Alloplastic sternal replacement in malignant sternal tumors. Case report and review of the literature

Although not seldom as a palliative procedure, the preferred treatment of locally recurrent breast cancer or chest wall involvement by metastases is full-thickness chest wall resection. For closure and coverage of the defect various techniques are described. Autoplastic reconstruction is indicated for smaller defects, while larger defects usually require alloplastic materials, especially in case of chest instability after resection. We report the case of a 55-year-old female who developed a locally recurrent breast cancer with infiltration of the sternum 4 years after left sided ablation. En bloc resection of the chest wall including the complete sternum was followed by replacement with a computer-aided custom made polyethylene sternal prosthesis. With this procedure we stabilized the chest wall with protection of the underlying organs, avoided prolonged postoperative ventilation and achieved a satisfying cosmetic result.     

Radiotherapy for post-operative inflammatory breast cancer

Two patients with inflammatory breast cancer treated with a combination of radical mastectomy, irradiation, and immunochemotherapy are reported. After radical mastectomy, both patients were given a dose of 4000 rad and 5000 rad to the chest wall and parasternal lymph nodes, and 5000 rad to the axillary and supraclavicular lymph nodes. However, both patients died of recurrence within the irradiated field of the chest wall and metastatic spread to the neighbouring skin. A discussion on the dose and field in radiation therapy for inflammatory breast cancer is presented.     

Extracapsular axillary node extension in patients receiving adjuvant systemic therapy: an indication for radiotherapy?

PURPOSE: This is a retrospective review into the patterns of failure of 82 patients with Stage II or III breast cancer who had extracapsular extension (ECE) of axillary nodal metastases and who received systemic chemotherapy or hormonal therapy without loco-regional radiation. METHODS AND MATERIALS: The clinical records of patients with axillary node positive (T1-T3, N1, 2) Stage II or III breast cancer seen at the London Regional Cancer Centre between 1980-1989 were reviewed. Patients were identified who underwent segmental mastectomy with axillary node dissection or modified radical mastectomy and received adjuvant chemotherapy or tamoxifen but did not undergo loco-regional radiation. Eighty-two patients within this group had pathologic evidence of extracapsular axillary node extension (ECE). For 45 of these patients the extension was extensive, and for the remaining 37 it was microscopic. This ECE-positive group was compared to a subgroup of 172 patients who did not have pathologic evidence of extracapsular axillary node extension but had metastatic carcinoma confined within the nodal capsule. RESULTS: Median age of the 82 ECE-positive patients was 56 years. Twenty-five patients had had a segmental mastectomy, the remainder a modified radical mastectomy. Median actuarial survival was 60 months, with a median disease-free and loco-regional failure-free survival of 38 months. Seventy-eight percent of these patients developed a recurrence, which was loco-regional in 60% (21% local, 21% regional, 2% local and regional, and 16% loco-regional and metastatic). There was a 36% recurrence rate in intact breast, 14% the chest wall following modified radical mastectomy, 7% relapsed in the axilla, 12% in supraclavicular nodes, and 1% in the internal mammary nodes. A comparison of the 82 ECE-positive patients with a group of 172 ECE-negative patients determined that there was a statistically significant difference between the two groups in terms of survival (overall and disease-free) and loco-regional recurrence. Univariate analysis of the entire 254 node-positive patient group revealed extracapsular nodal extension (ECE) to be a prognostically significant factor for actuarial and disease-free survival as well as for loco-regional failure, but ECE did not remain an independently prognostic factor after multivariate analysis. Segmental mastectomy, positive resection margins, and ER negative status increased the risk of loco-regional recurrence within the ECE-positive group. CONCLUSIONS: Extracapsular axillary node extension is a prognostically significant factor for actuarial survival, disease-free survival, and loco-regional failure but not independent of other adverse prognostic factors. It is a marker for increased loco-regional recurrence associated with doubling of breast, chest wall, and supraclavicular recurrence rates. The risk of axillary relapse in patients who have had an adequate level I and II axillary dissection but demonstrate extracapsular extension is low (7%). We recommend breast/chest wall and supraclavicular radiation for all patients with pathologic evidence of such extranodal extension who have had a level I and II axillary dissection regardless of the number of positive axillary nodes. Axillary irradiation should be considered for patients who have had only an axillary sampling or level I axillary dissection.     

