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Initially, total parenteral nutrition (TPN) was not used in cancer patients because of the fear of sepsis and the potential for stimulation of tumor growth. It was used first in cancer patients who had failed all attempts at enteral nutrition and in whom adequate anticancer therapy would have been otherwise impossible. TPN candidates today remain patients with responsive tumors who cannot tolerate the toxicity of cancer therapy because they are malnourished. [ABSTRACT FROM AUTHOR]

In September 1959, Dr. Clark was appointed as Chair and Dr. Murray M Copeland as Vice Chair of the Committee on Cancer. With their typical leadership style to improve the functions and value of organizations, they reorganized and revitalized the Committee on Cancer during the next 6 years. Thus, Drs. Clark and Copeland and the Committee members developed more uniform standards of cancer registries, implemented the American Joint Committee on Cancer Staging and End Results Reporting (with Dr. Copeland as Chair), published a revised Manual for Cancer Programs (which defined minimum standards requisite for approval of a cancer service), established a new regionalization program (with liaison surgeons from each state), and planned all the cancer educational programs for the College's annual Clinical Congress and Sectional Meetings. Importantly, Clark and Copeland led a 10-year strategic plan (called the "Program of the Sixties") to expand and revitalize the scale and scope of the Committee's activities and to reorganize the Committee structure by including liaison members from other physician, oncologic, and hospital organizations. As Dr. Clark completed his 5-year tenure as Committee Chair in October 1964, he formally recommended a reorganization of the Committee on Cancer to assume an even greater role in the cancer community as the Commission on Cancer. As the new Committee Chair, Dr. Copeland shepherded this recommendation to the ACS Board of Regents, which was approved and implemented in July 1965. The Regents emphasized that the functions and activities of the Committee on Cancer had become so complex and far reaching (under Clark's and Copeland's leadership) that its many subcommittees had already assumed duties of committee stature. Dr. Copeland thus became the first Chair of the Commission on Cancer until October 1965, when Dr. John Cline became Chair. For his contributions to the cancer field and to the College of Surgeons, Dr. Clark received their Distinguished Service Award in October 1969 "for his life-long devotion to the treatment of patients and to research in cancer, for notable service to this College, particularly as Chairman of the Cancer Commission from 1960 to 1964.", (© 2022. Society of Surgical Oncology.)

Background: The Intrabeam (Carl Zeiss) brachytherapy device (IB) is an electronic brachytherapy device that can be used to deliver low energy x-rays (50 kV) to a lumpectomy cavity at the time of lumpectomy for breast cancer. Reported experience with IB for breast cancer in the United States has been extremely limited. Here we describe our experience and analyze the impact of IB on our multidisciplinary breast cancer program., Study Design: This is a retrospective review of a prospectively collected breast cancer database. Patient characteristics, treatment characteristics, recurrence, and cosmesis were analyzed. Cost data were also analyzed to determine the impact of IB on the breast cancer program., Results: Seventy-eight patients underwent 80 IB treatments in this series between November 2010 and October 2012. Most patients had invasive ductal carcinoma. Mean total operative time for patients receiving lumpectomy, sentinel node biopsy, and IB was 132 minutes (range 79 to 243 minutes). Intrabeam brachytherapy was the only adjuvant radiation required in 81% of patients, and only 15% of patients required additional operation after the index lumpectomy procedure. At 12 months of follow-up, cosmesis was good to excellent in 92% of patients. There have been no local recurrences in patients treated in this series. Intrabeam brachytherapy is associated with considerably lower costs ($1,857) than conventional whole breast radiation therapy ($9,653)., Conclusions: Implementation of IB impacts treatment planning and operating room use in a multidisciplinary breast cancer program. The safety profile, ease of administration, and reduced costs of IB favor its more widespread use in selected patients with early-stage breast cancer., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Established in 1957, the University of Florida Department of Surgery has a solid foundation on which current faculty are driven to build a stronger tomorrow. The department is focused on promoting patient-centered care, expanding its research portfolio to improve techniques and outcomes, and training the surgical leaders of tomorrow. It fosters an environment where faculty, residents, students, and staff challenge long-held traditions with the goal of improving the health of our patients, the quality of our care, and the vitality of our work environment.

