed. Pancreaticoduodenectomy continues to carry a high postoperative morbidity; however, operative mortality is low, and management of complications has been made simpler with more sophisticated, nonoperative therapeutic options.
Abscess↗
Prognostic profile for patients with pheochromocytoma derived from clinical and pathological factors and DNA ploidy pattern.
Eighty-eight patients with pheochromocytoma and paraganglioma treated over a 28 year period (1960-1987) were studied. Based on clinical course, they were divided into three prognostic groups: benign (n = 57); multiple (n = 12); and metastatic (n = 19). Using clinical data, histopathologic findings, and tumor nuclear DNA content a prognostic profile for each group was constructed. The following variables were studied: age, familial pheochromocytoma, associated endocrine or neoplastic disorders, number and location of the lesion at diagnosis, size of the tumor, and the nuclear DNA ploidy pattern. Of these prognostic factors the most significant to predict a future malignant clinical course were large size and local tumor extension at time of surgery. Family history of pheochromocytoma, associated endocrine disorders, and young age at presentation predicted multiplicity. Old age, absence of familial pheochromocytoma or related endocrine disorders and DNA diploid tumors seem to be favorable findings. Using these variables in combination may be helpful for early identification of patients with malignant, multiple, or benign pheochromocytoma and paraganglioma.
Adrenal Gland Neoplasms↗
Laparoscopic cholecystectomy in children: initial experience and recommendations.
Our initial experience with laparoscopic cholecystectomy in children and the modification of techniques required for pediatric surgical patients is reported. Six children aged 6 to 17 years underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. All patients had biliary colic and did not require concomitant intraabdominal surgical procedures. Average operative time was 89 minutes; none were converted to open cholecystectomy. One patient returned home the evening of surgery, two patients were discharged the following morning, and two patients were discharged 2 days following the procedure because of their distance from home. There were no complications. All patients have remained asymptomatic on follow-up of 1 to 5 months. Based on this initial experience, several changes in the technique as reported in adults are recommended. Due to the softness and laxity of the anterior abdominal wall, an infraumbilical incision for the 10-mm camera trocar is more cosmetically acceptable and just as efficient. There is a smaller intraabdominal space with which to work, tempting one to overinflate the abdomen for better visualization. Care should be taken to ensure that the intraabdominal pressure does not exceed 15 mm Hg despite the small volumes required to do so. Placement of the second epigastric incision is more inferior and lateral than the standard recommendation for adults. The cystic duct must be controlled as early as possible in the operative course to prevent egress of stones from the gallbladder into the common duct. In one patient, these migrating stones were milked back into the gallbladder and a second clip placed.
Adolescent↗
Laparoscopic cholecystectomy: operative technique.
Laparoscopic cholecystectomy has become the routine procedure for most patients with symptomatic cholelithiasis. At our institution, a two-surgeon, four-cannula technique is used. In almost all patients, a pneumoperitoneum can be established with use of a closed technique. Adherence to standard operative principles and careful attention to details in the laparoscopic technique will routinely result in the safe completion of laparoscopic cholecystectomy. Cautery provides excellent hemostasis during dissection of the gallbladder from its attachments. Cholangiography through the gallbladder or the cystic duct is easily performed in selected patients. Minimal perioperative care is necessary for patients who undergo laparoscopic cholecystectomy, and the hospitalization time is usually less than 24 hours.
Cautery↗
Laparoscopic cholecystectomy: early Mayo Clinic experience.
Prospective data and follow-up information were collected on the initial 200 patients who underwent laparoscopic cholecystectomy at the Mayo Clinic. The operation was completed laparoscopically in all but five patients, who required conversion to laparotomy because of dense scarring or stones in the common bile duct. The median surgical time was 85 minutes. The major postoperative complications were retained stones in the common bile duct (in seven patients), intraperitoneal hemorrhage that necessitated transfusion (in two patients), and intra-abdominal abscess and pulmonary infection (in one patient each). The median hospital stay was 1 day (range, 0 to 8 days), and the median times to full activity and normal employment were 8 days and 12 days, respectively. Laparoscopic cholecystectomy is associated with a low frequency of complications in most patients with symptomatic gallstones and allows a rapid return to normal activity. Currently, laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis.
