P. Peter Rosen

Residual mammary carcinoma following simulated partial mastectomy.

Treatment of mammary carcinoma by partial mastectomy rather than by total mastectomy and axillary dissection may diminish the chances of long‐term cure by risking incomplete removal of all local carcinoma at the initial operation. This study was undertaken to determine by pathologic examination how often carcinoma might remain in the breast and axilla after partial mastectomy. The operation was simulated in 203 mastectomy specimens after operations for unilateral invasive carcinoma. In so far as could be determined on gross examination, the entire primary lesion was included in the quadrant which was excised in the simulated procedure. Among 100 women with primary lesions less than 2 cm in diameter, 26% had carcinoma in the breast which remained after simulated partial mastectomy. Six percent of them also had axillary node metastases. An additional 30% only had axillary node metastases. When the primary lesion was more than 2 cm in diameter, 38% of patients had carcinoma in the breast after simulated partial mastectomy, of whom 29% also had axillary metastases. After simulated partial mastectomy, carcinoma was found in 80% of breasts from patients with lesions in the subareolar area, in contrast with 25–35% of patients with a primary carcinoma in one of the four quadrants. None of the 9 patients with medullary and colloid carcinomas that measured under 2 cm had axillary metastases or carcinoma in the breast outside of the primary quadrant. The findings suggested that a familial history of breast carcinoma or a large primary lesion may be associated more often with multifocal disease, but factors such as age at diagnosis, axillary status, and the mammogram report did not have significant predictive value for distinguishing between patients who did or did not have carcinoma in breast tissue after the primary had been removed by a simulated partial mastectomy.

Tuberculosis complicating neoplastic disease. A review of 201 cases

Case records were reviewed of 201 patients that developed active tuberculosis (TB) complicating neoplastic disease at Memorial Hospital between 1950‐1971. TB occurred in 44 patients with lung cancer, 45 with head and neck cancers, 28 with breast cancer, 29 with lymphoproliferative disorders, 20 with gynecologic cancers, 7 with leukemia, 9 with, stomach cancer, and 19 with other neoplasms. Patients with lung cancer, reticulum cell sarcoma, lymphosarcoma, and Hodgkins disease had a TB prevalence of 92, 78, 88, and 96 cases per 10,000 patients, respectively, with each neoplasm. Patients with head and neck, stomach cancer, and acute lymphatic leukemia and acute myelogenous leukemia had a prevalence of 51, 55, 37, and 28 per 10,000 patients at risk, respectively. The prevalence in breast cancer, colon, and genitourinary cancer was 5 to 20 per 10,000. TB generally occurred when the neoplasm first developed in patients with lung and head and neck cancers, and after antineoplastic therapy for advancing disease in lymphoproliferative disorders and breast cancer. TB occurring after antineoplastic therapy caused more severe TB infection with a high mortality rate. Patients treated with adrenocorticosteroids also had more severe tuberculous infection. TB caused masses and adenopathy plus fatal pneumonias and disseminated infection. Over‐all mortality due to TB was 17%, compared with 48% in patients with lymphoproliferative disorders. Early diagnosis and treatment of TB is stressed.

Diffuse pulmonary infiltrates in immunosuppressed patients. Prospective study of 80 cases.

Over a two year period, we studied prospectively 80 cases of diffuse pneumonia at Memorial Sloan-Kettering Cancer Center. In 72 per cent of these, the patient had leukemia or lymphoma. Diagnostic procedures consisted of extensive serologic testing for antibody to known respiratory pathogens, including the agent of Legionnaires disease, and culturing of biopsy specimens for bacteria, viruses, mycoplasmas and fungi. Of 44 cases in which open lung biopsy was performed, a specific cause was found in 61.4 per cent: Pneumocystis carinii in 38.6 per cent, other infections in 9.1 per cent and tumor involvement in 13.7 per cent. There were nonspecific pulmonary changes in 38.6 per cent. Of the 56 cases in which biopsy, autopsy or both were performed, a specific diagnosis was made in 69.7 per cent: P. carinii infection in 37.5 per cent and other infections in 12.5 per cent. In cases in which neither biopsy nor autopsy was performed, a specific infection was diagnosed in 33 per cent; no specific diagnosis was made in the remainder. One patient in the entire group had a significant antibody titer for Legionnaires disease. Although diagnostic in some cases, extensive serologic testing proved relatively unfruitful. Pneumocystosis was the most frequent diagnosis in this study. The cause of some cases remained obscure, even after lung biopsy.

