State Cancer Hospital Research Articles

Abstract PO4-26-02: Evaluation of Tumor Infiltrating Lymphocytes as a predictive biomarker of recurrence in patients with Ductal Carcinoma In Situ of the breast

Abstract Introduction: Ductal carcinoma in situ (DCIS) represents around 20% of early breast cancer diagnoses globally. Some studies evaluated risk factors associated with DCIS recurrence. Among these, age, surgical margins, comedonecrosis (CN), high nuclear grade, negative hormone receptors and HER2 expression stand out. Recent approaches have been evaluating the role of the immune microenvironment and its association with recurrence and progression of DCIS. Objective: To evaluate the association between Tumor Infiltrating Lymphocytes (TILs) in DCIS samples and disease recurrence. To characterize the immunological microenvironment of DCIS, analyzing the presence of TILs, “touching TILs” and desmoplastic reaction and their association with recurrence. Epidemiological, clinical, histological and immunohistochemical (IHC) characteristics were also evaluated. Methods: This is a retrospective cohort study with patients diagnosed with DCIS and treated at Sao Paulo State Cancer Institute and Hospital das Clinicas of University of Sao Paulo. We included women over 18 years old with a diagnosis of DCIS who underwent treatment from Jan/2007 to Dec/2020. Male patients, patients with a diagnosis of invasive or microinvasive disease in the anatomopathological examination of the surgical specimen or patients with history of any neoplasm were excluded. The main outcome was survival analysis according to the quantification of TILs, adjusted for potential confounders. For that, we collected data on age, presence of palpable mass, imaging findings, histological and IHC characteristics, such as expression of estrogen receptor (ER), progesterone receptor (PR) and hyperexpression of HER2, type of surgical approach, type of radiation therapy, use of endocrine therapy, length of follow-up, recurrence, and its type. Two pathologists evaluated TILS in the sample with the highest tumor representation and numerically quantified it as percentage. They also evaluated the presence of “touching tils” (lymphocytes in contact with the basement membrane) and desmoplastic reaction in the tumor stroma. Kaplan-Meier curves, log-rank tests and Cox regression models were used to evaluate survival. Chi-square tests were used to evaluate the association between categorical variables. Results: 283 patients met the eligibility criteria. Mean age of patients was 55 years. 15% had a palpable nodule at physical examination. Clustered amorphous microcalcifications were the most prevalent mammographic presentation, found in 41% of the patients. The most frequent histological and IHC features were cribriform presentation (73%) and ER positivity (86%), respectively. Desmoplastic reaction was absent in 10.5%, discreet in 51.9%, moderate in 24% and intense in 13.6% of the patients. Breast conserving surgery was performed in 189 patients, and 100 of them received adjuvant radiation therapy. Mean follow-up was 77.2 months, with a recurrence rate of 9.2%. We observed that tumors with focal necrosis (HR 6.4 [1.39-34.71] p 0.018) or CN (HR 4.53 [1.34 – 15.28] p 0.015) had higher risks of recurrence. Patients with a percentage value of TILs greater than or equal to 17% also had a higher risks of recurrence (HR 2.97 (1.17-7.51) p 0.02). These patients were mostly under 65 years of age (OR 0.45 [0.21 - 0.97] p 0.049). In a multivariate model, CN and TILs>17% remained significantly associated with recurrence (p=0.034 and p=0.035 respectively). There was a trend for invasive recurrence in 76.9% of the patients that relapsed when TILS were greater than or equal to 17% (p 0.062). “Touching TILs” were present in 12.9% of the patients but were not associated with recurrence (p=0.575). Conclusion: In our cohort, high value of TILs (>= 17%) and presence of CN were independently associated with DCIS recurrence. Our findings suggest that TILS are a prognostic immunological biomarker in DCIS and warrant further investigation in prospective trials to determine the most adequate cut-point. Citation Format: Camila Pasetto, Fernando Aguiar, Marcella Peixoto, Maira Doria, Bruna Mota, Jonathan Maesaka, Jose Roberto Filassi, Edmund Baracat, Rodrigo Gonçalves. Evaluation of Tumor Infiltrating Lymphocytes as a predictive biomarker of recurrence in patients with Ductal Carcinoma In Situ of the breast [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-26-02.