The sepsis syndrome and the cancer patient: respiratory management and active physiotherapy

We describe the case of a 46-year-old man with lung cancer and simultaneous solitary adrenal metastases. Adrenalectomy was performed 12 weeks after lung resection through a right subcostal laparotomy. Treatment was complemented with chemotherapy. Twelve months after adrenalectomy the patient was found free of signs of disease and was in satisfactory condition. The advantages of and indications for surgical resection of suprarenal metastasis are discussed in the light of published literature. In some cases, survival may improve with exeresis and chemotherapy.     

The Taskforce 2000 survey on medical education in sleep and sleep disorders

A 71-year-old woman underwent radical resection in May 1994 for a mediastinal mass invading the anterior chest wall. Histopathological examination revealed adenosquamous cell carcinoma. She was treated with postoperative chemotherapy including 5-fluorouracil (5-FU) and 4'-D-tetrahydropyrayl-doxorubicin (THP), based on in vitro chemosensitivity testing (CST), by MTT assay, using a surgical specimen. In December 1994, a recurrent tumor was detected on the left anterior chest wall and the patient received two courses of 5-FU, THP and methotrexate (MTX). The size of the chest-wall tumor decreased 25%. In July 1995, the patient had involvement of the left axillary lymph node and brain metastases in addition to the mass on the chest wall. Therefore, cisplatin, 5-FU and MTX were selected as treatment agents, based on CST using a metastatic axillary lymph node. After two courses of these agents, chest computed tomography showed a 91% reduction in the size of the chest wall tumor. Radiation was administered for the brain metastasis. In March 1997, the patient died of thymic carcinoma.     

A case of a premenopausal woman with advanced breast cancer treated with aromatization inhibition in combination with luteinizing hormone-releasing hormone agonist

A 44-year-old premenopausal woman having local recurrence and pleural and bone metastases of breast cancer was treated with aromatization inhibition in combination with Luteinizing Hormone-releasing Hormone (LH-RH) agonist. The dominant site of metastasis was a painful local lesion invading the chest wall. A partial response by reducing the size of the local lesion was attained 3 months after initiation of treatment. This result suggested that treatment using aromatization inhibition in combination with LH-RH agonist would be effective in premenopausal breast cancer. To confirm the effectiveness of this treatment, comparative study between aromatization inhibition in combination with LH-RH agonist aromatization inhibition alone and anti-estrogen in combination with LH-RH agonist are needed.     

Pulmonary neoplasm with solitary cerebral metastasis. Results of combined excision

Twenty-two patients underwent excision of a primary pulmonary neoplasm and solitary cerebral metastasis. Six patients had metastatic tumor removed on two occasions and there was one operative death in 28 craniotomies. Seven of 22 patients (32 per cent) survived one year following craniotomy and were free of significant symptoms for one year. Survival for at least 9 months and freedom from significant symptoms was achieved in a total of 12 patients (55 per cent). Relief of severe neurologic symptoms for a minimum of 3 months was achieved in 17 patients (77 per cent). The over-all one-year survival rate was 45 per cent and the average survival period is 14 months with 3 patients still living. The following factors had a favorable bearing on the outcome: Stage 1 lung cancer at pulmonary resection, whole-brain radiation therapy, and a longer interval between pulmonary resection and cerebral metastasis. The experience encourages us to pursue an aggressive surgical approach to pulmonary neoplasm and solitary cerebral metastasis.     

