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Background: This study was designed to determine the minimum number of sentinel nodes necessary to accurately stage patients with breast cancer., Methods: Between August 1997 and February 2001, 509 consecutive patients were enrolled in a prospective sentinel node database. Nodes were characterized as either blue or hot (>2 times background), or both, and ranked based on the order harvested. Predictive value of the sentinel node based on these characteristics was evaluated to determine the minimum number necessary to stage the basin., Results: In all, 990 sentinel nodes were harvested from 465 basins. Pathologic stage in 126 of 128 positive basins was predicted by the first or second node harvested. The remaining 2 patients were positive by immunohistochemistry only. The hottest node predicted the status in 114 of 128 basins., Conclusions: Although all nodes should be examined, these data suggest that limiting frozen section analysis to the first two sentinel nodes identified will not compromise the accuracy of staging and may provide a vehicle for resource savings.

Objective: The purpose of this study was to determine the factors that predict the presence of metastasis in nonsentinel lymph nodes (SLN) when the SLN is positive., Methods: A prospective database was analyzed and included patients who underwent SLN biopsy for invasive breast cancer from July 1997 to August 2000 (n = 442). One hundred (22.6%) patients had one or more positive SLNs, and were analyzed to determine factors that predicted additional positive axillary nodes., Results: Of the 100 patients with a positive SLN, 40 patients (40%) had additional metastasis in non-SLNs. The only significant variables that predicted non-SLN metastasis were tumor lymphovascular invasion (P = 0.004), extranodal extension (P < 0.001), and increasing size of the metastasis within the SLN (P = 0.011). In analyzing just those patients who had lymphovascular invasion, extranodal extension, and a SLN metastasis > 2mm, 92% were found to have additional positive nodes., Conclusions: In patients with invasive breast cancer and a positive sentinel lymph node, lymphovascular invasion, extranodal extension, and increasing size of the metastasis all significantly increase the frequency of additional positive nodes.

Background: This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer., Methods: Patients with invasive breast cancer were injected with 99mTc sulfur colloid prior to sentinel node biopsy; preoperative lymphoscintigraphy was then performed in half of the patient population., Results: Sentinel node identification was possible in 45 of 50 patients (90%). All 14 patients (31%) with axillary nodal metastases had at least one histologically positive sentinel node (0% false negative rate). Lymphoscintigraphy revealed sentinel nodes in 17 of the 24 patients (70.8%) imaged. All 17 of these patients had one or more axillary sentinel nodes identified using intraoperative lymphatic mapping. In addition, 5 of 7 patients with a negative preoperative lymphoscintogram had an axillary sentinel lymph node(s) identified intraoperatively. None of the tumors showed drainage to the internal mammary lymph node chain by lymphoscintigraphy despite the fact that there were 5 patients with inner quadrant tumors. There was no significant advantage with respect to sentinel lymph node localization (91.7% versus 88.5%, P = not significant) or false negative rate (0%, both groups, P = not significant) in the group undergoing preoperative lymphoscintigraphy when compared with the patients in whom lymphoscintigraphy was not performed., Conclusions: Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.

Background: Experimental protocols are being used increasingly to treat breast cancer with > 10 positive nodes. An appreciation of the natural history of this disease is crucial for choosing the optimal therapeutic approach., Patients and Methods: We retrospectively reviewed the records of 141 patients who had breast cancer with > 10 positive nodes and received definitive therapy at our institution in the years 1969 through 1991. Because therapy evolved during this period, we compared the results from 1969 through 1981 to those from 1982 through 1991., Results: Ninety-one patients (65%) were > or = 50 years of age. Fifty-four (38%) were estrogen receptor (ER) positive, the remainder were ER negative or ER status unknown. Fifty-seven (40%) had 10 to 15 positive nodes, 63 (45%) had 16 to 25, and 21 (15%) had > 25. The ratio of positive nodes to total nodes was < 50% in 22 patients, 50% to 75% in 49, and > 75% in 70. One hundred thirty-four patients (95%) underwent modified or radical mastectomy. Forty (28%) received adjuvant chemotherapy, including 16 (11%) of 58 patients treated prior to 1981. Eleven patients (8%) were treated with adjuvant radiation therapy. The median survival for all patients was 52 months, with an actuarial survival of 29% at 10 years. Patients treated after 1981 had significantly improved survival. They lived a median of 68 months postoperatively, as compared to 41 months among patients treated earlier., Conclusions: This is a high-risk group of patients, yet there is a small subset who can obtain a long survival with standard treatment modalities.

Three hundred eight patients underwent parotidectomy for a benign parotid tumor between 1948 and 1979. Two hundred seventy-four had operation for primary tumor, and 34, for recurrent tumor. Ninety-eight percent of those with primary tumors had superficial or total parotidectomy, and 2 percent had local excision with a wide margin of normal tissue. In those with recurrent tumor, 91 percent had superficial or total parotidectomy and 9 percent had local excision with a wide margin of normal tissue. There were nine recurrences in the primary group (3.2 percent) and 10 in the recurrent group (29 percent), at an average follow-up of 10 and 13 years, respectively. The time to recurrence in the primary group was between 5 and 20 years, whereas, second recurrences in the recurrent group generally took place within 5 years. Seven patients in the primary group (2.5 percent) and 9 in the recurrent group (26 percent) had sacrifice of the facial nerve. Most facial nerve sacrifices in the primary group were minor, involving a branch of the nerve only. Facial nerve sacrifice in the recurrent group, however, usually involved division of the nerve or the nerve trunk. These findings demonstrate that the major morbidity associated with managing benign parotid tumors occurs in dealing with recurrent tumors. Recurrence is uncommon if superficial or total parotidectomy is performed for a primary tumor.

