Marc J. Homer

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.

Mediastinal Lipomatosis: CT Confirmation of a Normal Variant

Mediastinal lipomatosis is a common benign cause of mediastinal widening. While it may be associated with exogenous obesity, steroid ingestion, or Cushings syndrome, these factors often are not present. Evaluation of the mediastinum by CT should be the initial diagnostic study in the work-up of patients with abnormalities of the mediastinal contour; indeed, in many cases it can eliminate the need for other procedures.

Broadband Optical Mammography: Chromophore Concentration and Hemoglobin Saturation Contrast in Breast Cancer

This study reports the optical characterization and quantitative oximetry of human breast cancer using spectrally-resolved images collected with a broadband, continuous-wave optical mammography instrument. On twenty-six cancer patients, we collected two-dimensional optical mammograms and created maps of the concentrations of hemoglobin, water, and lipids, as well as the oxygen saturation of hemoglobin. For each cancerous breast, we analyzed the difference between the tumor region (as identified by x-ray and optical mammography) and the remainder of breast tissue. With respect to the surrounding tissue, we found that cancer regions have significantly higher concentrations of total hemoglobin (+2.4±0.4 μM) and water (+7±1% v/v), and significantly lower lipid concentration (8±2% v/v) and oxygen saturation of hemoglobin (5±1%). We also found a significant correlation between the tumor optical contrast and the grade of breast cancer as quantified by the Nottingham histologic score; this demonstrates how optical signatures may be representative of metabolic and morphological features, as well as the aggressive potential of the tumor.

NEAR-INFRARED, BROAD-BAND SPECTRAL IMAGING OF THE HUMAN BREAST FOR QUANTITATIVE OXIMETRY: APPLICATIONS TO HEALTHY AND CANCEROUS BREASTS

We have examined ten human subjects with a previously developed instrument for near-infrared diffuse spectral imaging of the female breast. The instrument is based on a tandem, planar scan of two collinear optical fibers (one for illumination and one for collection) to image a gently compressed breast in a transmission geometry. The optical data collection features a spatial sampling of 25 points/cm2 over the whole breast, and a spectral sampling of 2 points/nm in the 650–900 nm wavelength range. Of the ten human subjects examined, eight are healthy subjects and two are cancer patients with unilateral invasive ductal carcinoma and ductal carcinoma in situ, respectively. For each subject, we generate second-derivative images that identify a network of highly absorbing structures in the breast that we assign to blood vessels. A previously developed paired-wavelength spectral method assigns oxygenation values to the absorbing structures displayed in the second-derivative images. The resulting oxygenation images feature average values over the whole breast that are significantly lower in cancerous breasts (69 ± 14%, n = 2) than in healthy breasts (85 ± 7%, n = 18) (p < 0.01). Furthermore, in the two patients with breast cancer, the average oxygenation values in the cancerous regions are also significantly lower than in the remainder of the breast (invasive ductal carcinoma: 49 ± 11% vs 61 ± 16%, p < 0.01; ductal carcinoma in situ: 58 ± 8% vs 77 ± 11%, p < 0.001).

Development of Wire Localization for Occult Breast Lesions: Boston Remembrances

In the 1970s, the four authors of this article each set up mammographic screening programs and independently developed preoperative needle-wire localization techniques at different Boston-area hospitals. These innovations, which facilitated surgical biopsy of nonpalpable abnormalities, helped establish and popularize mammography and have only minimally changed over the ensuing decades. This historical perspective shares personal anecdotes of the early development of mammography and mammographic wire localizations.

Pre- and transoperative localization of nonpalpable breast lesions

Percutaneous needle localization should be performed before biopsy of a nonpalpable breast lesion, thereby eliminating the need for blind biopsy. With small cancers, transoperative localization is just as important to confirm excision of the lesion and ensure that representative sections are obtained from the area in question for histologic study.

Recurrent appendicitis: reexamination of a controversial disease.

The existence of recurrent appendicitis as a true disease entity is still disputed. The controversy surrounding recurrent appendicitis is discussed. This disease is thought to represent repeated inflammation of a nonperforated appendix. Case material supporting this concept is presented. The barium enema can provide evidence of the diseased appendix.

In situ breast cancer: a multidisciplinary approach.

The approach to these lesions is being reexamined in light of results with conservative surgery for invasive breast cancers. According to available data, the invasive potential of in situ lesions varies. Mammographic and pathologic findings may differentiate patients who will benefit from lumpectomy (with or without radiotherapy) from those requiring mastectomy.

Outpatient breast biopsies on a gynecologic service

One hundred forty-six breast biopsies in 143 patients were done on outpatient basis, without general anesthesia, on a gynecologic service between 1975 and 1980. This procedure has advantages over in-hospital biopsy in terms of cost, time, reduced immediate risk, and patient acceptance. Greater long-term risk, if carcinoma is found, has not been substantiated. Gynecologists need this procedure as an adjunct to the management of benign breast conditions and should be trained to do it.

The hilar height ratio.

The hilar height ratio is a value that expresses the normal position of a hilus in its hemithorax. Pulmonary volume changes, infrapulmonary, and subphrenic processes may produce an abnormal hilar height ratio. Detection of pathologic states that do not alter the relative hilar heights is made possible by the recognition of this abnormal ratio.