Background/aim: Tumor endothelial marker 8 (TEM8) is a tumor endothelial-associated antigen that is having an increasingly recognized role in tumor biology. The expression of TEM8 in triple-negative breast cancer (TNBC) has not yet been characterized., Materials and Methods: We hypothesize that TEM8 is overexpressed in TNBC and in metastatic TNBC in lymph nodes (LN) compared to normal breast tissue and normal lymphatic tissue, respectively. We studied expression of TEM8 in cases of primary (n=17) and metastatic (n=2) TNBC using immunohistochemical analyses., Results: All cases demonstrated increased expression of TEM8 in tumor tissue compared to non-cancerous breast tissue. TEM8 was expressed at a higher level in the stroma adjacent to the TNBC in all cases, with focal immunoreactive areas within the tumor. TEM8 was not expressed in normal lymphoid tissue, but showed expression at sites of LN metastases., Conclusion: TEM8 would appear to represent a new biologic target for designing novel diagnostic or therapeutic approaches for TNBC.

The early development of total parenteral nutrition and its evolution as an adjunct to the nutritional, metabolic, and antineoplastic therapy of cancer patients is described. Examples related to the sine wave of responses to new data and discovery are placed in context to understand better past, present, and how and where to proceed in the future to achieve optimal results from multimodal comprehensive management of patients with malignancies. Practical and philosophic thoughts are proffered to justify continued, intensified, logical, controlled clinical studies directed toward establishing the most rational, safe, and effective use of total parenteral nutrition in treating patients with cancer., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy., Methods: The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008., Results: Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (∼30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year., Conclusions: The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Shave biopsy of cutaneous lesions is simple, efficient, and commonly used clinically. However, this technique has been criticized for its potential to hamper accurate diagnosis and microstaging of melanoma, thereby complicating treatment decision-making., Study Design: We retrospectively analyzed a consecutive series of patients referred to the University of Florida Shands Cancer Center or to the Moffitt Cancer Center for treatment of primary cutaneous melanoma, initially diagnosed on shave biopsy to have Breslow depth < 2 mm, to determine the accuracy of shave biopsy in T-staging and the potential impact on definitive surgical treatment and outcomes., Results: Six hundred patients undergoing shave biopsy were diagnosed with melanoma from extremity (42%), trunk (37%), and head or neck (21%). Mean (± SEM) Breslow thickness was 0.73 ± 0.02 mm; 6.2% of lesions were ulcerated. At the time of wide excision, residual melanoma was found in 133 (22%), resulting in T-stage upstaging for 18 patients (3%). Recommendations for additional wide excision or sentinel lymph node biopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively. Locoregional recurrence occurred in 10 (1.7%) patients and distant recurrence in 4 (0.7%) patients., Conclusions: These data challenge the surgical dogma that full-thickness excisional biopsy of suspicious cutaneous lesions is the only method that can lead to accurate diagnosis. Data obtained on shave biopsy of melanoma are reliable and accurate in the overwhelming majority of cases (97%). The use of shave biopsy does not complicate or compromise management of the overwhelming majority of patients with malignant melanoma., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Isolated limb infusion (ILI) for recurrent or in-transit melanoma is an accepted technique that allows high-dose chemotherapy to be delivered to an extremity with minimal systemic toxicity. Current infusion systems have relied on manual delivery of drugs and circulation of blood during the treatment. Herein, we document our initial results with an automated circuit for ILI as an alternative to the manual technique., Methods: Patients undergoing ILI with an automated circuit for recurrent or advanced malignancy were identified. ILI was performed utilizing a Sarns 8000 roller pump attached to a Cobe 4:1 cardioplegia set with heat exchanger with a total priming volume of 80 ml. Melphalan (7.5 mg/L) and Dactinomycin (75 μg/L) doses which were corrected for ideal body weight were delivered via the infusion circuit after limb temperature reached 38 °C., Results: Fourteen lower extremity infusion procedures were performed in 10 