Plasma Interleukin-6 Levels in Relation to the Severity of Pain in Cancer Patients: A Case-control Study from a Tertiary Care Centre in North East India

Introduction: With increased levels of ferritin, C-Reactive Protein (CRP), and the proinflammatory cytokine Intrleukin-6 (IL-6) frequently seen in cancer patients, inflammation is acknowledged as a critical component in the context of cancer. For medical professionals, managing pain in cancer patients, whether from the illness or its treatment, remains a constant struggle. Aim: To compare the markers of inflammation between controls and cancer patients with pain and to correlate the degree of pain and IL-6 levels in this group of patients. Materials and Methods: The present case-control study was conducted from January 2022 to December 2022 on 45 age-matched controls and 40 cancer patients with varied levels of pain who were included in the Palliative Care Unit of a State Cancer Hospital, Guwahati, Assam, India. The intensity of pain was measured using a Numerical Rating Scale (NRS). Blood samples were taken to assess the levels of IL-6, ferritin, and CRP. The data were analysed statistically using one-way Analysis of Variance (ANOVA) and linear regression, and were presented as mean±Standard Deviation (SD). Results: Compared to controls, cancer patients had significantly higher levels of IL-6, CRP, and ferritin (p-value <0.001). Spearman’s correlation analysis revealed a positive link between pain intensity and IL-6 (p-value<0.001, r-value=0.516) and between pain and CRP (p-value=0.002, r-value=0.474) was found using Spearman’s correlation analysis. Conclusion: The study results suggest a possible role for IL-6 in cancer-related pain by indicating a clear correlation between elevated IL-6 levels and the severity of pain experienced by cancer patients. This lays the foundation for investigating IL-6 antagonists as potential painkillers for cancer patients.

Breast cancer: the real road of the Brazilian northeast.

To characterize the clinical and sociodemographic aspects of breast cancer patients undergoing cancer treatment in the State of Maranhão, in a public reference hospital. Descriptive, correlational and analytical cross-sectional study, conducted between January 2019 and February 2020, at the Tarquínio Lopes Filho State Cancer Hospital. The study population consisted of all women, in first consultation, with breast cancer undergoing chemotherapy, in agreement with the study and with no brain metastasis evidenced. Statistical analysis was performed using SPSS v. 19 software, considering a significance level of 5%. Eighty adult women were part of the study, whose average age was 52.54. Most of the women were born in São Luís, white, housewives, sedentary, married, former smokers, and Catholic. They had technical/specialized training. In the clinical results, the histological type of infiltrative ductal carcinoma predominated, as well as stage III, mastectomy and the doxorubicin-cyclophosphamide-taxol chemotherapy regimen. The knowledge of each regional profile assists health professionals regarding the characterization of a target population and the design of targeted preventive and self-care strategies by managers.

Multivariate analysis of the breast cancer patients in North-East India: Using cox regression

Breast cancer is the most common cancer affecting women in India. Breast cancer can develop to any age groups of females and with the age the risk increases. The survival of breast cancer patients depends on early diagnosis, stages of the disease and treatment. Materials and Methods: In our study 462 breast cancer patients were included in study who were treated during 3 year period (January 2016 until December 2018) and were followed up to December 2019 at North East Cancer Hospital, Jorabat and State Cancer Hospital, Guwahati. Death reported was 75. The Kaplan-Meier was used for data analysis and in order to analyze the different covariates Cox Regression model is used. Results: Based on Kaplan- Meier mean survival days was 1132 and overall 3 year survival rate was 63%. The 3 year survival rate of stage III and stage IV was 60% and 20%. Conclusions: Our findings support the observation that those women with higher stages have less chance of survival. Moreover early detection of breast cancer may help to increase the survival rate of those women who are at risk.

