Faculty Bibliography

Surgery is the most effective therapeutic intervention available for the treatment of breast cancer. It has been responsible for obtaining local control and long-term disease-free intervals in more patients over the past century than any other treatment modality. Trends toward earlier stage at diagnosis are likely to increase the importance of surgery and to secure its central role in the treatment of this disease. Unfortunately, during the 1990s the value of excellent local control of breast cancer has been minimized as the disease has come to be considered systemic from inception and as the results of adjuvant-therapy trials in patients with early-stage breast cancer have revealed survival advantages in patients receiving systemic therapy. Only rarely is it acknowledged that surgery alone achieves long-term disease-free states in 70% to 80% of all patients. At the core of this paradigmatic controversy is management of the axilla. The status of the axilla remains the most powerful predictor of outcome in patients with invasive carcinoma of the breast, and it is likely that a small but identifiable subset of patients obtains a survival benefit from the removal of disease-containing nodes. It is believed that no benefit is derived from the removal of negative nodes, and indeed there are even patients in whom complete elimination of the exploration of the axilla may be considered-all of which underscores the need to investigate the axilla selectively. Lymphatic mapping and sentinel lymph node (SLN) biopsy represents the most exciting development to date toward this end. The challenge today, as we move closer to a selective approach to the axilla, is to ensure that patients with positive nodes have those nodes identified and removed and patients with negative nodes experience minimal disturbance of their axilla.

OBJECTIVE:The objective of this study was to determine the clinical outcomes of patients with fallopian tube carcinoma treated with paclitaxel-based combination chemotherapy following primary cytoreductive surgery. METHODS:Twenty-four patients with the diagnosis of primary tubal adenocarcinoma treated between 1993 and 1998 were identified through the gynecology service database and the Memorial Sloan-Kettering Cancer Center tumor registry. Medical records were reviewed for information on age, stage, chemotherapy regimen, surgical intervention, relapse, and survival. All patients had their histologic material initially read or reviewed at Memorial Sloan-Kettering Cancer Center prior to treatment. The original slides were reviewed again by one of the authors (P.E.S.) to confirm the diagnosis of primary fallopian tube cancer. RESULTS:The mean age of the patients was 63 years (range, 44-76). Distribution by stage was as follows: four patients (17%) were Stage I, three patients (12%) were Stage II, 16 patients (67%) were Stage III, one patient (4%) was Stage IV. Four patients had grade 2 tumors, 20 had grade 3. Sixteen patients (67%) had optimal cytoreduction at the time of initial surgery with residual disease less than 1 cm. Eight patients (33%) had suboptimal cytoreduction. Following initial surgery, all patients were treated with paclitaxel-based chemotherapy for a median of five cycles. Twenty-three patients received paclitaxel at the dose of 135-175 mg/m(2) in combination with carboplatin or cisplatin; the majority, 17 of 23 (74%), received carboplatin. One patient received paclitaxel alone. Median follow-up from time of initial surgery was 24 months (range, 1-73 months). Two patients are dead of disease. Overall survival for the entire group was 96% at 12 months by Kaplan-Meier analysis, and 90% at 3 years. The overall median progression-free survival was 27 months (range, 5-57 months) for the entire group. The median disease progression-free survival at 3 years was 67% (95% CI, 45-100) in the optimally debulked group as compared with 45% in the suboptimally debulked group (95% CI, 27-57). Twelve patients (50%) had evidence of recurrence or persistent disease. There were fewer recurrences in the optimally debulked group: 5 of the 16 patients (31%) versus 7 of the 8 patients (88%) with suboptimal cytoreduction. CONCLUSION/CONCLUSIONS:Optimally cytoreduced patients with primary fallopian tube carcinoma treated with a paclitaxel-based chemotherapy regimen have an excellent possibility of survival.