Autoimmune bullous eruption localized to a breast reconstruction site: response to niacinamide

A case of bullous pemphigoid responding to niacinamide as monotherapy is reported. Clinically, the patient presented with bullous lesions localized to the left breast. She had a history of a left breast mastectomy for breast cancer. This was followed by radiation therapy to the left chest wall and delayed left breast reconstruction achieved with a transposition flap of the latissimus dorsi muscle. There have been reports of bullous pemphigoid treated with a combination of tetracycline and niacinamide. This is the first report, to our knowledge, of a case of bullous pemphigoid responding to niacinamide alone.     

Axillary lymph node metastases from bronchogenic carcinoma

BACKGROUND: Axillary lymph node metastases (ALNMs) from bronchogenic carcinoma are rare and their significance may be questioned. A surgical approach may allow a better understanding of the mechanism of their occurrence. METHODS: A retrospective study of 1,486 cases of surgically removed non-small cell lung carcinoma was performed. Twenty-two patients (1.5%) had extrathoracic nodal metastases. Nine of them were ALNMs (<1%). These cases form the basis of this study. RESULTS: In 1 patient ipsilateral ALNM was removed during a lung operation. It was a left non-small cell lung carcinoma invading the chest wall (T3 N2). In the other patients (n = 8) ALNMs were observed during postoperative follow-up; 4 underwent ALNM resection, 2 had radiotherapy, and 2 had symptomatic treatment only. For these 8 patients, in the TNM classification performed after an initial bronchogenic carcinoma operation, the lymph node status was, respectively, N0 in four cases, N1 in three cases, and N2 in one case. Survival ranged from 1 to 10 months, except for one patient who is still alive after more than 5 years. In this case, the ALNM was discovered 4 months after a right lower lobectomy for a T2 N0 adenocarcinoma. CONCLUSIONS: Axillary lymph node metastases may be involved through direct chest wall invasion of bronchogenic carcinoma or retrograde spread from supraclavicular lymphnode block. However, another mechanism seems to be the systemic vascular route.     

Successful management for chemorefractory testicular cancer with brain and lung metastases. A case report

This is a report of successful management for a far advanced, chemorefractory testicular cancer patient. A 29-year-old male was referred to our hospital for the treatment of progressive lung metastases with elevated hCG level, which had recurred after complete remission following 3 courses of BEP chemotherapy and progressed after transient partial regression following 2 courses of intensified EP chemotherapy. In addition, a 3 cm in diameter, solitary brain metastasis was detected on CT. First, we performed wedge resection of bilateral pulmonary lower lobe for chemorefractory pulmonary metastases. Histological examination revealed viable embryonal carcinoma identical to the primary one. Thereafter, whole brain irradiation in combination with VIP chemotherapy (etoposide 100 mg/m2, cisplatin 20 mg/m2 and ifosfamide 1200 mg/m2 daily for 5 consecutive days) was carried out to treat brain metastasis. By 2 cycles of VIP therapy and irradiation (36 Gy), partial tumor regression and normalization of hCG level were achieved, leading to salvage surgery of the brain metastasis which histologically proved to be necrosis. Following an additional cycle of VIP therapy, the patient has been free of recurrence 24 months after completion of the treatment.     

Ganciclovir-associated hypercalcemia in a renal transplant patient

We report a patient with nasopharyngeal cancer with long-term follow-up of more than 16 years after the first course of radiotherapy in 1981. He developed a lung metastasis in 1996 after having a second course of radiotherapy for neck recurrence in 1989. The patient was a 42-year-old man with a nasopharyngeal tumor and a fixed upper neck metastasis (T1N1M0), which was treated with definitive radiotherapy. He manifested regional recurrence, at the margin of the radiation portal, with an 8 year disease-free interval, which was treated successfully by definitive re-irradiation. He developed a solitary lung metastasis, which was treated by video-assisted thoracoscopic lung resection, 7 years disease-free after the second course of radiotherapy. For 20 months after the removal of the lung metastasis he has been generally well without any signs of recurrence of sequelae. This case indicates the efficacy of definitive re-irradiation for regional recurrence and the necessity for long-term observation after radiation therapy for nasopharyngeal cancer.     