Lymph Node Involvement in Oesophageal Carcinoma: A Single-Centre Observational Study From Western India.

IntroductionLymph node involvement is the most important predictor of prognosis in oesophageal cancer. The present study describes our single-centre experience of lymphadenopathy in oesophageal carcinoma cases at a tertiary care centre in the Marathwada region of Maharashtra state in western India.MethodsThis descriptive study included 31 patients who were operated for oesophageal carcinoma at the State Cancer Hospital in Marathwada from August 2015 to September 2017. Thirty patients underwent three-field lymph node dissections, and one patient underwent Ivor Lewis surgery with two-field lymph node dissections. Three-field lymph node dissections were through a thoracotomy, followed by laparotomy and left cervical incision. The lymphatic metastases were categorised as (a) adjacent node metastases, (b) multiple levels of lymph node metastases, and (c) skip node metastases. The histopathological assessment of the removed specimen and lymph nodes was done. Pathologists evaluated the character and depth of the primary tumour and its invasion and node involvement. The location and numbers of positive and negative nodes were recorded.ResultsA total of 31 patients were included in the study, of which 17 had lymph node involvement. A total of 946 lymph nodes were dissected and examined, and the average number of lymph nodes removed per patient was 30.51. Among the 28 squamous cell carcinoma cases, lymph node involvement was found in 14 cases (50%) whereas, in adenocarcinoma, all the three cases showed lymph node involvement. In 11 cases of squamous cell carcinoma, thoracic lymph nodes were involved, whereas abdominal lymph nodes were involved in nine and cervical lymph nodes in two cases. Thoracic lymph nodes were involved in two cases of adenocarcinoma and abdominal lymph nodes were involved in one case of adenocarcinoma.ConclusionsSquamous cell carcinoma was the predominant type, and lymph node metastasis was observed in 50% of these cases. Thoracic lymph nodes were more commonly involved. Tumour staging T2 and T3 had an increasing percentage of lymph nodes involved. Lymph node involvement was more in moderately differentiated and undifferentiated oesophageal cancers.

Survival and prognostic factors of breast cancer in women in the state of São Paulo

Introduction: Breast cancer is the first most common malignancy in the female population worldwide. Monitoring the survival of women with breast cancer has been a strategy often adopted at the international level as a measure to assess public policy progress for disease control. Objectives: To estimate the probability of five-year survival and to investigate the prognostic factors of women with breast cancer included in the São Paulo State Cancer Hospital Records Base (RHC-SP), established in 2000 and maintained by the Oncocentro Foundation of São Paulo (Fundação Oncocentro de São Paulo – FOSP). Material and methods: This is a historical cohort. The sample consisted of women with breast cancer diagnosed between 2002 and 2012 and included in the RHC-FOSP. The event studied was specific mortality from breast cancer. Live cases at the end of follow-up (December 31st, 2017), loss of follow-up and those who died from causes other than breast cancer were considered censures on the date of the last contact or date of death. Survival analysis was performed using the Kaplan-Meyer method and the survival curves were compared using the log-rank test. Hazard ratios (HR) and respective 95% confidence intervals (95%CI) were also estimated using the Cox's proportional hazards model. This study was approved by the Human Research Ethics Committee of the School of Medicine of Botucatu, UNESP. Results: In the period between 2002‒2012, 53,146 cases of invasive breast cancer were registered at RHC-FOSP. The median age of women at diagnosis was 55.9 years. By the end of the follow-up (December 31st, 2017), 20,683 patients died and 71.4% were due to breast cancer. The probability of specific survival for the entire cohort at 5 and 10 years was 76.1% (95%CI 75.7‒76.5%) and 64.8% (95%CI 64.2‒65.3%), respectively. In the multivariate analysis, the factors associated with the prognosis were: age at diagnosis, year of diagnosis, educational level, grouped clinical stage and histological type. Conclusion: Specific survival for breast cancer in the state of São Paulo is significantly associated with several characteristics. The knowledge of these characteristics can contribute to the development of public policies in the area.