Academic Medical Centers↗
Clinical performance of parathyroid hormone immunometric assays.
Three immunometric assays of parathyroid hormone (PTH)--a commercial immunoradiometric assay, an in-house immunoradiometric assay, and an immunochemiluminometric assay--were evaluated in 50 patients with surgically proven primary hyperparathyroidism. Of these patients, 43 had increased values with the commercial assay (sensitivity, 86%), whereas 45 patients had increased concentrations with both the in-house immunoradiometric and the in-house immunochemiluminometric assays (sensitivities, 90%). Because of the results of this comparison study, we confidently chose the immunochemiluminometric assay as our routine assay; this assay was evaluated retrospectively in 361 patients with surgically proven primary hyperparathyroidism. In 45 patients, PTH values were below the upper limit of normal (sensitivity, 88%). The results indicate that the sensitivities of current immunometric assays are approximately 90%. Twenty patients who had hypercalcemia associated with malignant involvement were assessed with the immunochemiluminometric assay. Of these 20 patients, 19 had subnormal PTH values, and 1 had a value within the normal range. In contrast, in the past, PTH values determined with radioimmunoassays have often been in the normal range for such patients. Thus, an immunometric PTH assay is superior to a radioimmunoassay in the differential diagnosis of hypercalcemia associated with malignant disease.
Diagnosis, Differential↗
Medullary thyroid carcinoma: clinicopathologic features and long-term follow-up of 65 patients treated during 1946 through 1970.
We retrospectively reviewed the medical records of 65 consecutive patients with medullary thyroid carcinoma, who had had their primary surgical treatment at the Mayo Clinic during the years 1946 through 1970. Of these patients, 58 had sporadic and 7 had familial medullary thyroid carcinoma. Thyroid nodules were the most common initial manifestation. Near-total thyroidectomy was the most frequent initial operation. Survival was affected by the following factors: male sex, familial inheritance, size of the tumor, stage of the tumor (American Joint Committee on Cancer), and completeness of initial resection of the tumor. The mean duration of follow-up was 23.5 years, and the maximal follow-up was 36 years. Among 52 patients without initial distant metastatic involvement and with complete resection of the tumor, 20-year survival free of distant metastatic lesions was 81%. Overall 10- and 20-year survival rates were 63% and 44%, respectively. Because of the substantial morbidity and mortality associated with medullary thyroid carcinoma, early diagnosis and thorough initial resection of the tumor are important.
Adolescent↗
Extended lymph node dissection for gastric cancer. Is it of value?
The value of extended lymph node dissection for gastric cancer has not been clearly defined. The incidence, staging, and, possibly, the biology of gastric carcinoma in Japanese and Western confound the evaluations of radical lymph node dissection. Surgeons and pathologists must be familiar with the unified international gastric cancer staging system, and careful attention should be given to accurate identification and rigorous examination of regional lymph nodal groups.
Europe↗
Routine use of selective venous sampling for the localization of functioning islet cell tumors of the pancreas.
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Adenoma, Islet Cell↗
Evaluation of DNA nuclear pattern as a prognostic determinant in resected pancreatic ductal adenocarcinoma.
From a cohort of 72 patients who underwent radical resection for ductal adenocarcinoma of the pancreas between 1951 and 1980, 62 paraffin-embedded specimens were analyzed by flow cytometry. Patients were divided into two groups according to the length of survival: long-term survivors (19 patients who survived 3 or more years after operation) and short-term survivors (43 patients who died within 12 months after resection). In 30 specimens (48%), the nuclear DNA pattern was diploid, whereas 32 were nondiploid (two tetraploid and 30 aneuploid). There were no significant differences in the number of diploid/nondiploid patterns, the fraction of cells in DNA synthetic (S) phase, or the DNA index between the two groups. These data suggest that there is no difference in the DNA content analysis of patients with pancreatic ductal adenocarcinoma when comparing long-term with short-term survivors following resection.