Insulin-like growth factor I-dependent regulation of prolidase activity in cultured human skin fibroblasts

In metastatic breast cancer the goal to reach must be the best possible palliation with minimum discomfort for the patient. We reviewed our experience with radiotherapy (20 or 30 Gy), systemic therapy and brace. Among 2200 breast cancer patients, we extracted 28 potential candidates for resection. All of them developed new metastases outside the treated field within one year. Local control was achieved in 68%, and 80% of them had stable or better performance status at 3 months. From our analysis, even patients with a so called "solitary lesion" do not seem to have a better prognosis than others. We conclude that radiotherapy (with systemic therapy and a brace) is still first-choice treatment for vertebral metastases; CT-guided percutaneous biopsy can avoid worthless major operations. The role of surgery should be limited to neurological compression, severe mechanical instability and to salvage the failures of conservative treatment.     

Solitary plasmacytoma of sternum--a case report and review of the Japanese literature

A 39-year-old woman complained of anterior chest pain. A lateral chest X-ray film showed destruction of bone in the body of sternum. CT scan showed a soft tissue density within the sternum. Serum protein electropheresis revealed mild monoclonal gammopathy of IgG-kappa, but the urine contained no Bence-Jones protein. A biopsy specimen showed plasmacytoma with cytoplasmic Ig IgG-kappa. Bone scintigraphy and systemic bone roentgenography revealed only the lesion in the sternum. Sternal subtotal resectin was performed. The defect of the anterior chest wall was reconstructed with double folded marlex mesh and pedicles from the major pectoral muscle. Iliac bone marrow aspiration revealed no evidence of myeloma. There was no serum evidence of monoclonal gammopathy two months after the operation. Therefore, the final diagnosis was solitary plasmacytoma of the sternum. It is now 41 months since surgery, and there have been no signs of fecurrence. Long term follow up is necessary in this case.     

Malignant tumors invading chest wall: treatment with CT-directed implantation of radioactive seeds

Computed tomography (CT) was used to direct permanent implantation of radioactive iodine-125 seeds in two patients with unresectable lung cancer and in one with recurrent breast cancer invading the chest wall. An average of 60 seeds were implanted, with a mean total radioactivity of 35.6 mCi (1,317 MBq). Tumor coverage was adequate and pain relief was good in all patients. One patient had histologically documented complete response and another had CT-documented partial response.     

Metastatic breast disease 40 years after the initial diagnosis

This is the case of a patient with metastatic disease diagnosed 40 years after a radical mastectomy which was followed by radiation treatment for breast cancer. The patient had nonspecific symptoms for 3 years, and a lymph node biopsy revealed the underlying cause to be recurrent breast cancer. Excision of the largest metastases combined with chemotherapy resulted in a further 3-year remission.     

Development of neurosurgery in southern California and the Los Angeles county/University of Southern California Medical Center

We reported a case of successful treatment of bilateral pulmonary metastasis from rectal cancer with high-dose 5'-DFUR plus MMC combination chemotherapy. A woman born in 1948 showed a recurrence in the bilateral lung about 29 months after low anterior resection. High-dose 5'-DFUR plus MMC combination chemotherapy was started in March, 1991. The chest X-ray examination 8 weeks after beginning this therapy showed a remarkable decrease in the size of the pulmonary metastatic foci and CEA decreased in the same way. The dose of 5'-DFUR was reduced after 5 courses, and then CEA increased. No remarkable side effect was encountered and the patient could be safely treated at an outpatient clinic. During this therapy no recurrence has been detected, and we performed a resection of the bilateral pulmonary metastasis by median sternotomy in October, 1991. The above findings suggested that this was an effective and safe therapy for pulmonary metastasis from colon cancers and could be a neo-adjuvant chemotherapy for surgical resection of pulmonary metastasis.     

