Faculty Bibliography

A case report of clear cell sarcoma of the tendinous portion of the quadriceps in the knee joint of a 33-year-old female is presented. This insidious, usually painless malignant tumor is often misdiagnosed and may be referred to the sports medicine specialist as a sport-related injury. The duration of symptoms and the size of the lesion are important prognostic factors. Wide excision or radical surgery is necessary to cure such tumors. With improved reconstructive techniques, including free vascularized myocutaneous flaps, limb-sparing surgery is now possible.

Radical en bloc excision of the clavicle is effective treatment for neoplastic disease and does not impair normal activity of daily living. The subjective patients' assessments were good to excellent, as were the cosmetic results. There was full range of shoulder motion. Biomechanic testing revealed some weakness in shoulder abduction, flexion, and adduction but not in internal rotation, external rotation, or extension

The determination of steroid receptors in human breast cancers has assumed increasing importance over the past several decades. Improper handling of the specimens could affect results obtained. This study details the effects excessive levels of heat that occur with the use of electrocautery can have on steroid receptor quantities and localization. Twelve resected primary and metastatic human breast cancers were analyzed for cytoplasmic and nuclear receptors by biochemical analysis. In addition, steroid binding was determined by direct fluorescent histochemical techniques. To a portion of each resected specimen a Boviec was applied to simulate electrocautery resection. Analysis of the different portions of the same tumor revealed that there was a decrease in measurable cytoplasmic receptor in all cauterized specimens and a concomitant increase in the nuclear receptor. A similar shift in steroid binding was noted in all the specimens analyzed by fluorescent histochemical techniques. The results of this study show that the application of excessive heat to human breast cancers will lead to false negative biochemical steroid receptor determination by shifting the receptors intranuclear.

Clinical correlation of treatment response with estrogen (ERP) and progesterone (PgRP) receptors in 81 patients revealed a remission rate of 76% if both receptors were present in the tumor. The response rate was 89% in those patients with positive receptors in whom an endocrine ablative procedure was performed and was 63% in those patients treated with tamoxifen, suggesting that the latter modality may not be effective in the treatment of some hormonally responsive tumors. An assay to determine receptor sensitivity to tamoxifen was developed and correlated with clinical response to tamoxifen treatment. Of the 56 human breast tumors analyzed, 29 tumors were ERP- and PgRP-positive and ten of these were tamoxifen-insensitive. Sixteen tumors were ERP- and PgRP-negative and tamoxifen-insensitive. Of the remaining 11 tumors, four were tamoxifen-sensitive. Nineteen of the 56 patients whose tumors were analyzed were treated for advance breast cancers with tamoxifen. Twelve patients who were ERP- and PgRP-positive and tamoxifen-sensitive responded to this modality of treatment. Seven treatment failures were noted in this group all of whom were ERP-positive and tamoxifen-insensitive. Endocrine ablation failed either prior or subsequently in three of these patients all of whom were PgRP-negative. Two patients who were ERP- and PgRP-positive and tamoxifen-insensitive subsequently responded to an alternative antihormonal treatment.

Massive gastrointestinal hemorrhage secondary to benign cecal ulceration is a rare occurrence. The diagnosis of bleeding from this benign condition is rarely entertained and is often a finding on a pathologic examination. A case of massive hemorrhage from a cecal ulcer is presented, and the literature is reviewed. The role of angiographic demonstration of the lesion, if angiography is readily available, is emphasized, but surgery is the definitive therapy.

A review of the current literature on immunohistologic and histochemical methods for the detection of steroid hormone binding sites in breast cancer, reveals that many, but not all of the criteria for establishing hormone-receptor binding interactions have been met. These include tissue specificity, binding between labeled ligands and soluble receptor in vitro, correlations between histochemical and biochemical assays, as well as between histologic procedures and tumor hormone responsiveness. However, histochemical binding phenomena do not appear to follow classical receptor dogma in regard to the concentration of ligand required, or specificity of binding as determined by competitive binding assays. It is concluded that these histologic techniques may be detecting classical receptor that may be reacting differently than would be expected from biochemical analyses, Types II and III binding sites, and/or organelle and membrane-bound receptors. Certainly no current method should presently be promoted as a laboratory method for the detection of classical receptor. New immunocytologic procedures employing specific, antireceptor sera currently under development, may obviate many of the criticisms leveled against earlier methods.

Estrogen and progesterone receptor determinations were performed on 518 specimens at the Surgical Research Laboratory of the Maimonides Medical Center. Of these, 41% were ERP and PgRP positive; 17% were ERP positive and PgRP negative; 38% were ERP negative and PgRP negative, and 3.9% were ERP negative, PgRP positive. Sixty-two patients with advanced breast cancer were treated with either an endocrine ablative procedure or with antihormonal therapy. In the two treatment groups the overall response rate when both receptors were positive was 79%, with a higher percentage of responders in the endocrine ablative group (88% vs. 69%). In addition, a greater duration of response was achieved in those patients treated with endocrine ablation. The overall predictability of response was achieved in those patients treated with endocrine ablation. The overall predictability of response or failure to hormonal therapy is 91% if the progesterone receptor alone is utilized to select treatment and an endocrine ablative procedure is performed. The predictability of response based on the estrogen receptors presence or absence is 70%.

Estrogen (ER) and progesterone (PgR) receptors were assayed by histochemistry in primary, recurrent, and metastatic breast cancer. Ligand-conjugates composed of 17 beta-estradiol and 11 alpha-hydroxyprogesterone covalently linked to bovine serum albumin and labelled with fluorescein isothiocyanate were employed. Results were compared with those of conventional biochemical receptor assays and correlated for ER in 92% of 314 tumors and for PgR in 86% of 86 specimens. ER and PgR determinations by both assay systems were correlated with clinical response to various endocrine therapies in 40 women with Stage IV disease. The histochemical assay enabled successful prediction of response in 80% of cases including eight which could not be fully analyzed biochemically.

A 16 year experience with 121 patients treated for squamous cell carcinoma arising in the cheek mucosa is described. Treatment was almost exclusively surgical, and 5 year determinate cure rates ranged from 77 and 65 percent in stage I and II lesions to 27 and 18 percent in those with stage III and IV lesions, respectively. Twenty-four percent of previously treated patients remained alive and well at 5 years. The 42 percent overall salvage rate was low, reflecting the high proportion of patients who developed cervical metastasis during the course of the disease. In an attempt to improve local control, we now advocate irradiation of the primary tumor and neck after aggressive resection with radical neck dissection in any patient who has clinical evidence of nodal involvement or other unfavorable findings.