Douglas J. Marchant

Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma.

PURPOSE The study was undertaken to assess the relationship among cosmesis and complications to factors related to disease presentation, surgical and radiotherapeutic technique, and adjuvant systemic therapy in conservative treatment for early-stage breast carcinoma. PATIENTS AND METHODS Between 1982 and 1988, 234 women with stage I/II breast carcinoma were treated with conservation therapy by a highly standardized protocol of limited excision and radiotherapy. Radiation boost and/or reexcision were determined by careful quantitation of the normal tissue margin around the primary tumor. Boosts to 20 Gy were preferentially performed with interstitial iridium-192 (192Ir) implants. Axillary node dissections were performed in all patients aged less than 70 years. Adjuvant therapy consisted of cyclophosphamide, methotrexate, (doxorubicin), and fluorouracil (CM[A]F) six to eight times for node-positive premenopausal women and tamoxifen for node-positive or -negative postmenopausal women. Median follow-up was 50 months (range, 20 to 80 months). Cosmesis was graded by defined criteria, and complications were individually scored. RESULTS Factors found to impact cosmesis adversely were palpable tumors (P = .046), volume of breast tissue resected (P = .027), reexcision of the tumor bed (P = .01), number of radiation fields (P = .03), radiation boost (P = .01), and chest wall separation (P = .01). There was a trend toward worse cosmesis (P = .062) in patients receiving tamoxifen. Cosmesis was not adversely affected by interstitial implant in spite of a higher prescribed dose. Factors influencing complication risk were axillary node dissection (P = .02), number of lymph nodes harvested (P = .05), and chemotherapy (P = .03). CONCLUSIONS Optimal cosmesis and minimal complication risk require careful attention to the technical details of surgery and radiotherapy. The impact of systemic therapies needs to be more thoroughly examined.

Tumor margin assessment as a guide to optimal conservation surgery and irradiation in early stage breast carcinoma

Between 1982 and 1985, 108 women with AJC Stage I and II invasive mammary carcinoma were treated to 115 breasts with conservative surgery and irradiation. The irradiation dose was adjusted to the histopathological normal tissue margin around the carcinoma in the tumor excision specimens. Margins were arbitrarily determined negative, close, and positive with normal tissue margins in the inked tumor excision specimens of greater than 5 mm, 2-5 mm, and less than 2 mm, respectively. Negative, close, and positive tumor margin patients were treated to radiation doses of 60, 65, and 70 Gy, respectively. The boost in excess of 50 Gy was directed to the tumor bearing quadrant of the breast using interstitial Ir-192 implants for doses greater than or equal to 70 Gy. The draining lymphatics were irradiated to 50 Gy except in patients with tumor in the lateral half of the breast and no axillary lymph node metastases. Histopathological evaluation of re-excision specimens revealed the difficulty of obtaining negative margins for tumors greater than 2 cm. By our criteria, 54% of the patients had a positive resection margin. None of the patients experienced a local recurrence at 60 months median follow-up. Three patients failed regionally, two in un-irradiated lymph node areas, one in the skin of the contralateral breast; five patients failed systemically. Overall and disease-free survival for Stages T1/N0, T1/N1, T2/N0 was 100 and 95%, respectively, and for T2/N1, 90 and 80%, respectively. The cosmesis was excellent in 66% of the patients with minimal treatment related complications. Carefully planned standardized irradiation with assessment of resection margins yields both excellent local control rates and cosmetic results.

Breast conservation in elderly women for clinically negative axillary lymph nodes without axillary dissection

Background. A prospective study was initiated to explore an approach of limited therapy in elderly patients with early clinical stage breast cancer.

Breast conservation therapy for early stage breast carcinoma with outstanding 10-year locoregional control rates: A case for aggressive therapy to the tumor bearing quadrant

