Search

Percutaneously inserted indwelling subclavian vein silastic catheters have revolutionized the administration of chemotherapeutic agents. Complications associated with insertion of such lines have always included bleeding, pneumothorax, haemothorax, arterial cannulation, and catheter displacement. Recently a patient receiving 5-fluorouracil and folinic acid for 11 months for small bowel carcinoma experienced a catheter fracture with distal segment embolization in the right atrium. A literature survey revealed 13 cases where mechanical shearing forces on the catheter caused by compression of the catheter between the clavicle and first rib were thought to be the cause for this complication. Interestingly all cases involved patients receiving chemotherapy. Radiologically, potential candidates for catheter fracture can be identified by the pinched-off sign with bending and pinching of the catheter at the thoracic inlet. Recommendations are for more lateral insertions of such percutaneously placed catheters and if the pinched-off sign is seen, then said catheters should be followed radiologically and probably should not remain in situ for longer than 6 months.

A recent case of a biliary granular cell tumor of the cystic duct prompted a literature review and an extensive pathological examination of the tumor in question. A total of 44 cases have been described mostly in black females. Most cases present with biliary symptoms, and simple surgical resection allows complete control of this benign condition. Granular cell tumors are most likely derived from neural crest cells.

Five cases of bloody nipple discharge during pregnancy without associated breast masses were seen over the past 3 years by the author. Because of the reported association of breast cancer with bloody nipple discharge, close follow-up of these women at monthly intervals during pregnancy and trimonthly during the postpartum period was carried out. In all instances, the discharge appeared late during the second trimester or during the third trimester of pregnancy. It was unilateral and spontaneous and arose from multiple ducts, and it was associated with an increase in breast size and always with the larger breast of the two. The discharge cytologic study done on all cases was negative for neoplastic cells and the discharges resolved spontaneously within 2 months of onset. Postpartum follow-up ranging from 6 months to 3 years has revealed no evidence of neoplastic changes thus far. Mammograms ordered before these patients were referred were not helpful due to the increase in density of the breast tissue secondary to the pregnancy. Because a few cases of breast cancer during pregnancy have presented solely with a bloody nipple discharge, I recommend extremely close follow-up of these women and no surgical intervention unless a mass is discovered or the nipple discharge cytology is either suspicious or positive at the initial visit or during follow-up.

TILs can be isolated and expanded in vitro in the presence of RIL-2. The resulting cells are highly cytotoxic in vitro and in vivo against a variety of tumor targets. Although most of the TILs bear T cell antigens on their cell surface, recent evidence suggests that natural killer (NK) cells may be part of the overall population of infiltrating cells. Based upon this evidence, we have evaluated the effects of Picibanil (OK-432), a well-known inducer of NK cell and T cell cytotoxicity, on TILs. OK-432 was administered intravenously at a dose of 100 micrograms, previously determined to be optimal for NK stimulation, to tumor-bearing animals. Two days later, control and experimental animals had their tumors harvested and processed in order to grow their TILs in vitro in complete medium containing RIL-2 at a final concentration of 1,000 U/ml. The following observations were made: 1) a greater than 300% increase in overall TIL number compared to controls on day 10 of culture returning to normal by day 30; 2) a marked increase in the percent of cells expressing cytotoxic and differentiation antigens in the experimental group compared to controls, such increase seen mostly from day 7 to day 10; 3) a marked increase in the cytotoxic activity of the experimental TILs against an NK-sensitive tumor target, the YAC-1 lymphoma, throughout the period of growth of the TILs (3-4 times controls) and to a lesser extent against an NK-resistant tumor target. These findings may have potential application, in immunotherapeutic trials against human tumors and may help to understand the reasons for the effectiveness of OK-432 in vivo against selected murine tumors.

Tumor infiltrating lymphocytes (TILs) are capable of mediating significant tumor regressions in vitro and in vivo in animal systems. In humans, however, many TIL cell lines are not cytotoxic in vitro, and clinical trials thus far have been less than encouraging. We attempted to correlate TIL cytotoxicity with time of tumor harvest and TIL cell surface antigenic expression. TILs harvested from early MC-38 adenocarcinoma tumors (days 9 and 20 post-tumor implantation), demonstrated significantly higher cytotoxicity against a variety of tumor targets compared to older TILs (days 31 and 37). The younger TILs had a higher expression of the Lyt-1 (Helper T cells), asialo GM1 (NK and T cells), and 49H.8 (NK cells) antigens. Comparison with the MCA-102 sarcoma, a tumor that does not lead to cytotoxic TILs, revealed a low expression of the Lyt-1 antigen on their cell surface. We conclude that TILs cytotoxicity is time-dependent and may be dependent on the presence of Lyt-1+ cells in the overall TIL population of cells.