patients. Successful infusion procedures were completed in all patients using the automated circuit. Constant flow rates of 50-70 cc/minute were achievable with the automated circuit. Acute toxicity and clinical results were similar to that reported with manual delivery systems., Conclusion: ILI for advanced malignancy utilizing an automated circuit is feasible and safe. This automated system offers a safe and reliable alternative to the manual infusion technique., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Local recurrence remains the major cause of death in patients with retroperitoneal sarcoma (RPS). There is no consensus regarding management of patients with recurrent RPS., Study Design: We performed a retrospective review of patients with recurrent RPS managed at 2 tertiary care centers between 1983 and 2008. Presentation, treatments, and outcomes were analyzed., Results: Seventy-eight patients were identified and analyzed. Sixteen patients (22%) presented with concurrent metastatic disease; survival in this subset of patients was poor (median 12 months). Forty-eight patients underwent resection of the first local recurrence of RPS. Palliation of tumor-related symptoms was achieved in 79% with operation. Survival was significantly better in patients having complete (p = 0.001) and incomplete resection (p = 0.02) compared with patients having biopsy only. Among patients with first local recurrence, high grade tumor (p = 0.0001) and no resection (p = 0.007) were significantly associated with reduced survival. On multivariate analysis, radiation therapy, multifocality, histologic subtype, and time to local recurrence did not significantly correlate with survival. Second and third local recurrences occurred at shorter intervals compared with first local recurrence and were less likely to be completely resectable. Patients undergoing resection of second and third local recurrences had survival similar to that in patients undergoing resection of first local recurrence., Conclusions: Tumor biology (high grade) is a significant prognostic factor for patients with recurrent RPS. Resection should be considered in patients with first and subsequent local recurrences (even if multifocal) of RPS because it is associated with improved survival. Operation should also be considered for palliation of symptoms in patients in whom resection is not possible., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Morbidity rates following pancreaticoduodenectomy (PD) remain high with delayed gastric emptying (DGE) and slow resumption of oral diet contributing to increased postoperative length of stay. A Braun enteroenterostomy has been shown to decrease bile reflux following gastric resection. We hypothesize that addition of Braun enteroenterostomy during PD would reduce the sequelae of DGE., Methods: From our PD database, patients were identified that underwent classic PD with partial gastrectomy from 2001 to 2006. All patients with reconstruction utilizing a single loop of jejunum at the University of Florida Shands Hospital were reviewed. Demographics, presenting signs and symptoms, pathologic diagnoses, and postoperative morbidity were compared in those patients undergoing reconstruction with an additional Braun enteroenterostomy (n = 70) to those not undergoing a Braun enteroenterostomy (n = 35)., Results: Patients undergoing a Braun had NG tubes removed earlier (Braun: 2 days, no Braun: 3 days, P = 0.002) and no significant change in postoperative vomiting (Braun: 27%, no Braun: 37%, P = 0.37) or NG tube reinsertion rates (Braun: 17%, no Braun: 29%, P = 0.21). Median postoperative day with tolerance of oral liquids (Braun: 5, no Braun: 6, P = 0.01) and solid diets (Braun: 7, no Braun: 9, P = 0.01) were significantly sooner in the Braun group. DGE defined by two criteria including the inability to have oral intake by postoperative day 10 (Braun: 10%, no Braun: 26%, P < 0.05) and the international grading criteria (grades B and C, Braun: 7% vs. no Braun: 31%, P = 0.003) were significantly reduced in those undergoing the Braun procedure. In addition, the median length of stay (Braun: 10 days, no Braun: 12 days, P < 0.05) was significantly reduced in those undergoing the Braun procedure. The rate of pancreatic anastomotic failure was similar in the two groups (Braun: 17% vs. no Braun: 14%, P = 0.79). Median bile reflux was 0% in those undergoing a Braun., Conclusions: The present study suggests that Braun enteroenterostomy can be safely performed in patients undergoing PD and may reduce the indicence of DGE and its sequelae. Further studies of Braun enteroenterostomy in larger randomized trials of patients undergoing PD are warranted., ((c) 2010 Wiley-Liss, Inc.)