Long term follow-up of women with ductal carcinoma in situ treated with breast-conserving surgery

Although in recent years there has been a dramatic increase in both the incidence of ductal carcinoma in situ (DCIS) and breast‐conserving therapy for patients who have this disease, the optimal treatment for these patients remains controversial. Most data regarding outcomes have come from small, retrospective studies, with little data published from prospective, randomized studies. This study investigates the effects of age, postoperative breast irradiation, and other factors on local relapse free survival after breast‐conserving surgery for women with DCIS in a large, single‐institution series.

Pulmonary Disease Caused by Candida Species

Candida species are often found in sputum specimens. Their role as a possible cause of pulmonary disease is a frequent consideration, particularly in patients receiving immunosuppressive or long-standing antimicrobial therapy. At Memorial Hospital and New York Hospital, 30 patients with histologic evidence of Candida pulmonary infection were identified over a two year period. These infections reached the lungs by hematogenous spread in 10 patients and by aspiration in 16 patients. Most the patients had malignant neoplastic disease. The Candida pulmonary disease appeared to be significant clinical factor in only three cases. Experience from our institutions and from the literature indicates that Candida species rarely cause significant pulmonary disease. When such involvement is extensive, the patient is usually terminally ill from multiple other factors.

Does clearing of axillary lymph nodes contribute to accurate staging of breast carcinoma

The major prognostic indicator in carcinoma of the breast is the presence of metastases in axillary lymph nodes. However, 25% of patients with negative axillary nodes by standard pathologic techniques are dead of metastatic breast carcinoma within 10 years. “Clearing” of the axillary fat has been shown to increase the yield of lymph nodes. Forty‐two pathologic Stage I and II breast carcinoma specimens were cleared following routine pathologic examination to determine whether stage was changed by the clearing procedure. A total of 857 lymph nodes were recovered from 42 patients by routine techniques. Clearing increased the number of nodes found by 30%, to 1114. In the 31 node‐negative patients an additional 178 nodes were identified, increasing the mean number of nodes per patient from 20 to 26. The number of additional nodes found per specimen ranged from 0 to 19. None of the additional nodes identified contained metastases. In the node‐positive patients, 79 additional nodes were found by clearing, including 33 with metastases. No change in stage resulted, although the mean number of nodes per patient was increased from 22 to 30. Although an occasional positive lymph node may be overlooked by manual dissection, the rarity of this event makes routine clearing of the axillary contents impractical for carcinoma of the breast except in a research setting. Whether this conclusion applies equally to other tumors and other lymph node groups requires further study. Cancer 53:1329‐1332, 1984.

Pneumocystis carinii pneumonia: Diagnosis by lung biopsy

Pneumocystis carinii pneumonia was suspected in 52 patients who underwent lung biopsy for diagnosis of diffuse pulmonary infiltrates. All but five of the procedures were limited thoracotomies. There were no instances of significant postoperative hemorrage or of pneumothorax compromising ventilation. The diagnosis of P. carinii pneumonia was made rapidly from imprints of the lung stained by the Gram-Weigert method in the 18 patients who had P. carinii pneumonia. Over-all, the rate of recovery from Pneumocystis pneumonia after treatment with pentamidine isethionate was 41 percent. However, among patients with no other pulmonary lesion (group A), the survival rate was 58 per cent; none of the patients with coexisting pulmonary disease (group B) recovered. The pulmonary infiltrates in the other 32 patients represented a variety of processes, of which 5 were fungal infections and 5 were due to lymphoma. Fifteen patients had an organizing interstitial and intraalveolar pneumonia of undertermined origin.

Intravesical formalin for the control of intractable bladder hemorrhage secondary to cystitis or cancer.

Between November 1971 and December 1973, 10 patients with intractable urinary bleeding secondary to radiation or cyclophosphamide cystitis, or to primary or secondary bladder cancer were treated with intravesical formalin. Good results were obtained in 8 of the 10 patients, with control of bleeding for 3 to more than 36 months. There were 2 failures, both with cancer.

Clinical studyPneumocystis carinii pneumonia: Diagnosis by lung biopsy☆

Pneumocystis carinii pneumonia was suspected in 52 patients who underwent lung biopsy for diagnosis of diffuse pulmonary infiltrates. All but five of the procedures were limited thoracotomies. There were no instances of significant postoperative hemorrage or of pneumothorax compromising ventilation. The diagnosis of P. carinii pneumonia was made rapidly from imprints of the lung stained by the Gram-Weigert method in the 18 patients who had P. carinii pneumonia. Over-all, the rate of recovery from Pneumocystis pneumonia after treatment with pentamidine isethionate was 41 percent. However, among patients with no other pulmonary lesion (group A), the survival rate was 58 per cent; none of the patients with coexisting pulmonary disease (group B) recovered. The pulmonary infiltrates in the other 32 patients represented a variety of processes, of which 5 were fungal infections and 5 were due to lymphoma. Fifteen patients had an organizing interstitial and intraalveolar pneumonia of undertermined origin.