Faculty Bibliography

BACKGROUND: Axillary lymph node status is still considered the most significant prognostic factor for breast cancer outcome, and treatment decisions are based on the presence or absence of nodal disease. Intramammary lymph nodes (IMLNs) can be a site of regional spread. Is this a marker for more aggressive disease? METHODS: We reviewed the cancer center pathology database from 1991 to 2005 for all cases of breast cancer with IMLNs. RESULTS: IMLNs were identified in 64 breast cancer patients, with metastatic spread in 20 patients, and benign IMLNs described in 44 patients. Positive IMLNs were associated with more aggressive disease, including higher rates of invasive versus noninvasive cancers (5% ductal carcinoma-in-situ [DCIS] with positive IMLNs vs. 23% with negative IMLNs), lymphovascular invasion (55% vs. 11%), and a higher rate of axillary lymph node involvement (72% vs. 18%). Patients with positive IMLNs were also more likely to undergo mastectomy (75% vs. 54%). CONCLUSIONS: IMLN metastases are a marker for disease severity; recognition of this may influence choice of adjuvant therapy. The presence of metastatic disease in an IMLN is associated with a high rate of axillary nodal involvement, and should mandate axillary dissection. Preoperative lymphoscintigraphy may help identify these extra-axillary metastases

PURPOSE: Underuse of adjuvant therapy is a potentially important and remediable explanation for the inferior survival of minority women with breast cancer. We sought to measure a racial disparity in the underuse of adjuvant treatments for early-stage breast cancer and to identify associated factors. METHODS: Cross-sectional study with review of all inpatient and outpatient medical records of 677 women treated surgically for a primary American Joint Committee on Cancer stage I or II breast cancer in 1999 to 2000. Underuse was defined as omissions of radiation therapy after breast-conserving surgery, adjuvant chemotherapy after resection of hormone-receptor-negative tumors > or = 1 cm, or hormonal therapy for receptor-positive tumors > or = 1 cm. RESULTS: One hundred forty-five (21%) of 677 women experienced underuse of appropriate adjuvant therapy: 16% in whites, 34% in blacks, and 23% in Hispanics (P < .001). Women referred to medical oncologists were less likely to experience underuse of necessary adjuvant treatments (relative risk [RR] for underuse = 0.2; 95% CI, 0.1 to 0.3). Women who were minorities (RR = 2.0; 95% CI, 1.3 to 3.1), had higher levels of comorbidity (RR = 1.4; 95% CI, 1.1 to 1.8) and lacked insurance (RR = 1.9; 95% CI, 0.9 to 4.0) were at greater risk for underuse. CONCLUSION: Minority women with early-stage breast cancer have double the risk of white women for failing to receive necessary adjuvant treatments despite rates of oncologic consultation similar to those for white women. Oncology referrals are necessary to reduce treatment disparities but are not sufficient to ensure patients' receipt of efficacious adjuvant treatment

BACKGROUND: This study evaluates differences in the utilization of breast conservation surgery (BCS) between major metropolitan areas in the United States (US) and the United Kingdom (UK). METHODS: Surgical and staging information were obtained from the Cancer Surveillance Program for Los Angeles County (LAC), the New York State (NYS) Department of Health Cancer Registry, and the UK National Health Service (NHS) Breast Screening Program. Demographic data were obtained from the census databases from the US, UK, Northern Ireland, and Scotland. Descriptive statistics, correlation analysis, and chi-square tests were used to compare rates of BCS across the locations under study. RESULTS: Breast conservation rates were highest in London (79.3%) compared to New York City (NYC) (69.7%) and LAC (66.5%) (P < .0001). Both in NYS and the UK, the cities differ from the surrounding regions in population density, education levels, agricultural activities, and unemployment. BCS rates tended to increase with population density and education levels, and decrease with increased unemployment and agricultural activity, but there was no impact on BCS rates when adjustments for these variables were included in regression models. BCS rates increase with increasing hospital case volume in LAC and NYC (P < .0001). CONCLUSION: When comparing large metropolitan areas in the US and UK there are significantly different rates of BCS in different locations. These differences reflect differences in population density, socioeconomic status (SES), education levels, hospital volume, and the effects of a nationally funded screening program