Background: The management of small pancreatic cystic lesions presents a clinical challenge., Methods: We reviewed our experience with 78 patients who presented with a cystic pancreatic lesion who underwent operative management between 1995 and 2005. Data on cyst characteristics were analyzed in the context of pathologic findings following resection., Results: Among 78 patients, there were 55 (71%) females; median age 63 years. Patients presented with: an incidental finding (48%), pain (40%), acute pancreatitis (4%), other (8%). Operations were distal pancreatectomy (n = 47), pancreaticoduodenectomy (n = 16), and other (n = 15). Most patients had a non-malignant lesion (n = 65, 83%) (mucinous cystadenoma (n = 29), serous cystadenoma (n = 15), IPMN without invasion (n = 8), pseudocyst (n = 8), other benign (n = 5)). Malignant lesions (adenocarcinoma, neuroendocrine tumor, and other) were found in 13 patients (17%). The risk of malignancy increased with size: <3 cm (n = 25), 4%; 3-5 cm (n = 23), 13%; and >5 cm (n = 30), 30%. Pre-operative cyst fluid cytology was performed in 41 patients. The negative predictive value (NPV) of cytology for malignancy was 88% and the positive predictive value (PPV) was 80%. The NPV of CA 19-9 for malignancy was 90%; the PPV was 50%., Conclusions: Initial conservative management of small cystic pancreatic lesions may be indicated in selected patients., ((c) 2009 Wiley-Liss, Inc.)

Purpose: To determine the utility of MRI for assessing axillary lymph node status in patients with breast cancer., Materials and Methods: A consecutive series of patients who underwent breast MR before surgical management of breast cancer with axillary sampling between 2005 and 2007 were identified. MRs were evaluated for the number of nodes, contrast kinetics, nodal area, and number of nodes with no fatty hilum. Data were analyzed in the context of final breast pathology, sentinel lymph node status, and axillary nodal status. Correlations were analyzed using Kendall's tau-b test. Reported P values are one-sided., Results: Fifty-six females (median = 58 years) were studied. Sentinel lymph nodes (SLN) were positive in 15/56 patients (27%). All SLN + patients (n = 15) had completion axillary dissection. Extent of nodal disease was 1 (n = 3), 2 (n = 4), >2 (n = 8). Presence of any axillary lymph node with no fatty hilum and the number of nodes with no fatty hilum on MR significantly correlated with pathologic node positivity (P = 0.04); while kinetics, node number, and node size did not correlate., Conclusion: Breast MR may be useful in the assessment of axillary nodes in patients with breast cancer., ((c) 2009 Wiley-Liss, Inc.)

The role of operation in patients with Multiple Endocrine Neoplasia Type 1 (MEN-1) and Zollinger-Ellison Syndrome (ZES) is controversial. Our institutional bias for this disease has, in general, been towards aggressive imaging and operative removal of localized gastrinomas. Few studies have reported long-term outcomes in patients with MEN-1 and ZES. A single institution retrospective review of all patients with MEN-1 and ZES from 1970 to present was performed. Twelve patients were identified (median age = 37 years at diagnosis). The median follow-up was 18 years from diagnosis of ZES. Common symptoms associated with gastrinoma in these patients were diarrhea (n = 6), abdominal pain (n = 4), and nausea/vomiting (n = 4). Most commonly identified sites of gastrinoma were: pancreas (n = 10), duodenum (n = 4), lymph nodes (n = 3), and liver (n = 1). Fifteen celiotomies were performed in total (median = 1; range 0-3). Operative procedures performed included: distal pancreatectomy (n = 4), acid reducing procedure (n = 4), enucleation of pancreatic gastrinoma (n = 3), duodenal resection (n = 3), pancreaticoduodenectomy (n = 1), and other (n = 7). One patient had a transient biochemical cure after operation lasting 3 years. Only one patient in this series had documented liver metastases of gastrinoma and no patients expired of metastatic gastrinoma. There was one postoperative patient death, secondary to respiratory arrest thought to be a result of aspiration or pulmonary embolus. Three patients died of nondisease related causes, and seven patients were alive at the time of last follow-up. Operations rarely result in biochemical cures in patients with MEN-1 and ZES. In our experience, resection of localized gastrinomas often did not require extended surgical resection and were associated with excellent long-term outcomes.