BACKGROUND:The introduction of SLNB has allowed accurate staging in early-stage breast carcinomas and has minimized the number of unnecessary ALNDs. Intraoperative frozen-section analysis is a fundamental component of the sentinel lymph node biopsy (SLNB) procedure. Some patients have positive nodes on frozen-section analysis and thus undergo a conventional axillary lymph node dissection (ALND) at the time of the SLNB. A few patients have negative nodes on frozen-section analysis but have subsequent evidence of metastases on final pathologic examination. The purpose of our study was 2-fold: to compare the hospital-related charges of patients undergoing staging by SLNB with those of patients undergoing conventional ALND and to assess whether the different outcomes associated with SLNB adversely affect the charges incurred with this procedure. METHODS:Our study group consisted of 100 patients with T1 breast cancer and breast conservation therapy who underwent either SLNB or ALND from July 1, 1997, to June 30, 1998. We identified the first 50 consecutive patients to undergo SLNB during this period. We chose a similar cohort of 50 patients for ALND. Mean hospital-related charges for the SLNB patients were categorized and compared with those for the ALND patients. RESULTS:Results for the two groups were analyzed using a two-sample Wilcoxon rank-sum test. Charges for the OR and hospital stay were less for the SLNB group (P < .05). Frozen-section analysis in the SLNB group contributed to the significant difference in charges for pathologic evaluation. Overall, the two groups showed no significant difference in total hospital-related charges. CONCLUSIONS:When SLNB is used for T1 tumors, a small percentage of patients (10% in our study) will return to the operating room for an ALND. This small percentage does not increase the charges related to SLNB, however, as the reduced stay for most patients offsets this subgroup's contribution to the total hospital-related charges. Thus, in patients with clinical stage I breast cancer, SLNB does not cause significantly higher hospital-related charges compared with conventional ALND.

The management of breast cancer associated with pregnancy encompasses many diagnostic and therapeutic dilemmas. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. The risk to the unborn child plays a major role in the decision process. Overall, the prognosis of patients with pregnancy-associated breast cancer is worse because a large proportion of patients are first seen with more advanced disease. However, stage for stage, the prognosis is similar.

Pregnancy-associated breast cancer has an overall worse prognosis than nonpregnancy-associated breast cancers because a large proportion present with more advanced disease. Stage for stage, however, the prognosis is similar. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. Often, a delay in diagnosis may contribute to a more advanced stage at presentation. The management of pregnant women with breast cancer is also different because it involves assessing the possible risks to the fetus versus the maternal benefits.

OBJECTIVE:To assess the relationship between CD4 lymphocyte population and stage of disease in cervical neoplasia. METHODS:Study population was 107 women with invasive cervical cancer, 116 women with cervical intraepithelial neoplasia (CIN), and 32 women without neoplasia diagnosed in 1988-1994. All women under age 50 were seronegative for the human immunodeficiency virus (HIV). All women over age 50 with CD4:CD8 ratio below normal were HIV-negative. Stage was defined by FIGO criteria using clinical findings. CD4 and CD8 lymphocyte populations were enumerated by flow cytometry prior to treatment. The normal range of CD4 counts was defined as 537-1571 cells/mm3. RESULTS:Distribution of CD4 count was similar in stages I (n = 40), II (n = 24), and III (n = 32), with 31% below normal and 9% above normal (mean CD4 count = 881). However, in stage IV (n = 11), 64% were below normal and 18% above normal (mean CD4 = 591). The difference in distribution between stages I-III and stage IV was statistically significant. Among 116 CIN patients, 10% had CD4 counts below normal and 3% above normal (mean CD4 = 910). Among 32 women without cervical neoplasia, 0% had CD4 counts below normal and 3% above normal. The difference between CIN and invasive cancer in the distribution of CD4 counts and CD8 counts was significant (P < 0.01). There was no difference in the CD4 count distribution by CIN severity. Forty-five percent of patients with below-normal CD4 counts at diagnosis developed recurrent cancer compared to 43% of patients with normal or above-normal CD4 counts. CONCLUSION/CONCLUSIONS:Women with invasive cervical cancer have lower CD4 counts and a broader distribution compared to women with preinvasive or no neoplasia. Metastatic cancer at diagnosis was associated with severely depressed CD4 count.