Familial and non-familial risk factors associated with incidence of colorectal cancer in young and middle-aged persons in Western Australia

AimsThe aim of this study was to examine factors including family history, medical history and comorbidities associated with the risk of colorectal cancer (CRC) in young (18–49 years) and middle-age (50–69 years) individuals. MethodsState records were used to identify individuals born in Western Australia between 1945 and 1996, and their first-degree relatives. Individuals in the cohort and their relatives were linked to State cancer registry, hospital and mortality data to identify diagnoses of CRC and other risk factors. The associations between CRC and identified risk factors were examined using multivariable logistic regression. ResultsFor both young and middle-aged patients, family history of CRC, and a history of smoking, inflammatory bowel disease, liver disease and non-CRC cancer were associated with a significant increase in odds of CRC. In middle-aged patients, having a colonoscopy in the previous 10 years was associated with a reduced odds of CRC regardless of the detection of polyps. However, in young patients only the absence of polyps as confirmed by colonoscopy was associated with a decreased risk of CRC (OR: 0.38, 95%CI: 0.26 – 0.54, p < 0.001). ConclusionsMany of the risk factors associated with CRC were similar in young and middle-aged persons, and should be used to identify high risk young patients for screening. The association between colonoscopy and polyps with CRC was modified by age, likely as the result of routine screening in middle-aged patients.

PO484 Lived Experience of Young Smokers With Respect to Smoking Ban on University Campus

The aim of this study was to examine factors including family history, medical history and comorbidities associated with the risk of colorectal cancer (CRC) in young (18–49 years) and middle-age (50–69 years) individuals.State records were used to identify individuals born in Western Australia between 1945 and 1996, and their first-degree relatives. Individuals in the cohort and their relatives were linked to State cancer registry, hospital and mortality data to identify diagnoses of CRC and other risk factors. The associations between CRC and identified risk factors were examined using multivariable logistic regression.For both young and middle-aged patients, family history of CRC, and a history of smoking, inflammatory bowel disease, liver disease and non-CRC cancer were associated with a significant increase in odds of CRC. In middle-aged patients, having a colonoscopy in the previous 10 years was associated with a reduced odds of CRC regardless of the detection of polyps. However, in young patients only the absence of polyps as confirmed by colonoscopy was associated with a decreased risk of CRC (OR: 0.38, 95%CI: 0.26 – 0.54, p < 0.001).Many of the risk factors associated with CRC were similar in young and middle-aged persons, and should be used to identify high risk young patients for screening. The association between colonoscopy and polyps with CRC was modified by age, likely as the result of routine screening in middle-aged patients.

Profile of Patients with Penile Neoplasms Who Have Undergone Penectomy

Introduction: Penile cancer accounts for 10% to 20% of the male urogenital tumors. In Brazil, the North and Northeast regions have the highest rates.&#x0D; Objective: Analytical, retrospective, and cross-sectional study addressing the profile of individuals with penile neoplasms who have undergone penectomy in Recife, Pernambuco, Brazil.&#x0D; Methods: The population of this study consisted of 305 men who underwent penectomy at the Pernambuco State Cancer Hospital (HCP), from 2000 to 2009. There was prevalence of elderly, low-schooling and low-income men, as well as individuals from municipalities outside the Metropolitan Region of Recife.&#x0D; Results: Poor hygiene, smoking, and phimosis were the main risk factors identified. Patients showed epidermoid carcinoma (type I) and metastasis. The early signs and symptoms were tumor and painful ulcer.&#x0D; Conclusion: Most of the individuals have undergone partial penectomy.&#x0D; Keywords: Penile Neoplasms; Epidemiology; Hygiene; Phimosis; Brazil.