BACKGROUND: Despite the National Institutes of Health consensus statement in 1991 that breast-conserving surgery (BCS) followed by radiotherapy is an appropriate approach to the treatment of early-stage breast carcinoma, studies have shown a relatively low rate of BCS in the United States. The current study investigated predictors of breast conservation therapy in a large, diverse patient population. METHODS: Between 1990 and 1998, 43,111 patients underwent surgery for breast carcinoma and were entered into the Cancer Surveillance Program database for Los Angeles County. Of these, 29,666 (68.3%) had complete data on patient demographics, staging, surgeon, type of surgery, and hospital. Data were collected regarding extent of disease, lymph node status, tumor size, age, race, socioeconomic status (SES), surgeon specialization, surgeon volume, hospital specialization, and hospital volume. Univariate and multivariate analyses were performed. RESULTS: Univariate analysis showed that extent of disease, lymph node status, tumor size, age, race, SES, surgeon and hospital specialization, and surgeon and hospital volume all were significantly associated with surgery type (P <0.0001). Multivariate analysis showed that not only did extent of disease impact choice of surgery, but so did race, SES, hospital volume, surgeon volume, and surgeon specialization (P <0.0001). CONCLUSIONS: These results suggest that not only does the extent of locoregional disease play a role in the likelihood of a woman undergoing breast conservation therapy, but patient age, socioeconomic status, racial/ethnic factors, and the experience of both the surgeon and hospital have an effect

We report three cases of abdominal wall necrotizing fasciitis that occurred as a result of leakage from displaced percutaneous endoscopic gastrostomy tubes. This is the first report of such a series. Patients underwent extensive operative excisions of their abdominal walls down to their posterior fascia. All patients tolerated their initial surgery, however, two patients ultimately expired from respiratory complications. The surviving patient underwent multiple repeat debridements and reconstructive abdominal wall surgery. We review the epidemiology of patients at risk for this complication and discuss its presentation, as well as the appropriate workup and management. We also address the issues of closure of large abdominal wall defects and future alimentation in this patient group. Finally, abdominal wall necrotizing faciitis from gastrostomy tube leakage is a devastating complication, and the development of preventative strategies for patients at risk is of paramount importance

Adult intussusception in the setting of inflammatory bowel disease (IBD) is a rare phenomenon. Giant pseudopolyps, while generally considered benign, may function as lead points for intussusception. Diagnosis and management of intussusception in the setting of IBD can be fraught with hazards. We report the case of a 27-year-old male, recently diagnosed with ulcerative colitis and giant pseudopolyps, who presented with colocolonic intussusception and obstruction. Diagnosis was confirmed using CT imaging and the patient underwent resection of the colocolonic intussusception without reduction. The following case underscores the challenges in managing adult intussusception in the setting of IBD and allows for a review of the literature to date. Resection of non-reduced intussusception, rather than endoscopic or enema reduction, should continue to be definitive treatment of patients presenting with this unusual problem

BACKGROUND: This study examines the epidemiologic and pathologic characteristics of indigent breast cancer patients followed up in a public city hospital in comparison to national standards. METHODS: A prospective oncology database was queried to identify all patients presenting with primary breast cancer. Medical records of 188 patients identified between March 1997 and May 2002 were retrospectively reviewed. Pathologic and epidemiologic data were compared with 1998 data reported by the Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: Among the patient population 10% were Caucasian, 13% African-American, 49% Hispanic, 25% Chinese, and 6% were of other background. The majority of patients were uninsured. Indigent patients within each ethnic group presented with more advanced disease when compared with patients reported by SEER. CONCLUSIONS: Indigent patients among all ethnic and racial backgrounds present with more advanced disease when compared with national statistics reported by SEER. The majority of these patients is uninsured and would benefit from more aggressive education, screening, detection methods, and follow-up