IBC-Ox26 Concomitant hiatal hernia repair during bariatric surgery: is it the reinforcement making the difference?

Background

Concomitant hiatal hernia repair (HHR) in patients who undergo bariatric surgery (BS) is under debate.

Aims

To evaluate on long-term the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with a biosynthetic, absorbable mesh, performed during BS. Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to conservative treatment and requiring revisional surgery.

Methods

The prospective database of 1948 patients undergoing BS in a center of excellence between 2011-2020 was searched. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely.

Results

268 patients undergone BS and concomitant HHR (13.7%). Simple PC (group A, 165 patients) was performed during 137 sleeve gastrectomies LSG, 5 re- sleeves and 23 gastric bypasses LGB; mean BMI 43.4 ± 5.8 kg/m2, HSA mean size 3.4 ± 2 cm2. Reinforced PC (group B) was performed in 102 cases: 64 primary LSG, 23 LGB and 15 revisions of LSG; mean BMI 44.6 ± 7.7 kg/m2, HSA mean size 6.7 ± 2 cm2. PC's failure, with intrathoracic migration (ITM) was encountered in 12 cases (7.5%) of simple vs. only 4 cases (3.9%) of reinforced PC (p=0.23); hence, a repeat, reinforced PC and LGB was performed in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 61 months), minimum 12 months. Only one case of cardiac metaplasia was detected 4 years postoperatively; conversion to LGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05).

Conclusions

Our results support the use of bioabsorbable, synthetic mesh as reinforcement of HH > 4 cm2 in obese patients during BS, showing excellent recurrence rate results (4%). Accurate patients’ and technique's selection, combined with PC (simple or reinforced) ensure effectiveness and safety, with a combined rate of failure (HH recurrence) at 4 years of 6.0%.

Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis

INTRODUCTION

Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve.

METHODS

Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve.

RESULTS

Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications.

CONCLUSIONS

This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Quality Control for Colposcopy in the Florence Screening Program for Cervical Cancer

The authors report on the quality control for colposcopy adopted in the Florence District screening program. The sensitivity of colposcopy was determined on all cases of CIN III recorded in the local cancer registry in a four-year period. However although this showed that a centralized colposcopic clinic employing a limited number of expert operators is superior to the performance of colposcopy in private practice, such a parameter was impractical for further routine quality control since differences among operators were too small and statistically insignificant. Other parameters for quality control were chosen, namely a) the rate of colposcopically directed biopsies performed, b) the detection rate of CIN II or more severe lesions, and c) the positive predictive value of a directed biopsy for CIN II or more severe lesions. Analysis of these indicators after stratification by cytologic report allows the identification of those operators who need additional training and provides useful information for colposcopists to optimize their diagnostic and operative criteria.

Testing Cervicography and Cervicoscopy as Screening Tests for Cervical Cancer

Aims and Background

Suboptimal sensitivity is currently reported for Pap test in screening for cervical cancer. Colposcopy is known to be more sensitive than cytology but its use as a screening test is not possible due to costs and complexity. Screening by cervicography has been suggested as a compromise being less costly and feasible. The present study evaluates the feasibility of screening by cervicography and cervicoscopy (naked eye examination of the cervix after acetic acid lavage) on a consecutive screening series.

Methods

Cervicography and cervicoscopy were performed by the smear taker in subjects consecutively attending a screening clinic. Women with abnormal cytology (atypia or more severe lesion) and/or abnormal cervicography or cervicoscopy (acetowhite lesion) underwent colposcopic assessment. The three screening methods were compared according to positivity rate, CIN 2-3 detection rate and positive predictive value.

Results

2105 consecutive subjects were screened. Positivity rate was 3.8 %, 15.3 % or 25.4 % for cytology, cervicography or cervicoscopy, respectively, 486 of 555 women attended the assessment phase, 281 directed biopsies were performed and 8 CIN 2-3 lesions were detected. Cytology, cervicography and cervicoscopy, detected 5.5, or 7 of 8 CIN 2-3 lesions, respectively. The positive predictive value was 0% for cytologic atypia, 25 % for cytologic SIL, 1.75 % for cervicography and 2.05% for cervicoscopy. Detecting one CIN 2-3 lesion at cytology cost $ 5,543. The cost per each additional cytologically negative CIN 2-3 lesion detected at cervicography or cervicoscopy was $ 12,947 or $ 3,916, respectively.

Conclusions

The study confirms the limited sensitivity of cytology for CIN 2-3. The association of cervicography was not cost effective. Cervicoscopy was poorly specific but increased the detection rate of CIN 2-3 at relatively low costs. Cervicoscopy is worth further evaluation as a screening test.