Carcinoma, Intraductal, Noninfiltrating↗
The spectrum of serous cystadenoma of the pancreas. Clinical, pathologic, and surgical aspects.
Serous cystadenoma of the pancreas is a rare lesion thought to be almost invariably benign. Since 1978, 211 cases have been reported in the literature. Some have been recognized by computed tomography (CT) when small and asymptomatic. The authors have reviewed their experience with 40 patients (median follow-up of 1.9 years, maximum of 22.2 years) from 1936 to 1991. One third (13) were asymptomatic, of whom eight (20%) were discovered intraoperatively. Of those 20 who had CT, an unequivocal preoperative diagnosis was reached in none. Needle biopsy proved accurate in two patients. Endoscopic retrograde cholangiopancreatography (ERCP) and biopsy were performed with diagnostic success on one occasion. Three patients presented acutely. The tumor was resected in 90%, with an operative mortality rate of 10%. Enucleation of the tumor without formal anatomic pancreatectomy necessitated reoperation for complications in four of eight patients. Survival after successful resection paralleled expected survival. Serous cystadenoma may be associated with von Hippel-Lindau syndrome. The current role for conservative management remains questionable because of our current inability to reliably differentiate many of these benign neoplasms from malignant cystic neoplasms of the pancreas.
Adult↗
The Zollinger-Ellison syndrome. A collective surgical experience.
A retrospective study of 90 surgically treated patients with the Zollinger-Ellison syndrome seen from 1958 through 1990 was performed. Fifteen patients had Zollinger-Ellison syndrome as a manifestation of multiple endocrine neoplasia type I. Preoperative tumor localization was positive in 46% of 54 patients studied. Gastrinomas were identified in 66% of patients, 38% of the tumors being malignant. Postoperative eugastrinemia was achieved in 11% of patients after a variety of surgical procedures. Exploratory laparotomy provides the only chance for cure and identifies the significant prognostic factors associated with long-term patient survival: small tumor size, extrapancreatic primary, and absence of tumor metastases.
Adolescent↗
Perioperative blood transfusion and determinants of survival after liver resection for metastatic colorectal carcinoma.
The authors reviewed their institutional experience with liver resection for metastatic colorectal carcinoma to (1) determine whether perioperative blood transfusion affects survival; (2) identify prognostic determinants; and (3) estimate the patient requirement for a prospective randomized trial designed to demonstrate efficacy of liver resection. Two hundred eighty consecutive patients treated by potentially curative liver resection between 1960 and 1987 were included. Data were obtained for all but 10 patients for at least 5 years after operation or through 1990. Actuarial survival curves related to potential prognostic determinants were analyzed with the log-rank test. Overall, survival was 47 +/- 3% at 3 years and 25 +/- 3% at 5 years, including 4% 60-day operative mortality rate. Eighty-one patients who did not receive blood 7 days before to 14 days after operation had 60 +/- 6% 3-year and 32 +/- 6% 5-year survival compared with 40 +/- 4% and 21 +/- 3% survival rates for 183 patients who received at least one unit (p = 0.03, operative deaths excluded). Extrahepatic disease (p = 0.015), extrahepatic lymph node involvement (p = 0.002), satellite configuration of multiple metastases (p = 0.0052), and initial detection by abnormal liver enzymes (p = 0.0005) were associated with poor survival rates. Synchronous presentation of metastatic and stage B primary disease was associated with a favorable prognosis (p = 0.003). The requirement for a prospective randomized trial estimated by an exponential survival model would be 36, 74, 168, or 428 patients if 5-year survival without resection were 1, 5, 10, or 15%. We conclude that (1) perioperative blood transfusion may be adversely associated with survival; (2) extrahepatic disease, extrahepatic lymph node involvement, satellite configuration, and initial detection by clinical examination or a liver enzyme abnormality portend a poor prognosis; and (3) a prospective randomized trial of liver resection is impractical because of the large patient requirement, at least by a single institution.