PURPOSE Between 1982 and 1988 233 American Joint Committee on Cancer Stage I and II invasive breast carcinomas were prospectively treated in 225 women with conservative tumor excision, careful assessment of histopathological margins, and dose-adjusted irradiation to maximum doses of 70 Gy to the tumor bearing quadrant of the breast. METHODS AND MATERIALS The pathological stages at presentation were T1N0 and T1N1 in 57% and 13% and T2N0 and T2N1 in 19% and 10% of the patients, respectively. All patients were irradiated according to a policy that, beyond the 50 Gy to the whole breast and draining lymphatics, the tumor-bearing quadrant was boosted in adjustment to the histopathological margin. Normal tissue margins of < 2 mm were considered positive, margins 2-5 mm close, and margins > 5 mm negative and were boosted with 20, 15, and 10 Gy, respectively. Patients in whom the margin could not be assessed were re-excised or boosted to 20 Gy. Re-excisions with no residual carcinoma were not boosted. Most patients boosted to 20 Gy to the tumor-bearing quadrant received interstitial 192-Ir implantations. RESULTS The actuarial local control rates in the treated breast were 97.5% at 10 years with three recurrences having occurred at a median of 4.5 years after completion of radiotherapy. An additional two patients failed regionally outside the irradiation portals. The overall and disease-free survival of the whole group is 87.5% and 77%, respectively. CONCLUSION The approach to breast conservation therapy followed in this study has resulted in outstanding local control rates and suggests that there may be a subset of patients that could be irradiated to the tumor bearing quadrant only.

Effects of pregnancy and progestational agents on the urinary tract

Abstract Numerous previous investigations have failed to demonstrate conclusively the etiology of hydroureter and hydronephrosis of pregnancy. A convincing argument has been made for both hormonal and mechanical factors. In the present study a total of 54 patients were studied, 44 of whom were pregnant and 10 of whom were receiving drug therapy. Those studied during the first trimester of pregnancy were admitted for therapeutic abortion. Employing intravenous pyelography and urometry, dilatation of the ureters was demonstrated in 2 of 17 patients in the first trimester, 4 of 7 in the second trimester, and 4 of 5 in the third trimester. Patients receiving large doses of the progestational agents and synthetic estrogen demonstrated no alteration in ureteral function and no dilatation of the ureters.

Congenital absence of the uterine cervix

Surgical correction of congenital atresia of the uterine cervix by creation of a fistulous communication between the functioning endometrial cavity and the vagina with the use of the atretic cervix as a conduit has been performed in two patients. This technique, which permits egress of menstrual blood and the retention of the capacity to reproduce, should replace hysterectomy as the treatment of choice for this extremely unusual and formerly hopeless Müllerian duct anomaly.

Reconstructive Surgery for Congenital Atresia of the Uterine Cervix

Reconstructive surgery for congenital atresia of the uterine cervix, utilizing the atretic cervix as a conduit for the permanent fistulous communication between the endometrial cavity and vagina, has resulted in the establishment of cyclic menses in four patients followed for up to 27 months postoperatively. A detailed review of maternal obstetric histories failed to reveal a common factor causally related to this extremely unusual and formerly hopeless congenital anomaly of the Müllerian ducts.

Routine noninvasive hysterography in the evaluation and treatment of endometrial carcinoma

Abstract Hysterography is an important aid in the diagnosis and treatment of endometrial carcinoma. Using a noninvasive technique, no significant complications have occurred in 134 patients. Important information concerning site of origin, size, and extent of the tumor and uterine deformities has been obtained and has altered the treatment in 28% of the cases studied. The importance of having a knowledgeable observer to direct and interpret the study is stressed. The significance of possible transtubal and hematogenous spread is discussed.

Evaluation of Stress Urinary Incontinence

Stress urinary incontinence is a socially disabling disease and should be corrected only when the loss of urine is demonstrable and produces sufficient symptomatology to be noted by the patient. Careful evaluation of the history, physical examination results, and laboratory studies will indicate weight reduction, control of respiratory disease, or treatment of neurologic deficits or severe emotional problems more often than surgery.

Preoperative irradiation for carcinoma of the endometrium: indications and results.

Abstract One hundred thirty patients with carcinoma of the endometrium were treated preoperatively with external irradiation (4000 rad) and radium application (2500 mg/hr or 2000 rad). Criteria for preoperative irradiation included: large uterus [19], signs of myometrial invasion on hysterogram [50], cervical involvement [37], poorly differentiated or anaplastic carcinoma [13], adenosquamous cell carcinoma [10], or squamous cell carcinoma [1]. Hysterography was performed as part of the pretreatment work-up in 93 patients (71%). Diffuse, multiple or single large defects were observed in the fundus in 72%, 8% had defects in the lower uterine segment, and the remaining 20% showed no gross defects on hysterography. Eighty-seven (67%) had no residual tumor in the hysterectomy specimen, while residual carcinoma was seen in forty-three (33%). No local recurrence has developed in the pelvis or vagina. Six patients have developed extra-pelvic metastasis, and four have died of disease. Overall survival is 97% with follow-up of 1 to 6 years.