Due to the recent surgical and technical developments in aesthetic surgery and occasional dissatisfaction of women with their external contour, augmentation mammaplasty has become a common occurrence in the surgical practice of the aesthetic surgeon. Breast carcinomas, incidentally associated with augmentation mammaplasty, have been sporadically reported in the literature and have all been treated with a mastectomy when resection was possible. We present a case of breast carcinoma occurring 5 years after augmentation mammaplasty performed with silicone-gel-filled implants. Therapy of this carcinoma was achieved through a segmental mastectomy followed by postoperative radiation. The patient remains well 15 months postoperatively. A large number of breast implants are performed each year and the likelihood of a higher incidence of incidental breast carcinomas seen with implants is certainly possible as these patients become older; thought should be given to the notion that possibly not all of these cases need to be managed with radical surgery.

Pathological curiosities have always fascinated the surgical community, and management of breast cancer by the physician has, at times, revealed such rarities. A recent case of squamous cell carcinoma in a clear fluid breast cyst has prompted a review of our experience with this rare pathology, and allowed us to make the following statements: We propose that squamous cell carcinoma of the breast arises from ductal metaplasia. When the T.N.M. system is applied to the squamous cell lesion, the apparent poor prognosis that it is believed to carry may not be so apparent. If no other primaries are identified after extensive metastatic work-up, surgical therapy consisting of total mastectomy with complete axillary dissection, is very effective in local control of tumor progress. Nodal status will indicate the need for additional modalities of therapy.

Since 1921, when Henry Hartmann first described his procedure for rectal carcinoma, multiple modifications of the original technique have been proposed. However, the basic principle of a rectal pouch has always been retained. Two cases of carcinoma developing in such a pouch are described; both occurred years after creation of the pouch. One was managed by local resection through a transsacral approach; the other required an abdominoperineal resection. Consideration must be given to careful examination and sigmoidoscopy of these pouches as they tend to be forgotten by the physicians due to their hidden location.

A large number of cases of ocular melanoma have been entered in The Provincial Cancer Registry of Alberta over the past 40 years. This study was undertaken in order to describe further the natural history of this disease and derive management recommendations for use at the provincial level. A retrospective chart review was carried out on all cases of ocular melanoma registered through The Alberta Provincial Cancer Registry between 1949 and 1987. Two hundred fifty-one cases were identified: 143 were males and 108 were females. The mean age of the patients at diagnosis was 60. The majority of the melanomas arose from the choroid of the eye (82%) with the remainder arising from the iris, conjunctiva and ciliary body, respectively. According to the Callender classification for ocular melanomas, the majority of the melanomas were of the spindle cell type (53%), the others being either mixed cell (23%), epithelioid (8%), or fascicular (1%). Survival rates differed depending on the cell type. Spindle cell tumors demonstrated a mean survival time of 5.2 years; epithelioid tumors 4.8 years and the mixed cell tumors appeared to be the most aggressive with a mean survival time of 2.7 years after diagnosis. The majority of deaths from ocular melanoma occurred within 5 years of diagnosis, although 14% of patients in this review presented with metastases more than 10 years after diagnosis. Some of the cases of ocular melanoma could be classified pathologically as small, medium, or large. Patients with large ocular melanomas had a 5 year survival rate of 33% compared to 70% and 66% for patients with small and medium sized tumors. Of note, 43% of patients with large ocular melanomas who were dead from their disease within 5 years of diagnosis were also found to have mixed cell tumors. These findings call for a longer follow-up period for ocular melanomas and point to the importance of cell type and tumor size as predictors of survival and as guides in planning prophylactic therapeutic interventions.

A 60-year-old homosexual male with a diagnosis of squamous cell carcinoma of the rectum, arising 7 cm from the dentate line, was treated with a rectal preserving multimodality approach consisting of excisional biopsy and chemotherapy with 5-fluorouracil (5-FU) and mitomycin-C with concomitant administration of radiation therapy to the tumor and pelvic nodal bearing areas. The patient has remained disease-free with full preservation of anorectal function on follow-up at 2 years. This approach to a difficult and unusual problem is recommended as a first line of therapy rather than surgical resection if it is deemed that the patient can tolerate a combination of chemo and radiation therapy and the patient will be able to participate in a long-term follow-up.