Peter W. Brown

Postirradiation sarcoma (malignant fibrous histiocytoma) of axilla.

A case is reported of a patient who developed a histologically unusual sarcoma in the axilla and chest wall 8 years after receiving radiation therapy (6500 rad) for carcinoma of the breast. This sarcoma showed light, and electron‐microscopic features of a malignant fibrous histiocytoma, a tumor not documented among 24 previously reported cases of postirradiation sarcoma following the diagnosis of breast carcinoma. In addition, the literature is reviewed and discussed regarding postirradiation sarcoma in general following breast carcinoma.

Medical and surgical adrenalectomy in patients with advanced breast carcinoma

Twenty‐four postmenopausal patients with metastatic breast carcinoma were placed on aminoglutethimide and dexamethasone as a form of reversible medical adrenalectomy. Six patients experienced adverse side‐effects. Of the 18 remaining patients 50% had a definite subjective or objective response to therapy. Thirteen of these patients underwent subsequent surgical adrenalectomy after a maximum of 3 months trial of the medical regimen. In every patient the response to therapy was identical with the two modalities of therapy. In those postmenopausal patients with metastatic breast cancer who are felt to have a hormone‐ dependent tumor by clinical and/or hormonal assay criteria, medical adrenalectomy may eventually be a feasible replacement for surgery in selected cases. As important, perhaps, is the potential value of this medical adrenalectomy as a reliable indicator of the subsequent response to endocrine ablative therapy.

An evaluation of the wire mesh prosthesis in primary reconstruction of the mandible.

A stainless steel wire mesh prosthesis was used as a primary mandibular replacement in 102 patients after resection of malignant neoplasms arising in the head and neck. In sixty-seven patients the prosthesis was considered successful. Failure of the host to tolerate the prosthesis was associated with a history of previous irradiation, extensive resections, and loss of distant skin flaps used for coverage of the prosthesis. We conclude that the wire mesh mandibular prosthesis is an excellent means to accomplish prompt functional and cosmetic reconstruction after mandibular loss and does not preclude the use of a more complex modality of reconstruction if the initial implant is removed.

Survival after palliative surgery for advanced intraabdominal cancer

The clinical course of 300 patients with known intraabdominal neoplasm requiring surgical exploration was analyzed. The most common primary tumor sites were the gastrointestinal tract (60 per cent), female reproductive organs (17 per cent), and urinary tract (6 per cent). Gastrointestinal and extrahepatic biliary obstruction, gastrointestinal bleeding, and peritonitis were the most common indications for surgery. The overall operative mortality was 26 per cent, and the mean survival time was 6.6 months. Small bowel fistulas, intraabdominal abscesses, and cardiopulmonary and renal failure were the leading causes of death. Palliative procedures in patients less than sixty years old with single site of obstruction or with tumor of gastrointestinal origin were associated with a low operative mortality and prolonged survival. On the other hand, surgical intervention in patients more than seventy years old undergoing chemotherapy, with multiple sites of obstruction, peritonitis, or primary tumor originating outside the gastrointestinal tract, was associated with high operative mortality and seldom benefited from palliative intervention. Surgical intervention to relieve a distressing symptom in a patient with advanced neoplasm is a well established procedure, but the risks and benefits of such intervention should be carefully weighed against the expected mortality and the quality of survival.

Primary reconstruction of the mandible with a wire mesh prosthesis

A stainless steel wire mesh prosthesis was used as a primary mandibular replacement in 102 patients following resection of malignant neoplasms arising in the head and neck. In 67 patients the prosthesis was considered successful. Failure of the host to tolerate the prostheses was associated with history of previous irradiation, extensive resections, and the loss of distant skin flaps used for coverage of the prosthesis. But the prosthesis is tolerated by the host in 90% of the cases if it is inserted in a non-irradiated bed, covered with local tissues, and the resection is limited to the maxillo-oral complex only.

Medical adrenalectomy in patients with advanced breast cancer

Medical adrenalectomy, consisting of aminoglutethimide plus either dexamethasone or hydrocortisone, was administered to 53 women with advanced breast cancer. Sixteen (30%) patients had an objective response, five patients had stabilization of disease, 26 patients demonstrated progression of disease, two patients did not adhere to protocol, and four patients had severe toxicity necessitating discontinuation of the drugs. Medical adrenalectomy accurately predicted response to subsequent surgical adrenalectomy in 23 patients. Estrogen receptor (ER) data accurately predicted response (eight of nine (89%) ER‐positive patients responded) or failure (only two of 14 (14%) ER‐negative patients responded) to medical adrenalectomy. Thirty (of 51 women adhering to protocol) had no toxicity. Therefore, it appears that medical adrenalectomy is safe, usually well tolerated, and can accurately predict response to surgical adrenalectomy. Its use should be limited to ER‐positive patients, and it may totally supplant surgical adrenalectomy in the management of advanced breast cancer.

The draping of the surgical field for major head and neck surgery

Due to the complexities involved in extensive resections and primary reconstruction necessary in the management of head and neck cancer, a standard draping of the sterile surgical field has been adopted to allow the performance of the anticipated surgical plan or alternatives in an orderly fashion, without disrupting the function of other members of the surgical team.