Aged↗
Cushing's syndrome associated with ectopic production of corticotrophin-releasing hormone, corticotrophin and vasopressin by a phaeochromocytoma.
We describe a case of Cushing's syndrome caused by a phaeochromocytoma secreting corticotrophin-releasing hormone (CRH) and corticotrophin (ACTH). A 49-year-old white woman presented with a 1-month history of lower limb oedema, polydipsia and polyuria. Physical examination revealed a patient with plethoric facies, lanugo-type facial hair, central obesity, red abdominal striae, lower limb oedema, and blood pressure of 210/115 mmHg. Laboratory studies showed high plasma ACTH and markedly elevated urinary cortisol excretion that suppressed more than 50% with high-dose dexamethasone administration. Computed tomographic scan of the abdomen showed a 4-cm left adrenal tumour. Catecholamines and metabolites were markedly increased in a 24-hour urine collection. Results of venous catheterization studies showed that CRH and ACTH were secreted by the tumour. In addition, with ovine CRH administration, inferior petrosal sinus sampling showed pituitary secretion of ACTH. Left adrenalectomy resulted in complete remission of Cushing's syndrome. Light microscopic and immunohistochemical studies revealed a phaeochromocytoma that produced CRH, ACTH and vasopressin. RNA studies showed that this tumour, in contrast to normal adrenal and other reported phaeochromocytomas, transcribed a lone pituitary-sized (1200 nucleotide) pro-opiomelanocortin mRNA. This is the second reported case of a CRH-secreting phaeochromocytoma.
Adrenal Gland Neoplasms↗
Carcinoma of the body and tail of the pancreas: is curative resection justified?
BACKGROUND: The role of resection in the treatment of carcinoma of the distal pancreas remains unclear. The less frequent occurrence of tumor in the distal gland, advanced tumor stage at diagnosis, and a lack of reported success have combined to produce therapeutic nihilism in the minds of many surgeons. The goal of this review was to assess long-term survival after distal pancreatectomy for carcinoma of the pancreas. METHODS: The records of all patients undergoing distal pancreatectomy at the Mayo Clinic for a primary pancreatic malignant tumor during the 25-year period from 1963 to 1987 were reviewed. Forty-four patients undergoing potentially curative distal pancreatectomies were identified: 26 patients for ductal adenocarcinoma, 12 patients for islet cell carcinoma, and six patients for cystadenocarcinoma. RESULTS: Major postoperative morbidity occurred in 9% of the patients and operative death in 2% of the patients. Patients with ductal adenocarcinoma frequently were admitted with advanced disease (stage II or III). The median overall survival for patients with ductal adenocarcinoma was 10 months. Fifteen percent of the patients survived 2 years after operation, and 8% of the patients survived 5 years. In contrast, the 5-year survival after resection of islet cell carcinomas and cystadenocarcinomas was excellent (83% and 100%, respectively). CONCLUSION: The prognosis for patients with ductal adenocarcinoma in the distal pancreas who were treated with potentially curative distal pancreatectomy is poor; however, the results are not substantially different from those reported after pancreaticoduodenectomy for malignant tumors of the proximal pancreas. Some patients with adenocarcinoma of the distal pancreas who were treated with resection may be long-term survivors. We recommend resection of carcinoma of the distal pancreas when the disease is limited to the gland and believe that all patients with ductal adenocarcinoma should be considered for postoperative adjuvant radiation and chemotherapy.
Adenocarcinoma↗