Robert E. Scully, MD (1921-2012)

Robert Edward Scully, MD, a surgical pathologist at the Massachusetts General Hospital (MGH) for 55 years and Emeritus Professor of Pathology at Harvard Medical School, died in Boston, MA, on October 30, 2012, after suffering a stroke. He was born in Pittsfield, MA, on August 31, 1921, graduated magna cum laude from the College of the Holy Cross in 1941, and received his MD from Harvard Medical School in 1944. Dr Scully trained in pathology at Peter Bent Brigham Hospital and Boston Children’s Hospital under Dr S. Burt Wolbach and Dr Sidney Farber. He then spent a year as resident at the Free Hospital for Women in Brookline, MA, and Boston Lying-In Hospital under the direction of Dr Arthur T. Hertig. That was followed by a year at Pondville State Cancer Hospital in Norfolk, MA. Dr Scully was next an instructor in pathology at Harvard Medical School for a year before being recruited by Dr Tracy B. Mallory to the MGH. His early tenure there …

Hospitalisation for cancer and co‐morbidities among people with learning disability in Australia

Accessible summary People with learning disability are just as likely as people in the general population to get cancer. In this study we have looked at how often clients who get cancer are admitted to hospital. We found that clients who get cancer are admitted to hospital much more often than clients who do not get cancer. We also looked at the experiences of two clients to show what clients have to go through when they get cancer. This research could help parents/carers and clients to know what to expect when people with learning disability need treatment and care for cancer. SummaryIn Australia, general health and medical services are subsidised by the government. This includes care for people with disabilities, screening and diagnostic services for common diseases, including cancer, and care and treatment for various medical conditions. In Western Australia, the majority of state‐provided health services are well documented in linkable databases. We have examined data from a large cohort of people receiving services for learning disability from the state and linked this with the state cancer registry and hospital records. While people with learning disability appear to be at similar risk for cancer, they may have poorer treatment outcomes as they already experience a range of health conditions which can exacerbate medical complications associated with treatment and/or other primary or secondary co‐morbid conditions. Our results show that the mean number of hospital admissions were higher for the cancer group, even when adjustments were made for conditions such as childhood leukaemia and renal dialysis both of which often require frequent hospitalisations. Multivariate regression analyses showed that younger age, female sex and severe or unspecified level of disability were significant contributors to the frequency of hospital admissions. Qualitative information gleaned from detailed chart reviews showed that in addition to considerable morbidity, some patients were admitted repeatedly either because of lack of supportive environments and/or lack of compliance with treatment. Issues in providing appropriate support services for individuals and their carers are discussed.

Cancer: Diagnosis, treatment, and prognosis. By Lauren V. Ackerman, M.D., and Juan A. del Regato, M.D., Ellis Fischel State Cancer Hospital. 9¾ × 6⅞ in. Pp. 1115, with 745 illustrations and 9 coloured plates. 1947. London: Henry Kimpton. 100s. net

Cancer: Diagnosis, treatment, and prognosis. By Lauren V. Ackerman, M.D., and Juan A. del Regato, M.D., Ellis Fischel State Cancer Hospital. 9¾ × 6⅞ in. Pp. 1115, with 745 illustrations and 9 coloured plates. 1947. London: Henry Kimpton. 100s. net