Inadequate attention has been paid to optimal closure of the postmastectomy incision in patients not desirous of breast reconstruction. Herein, we describe the use of a basic plastic surgical technique at the time of mastectomy to eliminate the dog-ear deformity at the axillary end of the incision. The technique is conceptually simple and expedient, and gives an excellent cosmetic result.

Findings in our series of patients and a review of the literature seem to suggest that metastatic cancer to the thyroid is much more common that is clinically evident. The clinical presentation of an asymptomatic mass, normal thyroid functions, and a cold nodule on thyroid scan can occur months to years after treatment of a primary cancer and thus often produces a clinical dilemma. Workup should include ruling out other metastatic cancer and fine-needle aspiration of the thyroid mass. If isolated metastatic cancer to the thyroid is found, surgical resection should be performed, usually by lobectomy and isthmusectomy. Unfortunately, the prognosis is poor, but surgery often prolongs the disease-free interval and occasionally will be curative.

This series of 307 patients who underwent radical neck dissection showed an overall recurrence rate of 19 percent. Clinical staging of disease was an accurate predictor of both recurrence and survival. Extranodal disease dramatically increased recurrence and decreased survival. Although our recurrence rate after radical neck dissection was lower than that previously reported for surgery alone, it was still significantly higher than that after adjuvant radiotherapy. We conclude that histologically proved neck disease should be treated by radical neck dissection, followed by adjuvant radiotherapy to decrease recurrence and, it is hoped, improve survival.

Needle localization of mammographically detected lesions has been shown to detect early breast cancer. One hundred seven patients who underwent needle localized biopsy from June 1977 to September 1985 were reviewed. Eighty percent of the biopsies were benign and 20 percent were cancers (22 patients). In patients undergoing modified radical mastectomy, 80 percent of the axillary specimens were node-negative. During the same 8 year period, 570 breast cancers were diagnosed. Needle localization was responsible for only 4 percent of all cancers found. Though needle localization represents an advance in the detection of early breast cancer, the majority of cancers are found by physical examination. The importance of routine examination by a physician and self-breast examination remains paramount.

Preliminary data from this institution suggested that flow cytometric DNA analysis was an objective prognostic indicator in archival localized squamous cell carcinoma of the tongue. Technical improvements were made, including analysis of tumor, normal tissue, and a combination of the two; standardized cursor placement; mathematic determination of tetraploid populations; and development of a statistical analysis. A larger number of patients (60) with this disease were reviewed. DNA content was related to disease-free survival, local recurrence, regional metastasis, and incidence of second primary tumors. There was no significant difference between aneuploid and diploid tumors with respect to the variables analyzed. We believe these technical improvements will enhance flow cytometric DNA analysis of paraffin-embedded tissues. However, in this retrospective review of localized squamous cell carcinoma of the tongue, DNA analysis was not a valuable prognostic indicator. Only prospective studies will address this issue.

The mortality of squamous cell carcinoma of the tongue has not significantly improved in decades. Much of the information that has been gathered to date has been based on retrospective analyses. There is little consensus on treatment of the disease. In an attempt to define an objective prognostic indicator of aggressiveness of these tumors, a retrospective analysis of 15 paraffin-embedded specimens using flow cytometry was performed. Ten patients (67 percent) had aneuploid tumors and had a 5 year disease-free survival rate of 33 percent, whereas patients with diploid tumors (33 percent) had a 5 year disease-free survival rate of 80 percent. Although the number of patients was small, it appears that flow cytometry may be an objective prognostic indicator in patients with squamous cell carcinoma of the tongue. Larger series of archival paraffin-embedded flow cytometry analyses are recommended, as well as examination of variables other than the disease-free survival rate.

Thyroid and parathyroid surgery is associated with a 1 to 6 percent incidence of injury to the recurrent laryngeal nerve. Electrical stimulation of the recurrent laryngeal nerve produces vocal cord motion that can be monitored by means of a double-cuffed endotracheal tube. Twelve patients underwent prospective evaluation with this monitoring system, and in all 12, the recurrent laryngeal nerve was accurately identified and localized. The nerve could be stimulated from a mean distance of 1.7 cm by a mean amperage of 1.3 mA. Postoperative indirect laryngoscopy demonstrated normal vocal cord function in all patients.

Many asymptomatic patients suspected to have recurrent colorectal cancer based on an elevated carcinoembryonic antigen level will be spared unnecessary operation if strict attention is paid to their preoperative evaluation. Liver and renal function should be assessed. Unresectable extraabdominal and intraabdominal recurrence or metastases should be excluded. Patients being evaluated for recurrence after curative resection of a rectosigmoid cancer should undergo a bone scan. Having satisfactorily ensured normal results for these investigations, the surgeon should then proceed to search for an intraabdominal source of tumor recurrence.