Objective: To investigate axillary 2-dimensional treatment planning accuracy., Methods: Computed tomography (CT) simulation data for 16 breast cancer cases taken after level I-II axillary dissection were analyzed. An additional 6 patients underwent CT simulation using the historical 90-degree position (HP), and the standard-bore CT position (CT-P). Two physicians identified the lateral and medial borders of the coracoid process (CCP) on digitally reconstructed radiography (DRR). The DRR-identified x coordinates were compared with the CT-measured x coordinates. x coordinates differences between the most medial surgical clip and the borders of the CCP as identified on CT were analyzed. Fields were designed to cover various amounts of the axilla, and treatment plans were generated to compare doses to the most medial surgical clip., Results: In 11 and 6 cases for each physician, respectively (lateral border), and in all cases for both physicians (medial border), the DRR identification of the CCP was medial to that on CT. In 9 and 8 cases, the most medial surgical clip was lateral to the medial and lateral borders of the CCP, respectively. In all data sets, the average difference was larger in the HP compared with CT position. The number of patients who received more than 90% of the prescribed dose when using the plans with the mid humeral head border, lateral border of the CCP, and medial border of the CCP were as follows: 6, 1, and 0, respectively., Conclusions: When using 2-dimensional treatment planning, the dose to the undissected axilla can vary depending on the anatomic landmark used to define the lateral border of the axillary field. This may account for outcome differences found in older radiotherapy studies.

Purpose: To characterize the magnitude of volume change in the postoperative tumor bed before and during radiotherapy, and to identify any factors associated with large volumetric change., Methods and Materials: Thirty-six consecutive patients with early-stage or preinvasive breast cancer underwent breast-conserving therapy at our institution between June 2006 and October 2007. Computed tomography (CT) scans of the breast were obtained shortly after surgery, before the start of radiotherapy (RT) for treatment planning, and, if applicable, before the tumor bed boost. Postoperative changes, seroma, and surgical clips were used to define the tumor bed through consensus agreement of 3 observers (B.P., D.I., and J.L.). Multiple variables were examined for correlation with volumetric change., Results: Between the first and last scan obtained (median time, 7.2 weeks), the tumor bed volume decreased at least 20% in 86% of patients (n = 31) and at least 50% in 64% of patients (n = 23). From the postoperative scan to the planning scan (median time, 3 weeks), the tumor bed volume decreased by an average of 49.9%, or approximately 2.1% per postoperative day. From planning scan to boost scan (median interval, 7 weeks), the median tumor bed volume decreased by 44.6%, at an average rate of 0.95% per postoperative day. No single factor was significantly associated with a change in tumor bed volume greater than 20%., Conclusions: The average postlumpectomy cavity undergoes dramatic volumetric change after surgery and continues this change during RT. The rate of change is inversely proportional to the duration from surgery. In this study no factors studied predicted large volumetric change.

Nodular fasciitis (NF) typically presents as an enlarging soft tissue mass with imaging characteristics that may be suggestive of soft tissue sarcoma or desmoid tumor. This presentation can make a correct diagnosis and management of patients with NF a challenge. We report our recent experience with two cases of NF that were both referred with a diagnoses of "soft tissue sarcoma." Patient 1 was a 46-year-old woman who had undergone breast augmentation and was referred with a rapidly growing firm mass on the left chest wall beneath the breast implant. Computed tomography of the chest noted the mass to be 8 cm x 11 cm in size displacing the implant laterally with no radiological involvement of the bony structures of the chest. Core biopsy was suggestive of inflammation only. Given the clinical suspicion of malignancy, the patient underwent resection of the mass with implant removal. Final pathology showed NF. Patient 2 was a 65-year-old woman referred with an enlarging tender 3-cm infraclavicular mass and a clinical diagnosis of "soft tissue sarcoma." Preoperative biopsy suggested NF. The patient underwent complete excision, which confirmed the diagnosis. These cases highlight the clinical issues associated with management of patients with NF. Current approaches to evaluation, diagnosis, and treatment of NF are discussed.