Bladder substitution after pelvic evisceration

(Reprinted with permission from Surg Clin North Am, 30: 1511-1521, 1950) The problem of developing a suitable substitute for the urinary bladder has been one that has intrigued surgeons intermittently for a good many years. Practically all anatomical possibilities were exhausted at the beginning of this century. Hinman and Weyrauch I have reviewed the various attempts at bladder substitution by ureteroenterostomy. Apparently the first attempt to divert the urinary stream into an isolated segment of ileum and ascending colon was done by Verhoogen 2 in 1908. Such attempts were subsequently discarded because of the prohibitive mortality and the problem of ureteral disposal following cystectomy was solved for many years by the simple implantation of the ureters into the intact sigmoid colon. This procedure is still the one of choice following cystectomy and it will probably remain the procedure of choice in cases in which the sigmoid and rectum can be preserved. However, the recent development of pelvic evisceration as a therapeutic procedure has focused attention again on the problem of what to do with the ureters in cases in which this procedure is used, since the sigmoid colon and rectum are not available as a receptacle. Our interest in carrying forward the radical surgical attack on malignant lesions dates back to 1940 at the Ellis Fischel State Cancer Hospital at Columbia, Missouri. It became evident at that time that in dealing with some lesions, particularly of the colon, we would be limited in our resections only by certain philosophical considerations. The concept of radical amputative surgery could be carried to such a stage that what was left with the patient became a consideration of equal importance to that which was removed. It seemed that if we could not leave a patient in a physiological state compatible with a comfortable existence we were not morally justified in doing some of the extensive procedures. Pelvic evisceration was one of our interests at this time. The procedure was directed at a few advanced lesions of the~Cbladder and prostate. In these cases all pelvic viscera were removed by an abdominoperineal technic. It appeared unnecessary, however, to do a high resection of the sigmoid colon for pathologic lesions of this type. Consequently, we were able to save an isolated segment of sigmoid colon into which the ureters were implanted (Fig. 435, 1, a). Itnever occurred to us at that time to implant the ureters into the intact colon, which was to drain through a colostomy opening, the so-called colostomy. This, of course, was before the days of the Rutzen bag and a wet colostomy would not have fitted in with our ideas of leaving the patient in a physiological state compatible with a comfortable existence. Only two of the four patients operated upon at that time survived the operative procedure; one of these, with carcinoma of the prostate, survived for eighteen months and subsequently died of

Exenterative pelvic surgery.

A review of the history, indications, basic technique, end results, and complications of exenterative surgery for pelvic neoplasms is provided. The authors discuss their broad personal experience with the operation. Much of this experience evolved from work at Barnes Hospital and the Ellis Fischel State Cancer Hospital. The techniques are applicable to advanced neoplasms of the cervix uteri, scrotum, urinary bladder, and other, less frequent neoplasms still confined to the pelvis.

Rates of growth of human solid neoplasms: Part I.

The purpose of this article is to consolidate data collected from a variety of sources that have permitted calculations of the rates of growth of human neoplasms. These sources include Fischel State Cancer Hospital (Columbia, MO); Mallinckrodt Institute of Radiology, (St. Louis, MO); Roentgen Diagnostic Institute, Allmanna Sjukhuset (Malmo, Sweden); University of Louisville (Louisville, Kentucky); University of Heidelberg (Heidelberg, Germany); and St. Luke's Hospital (St. Louis, MO). Included in the data are laboratory measurements of cell replication rates. All gross measurements were made either on imaging studies or with a centimeter scale for surface or palpable neoplasms. Data have been reported for breast and pulmonary cancers and metastases of many types, melanomas, skeletal sarcomas, benign and malignant colonic neoplasms, and isolated cases of less frequent neoplasms. Related cytokinetic measurements by tritriated thymidine labelling, bromodeoxyuridine labelling, S-phase fraction from DNA flow cytometric analysis, and mitotic indices are discussed. The various mathematical formulae applicable to the analysis of the collected data and the determination of rates and patterns of growth are included. Also considered are the clinical implications of these data and the importance of ever better knowledge on the cytokinetics of human cancer. Prior studies on the evolution of insight into this field are cited and discussed. The authors conclude that a more accurate quantification of the growth rates of human cancer is essential for understanding the biological variance of human cancers seen clinically.