Breast cancer in older women

The American Geriatric Society currently recommends screening mammography for women up to 85 years of age whose life expectancy is three years or longer. The value of clinical breast examinations in older women needs further study. Total mastectomy and partial mastectomy with postoperative radiation therapy yield similar results in localized breast cancer. Postoperative irradiation may be avoided in women with small tumors (2.5 cm or less in diameter) who have undergone quadrantectomy. Lymph node dissection is important for tumor staging but significantly increases the risks and morbidity of surgery. Lymph node mapping may obviate the need for lymphadenectomy in many older women. Adjuvant hormonal therapy for at least two years appears to be beneficial in all women with hormone-receptor-rich tumors. Adjuvant chemotherapy is indicated in women with lymph node involvement or high-risk tumors with no lymph node involvement. Unless life-threatening metastases are present, hormonal therapy is the first approach to metastatic cancer. Chemotherapy is indicated if endocrine therapy is unsuccessful or life-threatening metastases are present. Most chemotherapy regimens appear to be well tolerated, even by women over 70 years of age. Special treatment should be employed for metastases to tumor sanctuaries (i.e., brain, eyes), the long bones, the spine and the chest wall.     

Physiopathologic mechanisms in acute progressive neuronal death: pharmaco-therapeutic consequences]

Although surgical intervention for advanced lung cancer invading the aortic wall is challenging, we successfully carried out such radical surgery under cardiopulmonary bypass as previously reported in this journal. One patient has now been followed for more than 5 years after the operation, so that we conclude if there is no evidence of metastatic cancer in selected patients then complete resection should be attempted using circulatory support, with the hope of an occasional cure.     

Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?

BACKGROUND: Conventional management of stage IV colorectal carcinoma is palliative. The value of resecting both liver and lung colorectal metastases that occur in isolation of other sites of metastasis is undetermined. OBJECTIVES: Our objectives were to (1) assess the efficacy of resecting both hepatic and pulmonary metastases, (2) investigate the influence of the sequence and timing of metastases, and (3) identify the profile of patients likely to benefit from both hepatic and pulmonary metastasectomy. Patients and methods: Of 48 patients identified with resection of colorectal cancer and, at some point in time, both liver and lung metastases, 25 patients underwent metastasectomy (resection group). The remaining 23 patients comprised the nonresection group. Risk factors for death were identified by multivariable analyses. RESULTS: Median survival was longer after the last metastatic appearance in the resection group (16 months) than in the nonresection group (6 months; P <.001). The pattern of risk also differed; it peaked at 2 years and then declined in the resection group but was constant in the nonresection group. In the resection group, patients with metachronous resections survived longer after colorectal resection (median, 70 months) than patients with synchronous (median, 22 months) or mixed resections (median, 31 months; P <.001). Risk factors for death included older age, multiple liver metastases, and a short disease-free interval. CONCLUSIONS: Younger patients with solitary metachronous metastases to the liver, then the lung, and long disease-free intervals are more likely to benefit from resection of both liver and lung metastases. Patients with risk factors also had better survival with resection than without resection.     

Analysis of 1alpha,25-dihydroxyvitamin D3 receptor in cell extracts with low protein concentration

Of 1190 patients with carcinoma of the uterine cervix, 15 (1.3%) developed skin metastases. The incidence of skin metastasis was 0.8% in stage I, 1.2% in stage II, 1.2% in stage III, and 4.8% in stage IV. The incidence of skin metastasis seemed to be higher in patients with adenocarcinoma and undifferentiated carcinoma than in patients with squamous cell carcinoma. The interval between the diagnoses of cervical cancer and skin metastasis ranged from 0 to 69 months, with a mean of 16.9 months. The most common sites of skin lesions were the abdominal wall and vulva, followed by the anterior chest wall. Skin lesions presented as nodules in 86.7% (13/15), and 66.7% of the patients had multiple lesions. Skin metastasis was detected as the initial metastatic lesion in 9 patients. However, only 4 patients had neither local recurrence nor other distant metastasis at the time of diagnosis of skin metastasis. The prognosis was grave, but 3 patients survived more than 12 months after the diagnosis of skin metastasis. The main treatment for these patients was extirpation of the skin lesion followed by radiotherapy.