Background: Most patients with Zollinger-Ellison Syndrome (ZES), even those in whom gastrinoma is found and resected at initial operation, will suffer from persistent or recurrent disease in longterm followup. There is currently no consensus about managing patients with recurrent or persistent ZES. Our unit has historically maintained an aggressive approach toward monitoring and reoperation for patients with sporadic ZES., Study Design: We performed a review of a consecutive series of patients evaluated and managed at our institution between 1970 and 2007 for ZES. "Biochemical cure" was defined as normal serum gastrin assays and negative imaging studies. Reoperations were performed for elevations in serum gastrin assays and positive findings on imaging studies., Results: Fifty-two patients with sporadic ZES were analyzed. Median followup was 14 years. Among patients with sporadic ZES, 37 patients underwent operative management. The most common operations were resection of duodenal gastrinoma (n=8) and total gastrectomy (n=7). Nine patients underwent 15 reoperations for recurrent or persistent disease. "Biochemical cure" was obtained in four patients (44%) undergoing reoperation for ZES. Three of these patients remained without evidence of recurrence at 4, 9, and 12 years after their curative re-resection. Only one of nine patients who underwent reoperation died of metastatic gastrinoma., Conclusions: Primary and reoperative surgery in patients with sporadic ZES results in a significant rate of "biochemical cure." In selected patients with recurrent or persistent disease, reoperation for resection of gastrinoma is associated with excellent longterm survival and is warranted.

Pathologic nipple discharge often presents a diagnostic and therapeutic dilemma for clinicians. We present two patients with pathologic nipple discharge in whom breast MR facilitated preoperative identification of and management of otherwise occult index lesions. Breast MR should be considered in the toolbox for evaluation of occult nipple discharge when other available strategies have failed to demonstrate an underlying etiology for the pathologic discharge. The use of breast MR in this setting may permit directed evaluation and management of potentially malignant lesions.

Background: The role of preoperative bilateral breast MRI in breast cancer patients being considered for breast-conserving therapy has been controversial. We hypothesized that preoperative MRI, along with an active program in MRI-directed biopsies, would lead to a change in multidisciplinary treatment planning for patients being considered for breast-conserving cancer therapy, and it would be associated with reduced rates of margin-positive partial mastectomies., Study Design: A retrospective review of a consecutive series of patients who were treated for breast cancer at a single center between January 2005 and July 2007 was conducted. Patients in the study were candidates for breast-conserving cancer therapy based on physical examination, mammography, and ultrasonography. All patients were evaluated by a preoperative breast MRI. Analysis included number and result of MRI-directed biopsies, impact of MRI on treatment planning, and incidence of margin-positive partial mastectomy within the series of patients., Results: Seventy-nine female patients were analyzed. Median age was 57 years. MRI led to the performance of 25 MRI-directed biopsies for previously unrecognized suspicious lesions in 21 patients. Forty-four percent of MRI-directed biopsies were positive for cancer. MRI was associated with a change in management in 15 patients (19%) for multicentric ipsilateral cancer (n = 7), a more extensive primary lesion size (n = 6), or contralateral breast cancer (n = 2). Incidence of margin-positive partial mastectomy requiring additional resective operation was very low in this series (10%)., Conclusions: Bilateral breast MRI, when used in conjunction with MRI-directed biopsy procedures, can be helpful in planning multidisciplinary treatment of candidates for breast-conserving cancer therapy. By allowing more accurate local staging of tumors, MRI is a tool that can be used to help reduce high reexcision rates for margin-positive partial mastectomies.