The radioresponsiveness of melanoma

The variability of malignant melanoma in its response to irradiation is well documented. Recent radiobiological studies suggest that high individual dose and low total fraction regimens will enhance the responsiveness of this tumor to irradiation. The experience of the Ellis Fischel State Cancer Hospital and the Cancer Research Center, Columbia, Missouri was reviewed with particular attention to such radiotherapeutic regimens. Of 41 lesions in 27 patients, the overall response rate to irradiation was 37%. When regimens using more than 400 cGy per fraction were analyzed, a 67% response rate was noted. Complete response and small volume of tumor correlated significantly (p = 0.008) with long-term survival.

Experience with a modified Witzel gastrostomy without gastropexy.

The records of 161 adult patients who underwent a modification of the Witzel gastrostomy without gastropexy at Ellis Fischel State Cancer Hospital, Columbia, Missouri, between 1977 and 1980, are reviewed in detail and form the basis of this report. Six of these patients had gastrostomies on two different occasions. There was no mortality or major complication directly attributed to the procedure in this group of patients. Technical details are examined and considered most important in preventing intraperitoneal or extraperitoneal leak of gastric contents and migration of the catheter, the most commonly found complications of other techniques. Anterior gastropexy is considered unnecessary, thus simplifying the operation and eliminating gastric deformity and other related problems. The liberal indications of this procedure are discussed, and potential areas of technical pitfalls are reviewed. The personal experience of one of the authors (EMB) with 774 gastrostomies during a 15-year period using this technique confirms these conclusions. A random sample of 200 records of these patients were examined for complications of the operation. This study suggests that tube gastrostomy by the technique described is a reliable and safe procedure with wide applicability for patients undergoing major abdominal surgery. The relatively few complications are more than compensated for by the degree to which postoperative comfort and care are facilitated.

Isolated regional lymph node dissection: morbidity, mortality and economic considerations.

Between 1971-1979, 330 consecutive isolated regional lymph node dissections (RLNDs) were performed as therapeutic procedures for metastatic disease, at the University of Louisville Affiliated Hospitals and the Ellis-Fischel State Cancer Hospital in Columbia, Missouri. This retrospective analysis includes 133 radical neck RLNDs, 87 axillary RLNDs, and 110 superficial groin RLNDs. All accessioned cases were elective and were performed as isolated procedures, discrete from resection of contiguous or remote organs. No patients received preoperative irradiation, chemotherapy or immunotherapy. Forty-eight per cent of the 330 RLND procedures resulted in some form of postoperative complication. However, 91% of the incurred morbidity was localized to the operative site and was related to serum collection and/or flap necrosis. The occurrence of postoperative complications for each RLND site resulted in a prolongation of the patients' hospital stays by a mean of 9 days, and was most extended for the superficial groin RLND by a mean of 11 days. Nine patients (3%) died. These data for morbidity and mortality rates, as well as the implicit economic impact, represent substantial factors in the utilization of elective RLND.

Repair of Postirradiation Rectovaginal Fistula and Stricture

Department of Surgery, Ellis Eischel State Cancer Hospital, and Cancer Research Center, Columbia. Missouri

Inflammatory carcinoma of the breast.

Fifty-eight patients with clinical inflammatory breast carcinoma and 15 patients with "occult" inflammatory cancer (dermal lymphatic carcinomatosis without clinical inflammation) are grouped and reviewed to determine whether diagnosis is pathologic or clinical. All cases represent a retrospective study of records from the Ellis Fischel State Cancer Hospital, Columbia, Missouri. Lesions of clinically apparent and occult inflammatory carcinoma demonstrate similar gross and microscopic growth patterns, histologic types, axillary involvement and early widespread metastases. Regardless of pathologic evidence of dermal lymphatic tumor, patients with clinical inflammation had rapid deterioration. Cases with only a pathological diagnosis were slightly less fulminant in progression. Either clinical or pathologic criteria justify use of the term "inflammatory breast carcinoma" to indicate short-term prognosis despite available treatment.