Idiopathic granulomatous mastitis, also known as idiopathic granulomatous lobular mastitis, is a benign breast lesion that represents both a diagnostic and therapeutic dilemma. We report two cases of granulomatous mastitis recently evaluated and managed at our institution. To better understand this rare disease, we analyzed treatment outcomes in reported cases of granulomatous mastitis. One hundred sixteen cases were subsequently analyzed. Primary management strategies included observation (n = 9), steroids (n = 29), partial mastectomy (n = 75), and mastectomy (n = 3). Success rates with each treatment were observation, 56 per cent; steroids, 42 per cent; partial mastectomy, 79 per cent; and mastectomy, 100 per cent. Based on this analysis, we propose a clinically useful algorithm for both workup and management of these challenging cases.

Background: This study investigates the effect of full-thickness versus superficial closure of the breast parenchyma on the likelihood of subsequent infection and local recurrence after lumpectomy for early-stage breast cancer. In patients undergoing breast-conserving therapy (BCT), operative closure technique has been largely influenced by expected cosmetic outcome. However, the common practice of promoting postoperative fluid collection raises concerns about potential bacterial colonization, tumor cell migration, and impaired post-BCT surveillance., Methods: From 1985 through 2004, operative closure technique was determined in 516 breasts in 580 women with stage T0-2N0-1 breast cancers undergoing BCT. Medical records were reviewed to determine closure technique, incidence of postoperative infection, and local recurrence characteristics., Results: Median follow-up was 6.4 years from the completion of radiotherapy. The rate of acute infection was higher with the superficial closure technique: 11.7% (27/230) versus 5.2% (15/286) (P = .009). In T1-2 patients, there was no difference in the rate of local recurrence based on closure type: 5.6% (11/195) versus 3.5% (8/231) (P = .348). On multivariate analysis, acute infections and margin status were associated with increased local recurrence. Superficial closure was associated with larger recurrences less likely to be detected on mammogram. In stage T0-T2 patients, 80% of recurrent tumors after superficial closures were greater than 1 cm compared with no recurrent tumors greater than 1 cm after full-thickness closures (P = .005). In patients with superficial closure, 29% of recurrences in the tumor bed were initially detected on mammogram versus 100% in patients with deep closure (P = .003)., Conclusions: Closure method was not predictive of local recurrence. Our findings regarding infection and post-treatment surveillance suggest, however, that full-thickness closure may be the preferred technique in BCT patients.

Purpose: To determine the long-term outcome of a consistent treatment approach with electron beam postmastectomy radiation therapy (PMRT) in breast cancer patients with > or =10 positive nodes treated with combined-modality therapy., Methods and Materials: TSixty-three breast cancer patients with > or =10 positive lymph nodes were treated with combined-modality therapy using an electron beam en face technique for PMRT at the University of Florida. Patterns of recurrence were studied for correlation with radiation fields. Potential clinical and treatment variables were tested for possible association with local-regional control (LRC), disease-free survival (DFS), and overall survival (OS)., Results: TAt 5, 10, and 15 years, OS rates were 57%, 36%, and 27%, respectively; DFS rates were 46%, 37%, and 34%; and LRC rates were 87%, 87%, and 87%. No clinical or treatment variables were associated with OS or DFS. The use of supplemental axillary radiation (SART) (p = 0.012) and pathologic N stage (p = 0.053) were associated with improved LRC. Patients who received SART had a higher rate of LRC than those who did not. Moderate to severe arm edema developed in 17% of patients receiving SART compared with 7% in patients not treated with SART (p = 0.28)., Conclusions: TA substantial percentage of patients with > or =10 positive lymph nodes survive breast cancer. The 10-year overall survival in these patients was 36%. The addition of SART was associated with better LRC.

Apocrine adenocarcinoma is a rare malignancy with invasive potential. Its clinical behavior and histologic appearance are highly variable, making accurate diagnosis difficult. We report on a case of apocrine carcinoma presenting with lymph node infiltration and extensive extramammary Paget's disease. Wide local excision with lymph node dissection is the mainstay of treatment. The role of adjuvant therapy has yet to be established.

Purpose: Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC., Methods and Materials: From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome., Results: Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC., Conclusion: Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.