Response of Primary Breast Cancer to Tamoxifen Alone in Elderly Women

The authors report on a consecutive series of 62 evaluable, elderly (age > 69 years) women with primary operable breast cancer treated only with tamoxifen. The treatment schedule was 160 mg on day 1 followed by a daily maintenance dose of 20 mg. Compliance to treatment was excellent, and subjective side effects were minimal. The best response achieved after at least 6 months of treatment was complete in 7, partial in 22 and minor in 3, whereas stable disease or progression was observed in 28 and 2 patients, respectively. The response rate decreased and progressions increased with time. At 6, 12, 24, 36 and 48 months of treatment, the complete + partial response rates were 30.6 %, 45 %, 45.6 %, 38.7 % and 25% and the progressive disease rates 4.8%, 19.6%, 34.8%, 45.2 % and 66.6 %, respectively. These results do not confirm some previous reports of a high response to tamoxifen. This difference is only partially explained by the use of mammography, which is more sensitive than palpation, to assess tumor size and treatment response. The present study does not support primary hormone therapy as a current alternative to surgery, which should be the standard treatment in otherwise healthy elderly patients with operable breast cancer.

Screening History of Incident Cases of Invasive Carcinoma of the Cervix. Florence District 1988-1989

Background

Incident cases of carcinoma of the cervix may be assumed as failures of a population-based cytologic screening program. Monitoring such cases would provide an estimate of screening effectiveness, and evaluating the causes of the failures would improve screening performance.

Study design

All incident cases of cervicocarcinoma registered in 1988 and 1989 in the Tuscany Tumor Registry were eligible for the study and were reviewed.

Results

Sixty-nine eligible cases were considered. Non- or irregular attendance (negative smear-to-diagnosis interval > 5 years) for the Pap smear was recorded in 53 subjects. A false-negative smear (smear-to-diagnosis interval < 5 years) and refused or inadequate assessment/treatment at private practices or local hospitals were recorded in 12 cases. False-negative smears by the local screening program were recorded in 4 cases only.

Conclusions

Non- or irregular attendance was the major cause of screening failures. Since cytologic screening or diagnostic assessment outside the screening program may be inadequate, central screening and follow-up is recommended. Non-attenders showed a strong negative attitude towards screening, and general practitioners and gynecologists need to be further stimulated for systematic screening promotion. Immediate evaluation of the screening history of incident cases of cervicocarcinoma should be mandatory in any screening program.

Evaluation of the Sensitivity of Cervicography in a Consecutive Colposcopic Series

Cervicography was performed in 606 women referred for colposcopy. Cervigrams were blindly reviewed by two independent readers. The positivity rate at cervicography was high (operator A = 50 %, B = 58.8 %). The sensitivity for papillomavirus infection (HPV)/cervical intraepithelial neoplasia I (CIN I) (n = 141) was 79.4 % for operator A and 80.8 % for operator B. The sensitivity for CIN II or more severe lesions (n = 22) was 95.2 % and 90.5 % for operators A and B, respectively. The positive predictive value for HPV/CIN I or CIN II, or more severe lesions was 36.9 % and 6.9 % for operator A and 32.1 % and 5.3 % for operator B, respectively. Interobserver variability was acceptable (kappa = 0.62). Cervicography suspected 27 HPV/CIN I, 1 CIN II and 1 CIN III which showed no cytologic abnormalities. This study confirms that cervicography has a good sensitivity for cervical lesions, but it is based on a selected series, not representative of a screening condition. The combination of cervicography and cytology in screening is presently under evaluation in a prospecitve study of screened women.

Fine Needle Aspiration Cytology and Breast Cancer Diagnosis

The authors report on 315 histologically confirmed consecutive breast cancer (BC) cases undergoing fine needle aspiration cytology (FNAC). Inadequate smears were infrequent (7%), particularly when reaspiration of inadequate cases was employed (1–2%). FNAC suspected BC in 81% of the total or 88% of adequate smears. Univariate and multivariate (Cox's model) analyses showed no correlation between inadequacy or suspect/positive FNAC rate and patient age, T category or histologic type. Differences in the inadequacy and suspect/positive rate were recorded among 30 operators (surgeons, oncologists, radiologists) performing the sampling, but the average results were consistent with literature reports. FNAC was found to be a useful diagnostic tool for BC diagnosis, and proper training of the highest number of operators is recommended to allow the widest diffusion of this diagnostic technique.

Hysteroscopy and Endometrial Cancer Diagnosis: A Review of 2007 Consecutive Examinations in Self-Referred Patients

The authors reviewed 2007 consecutive outpatient hysteroscopies performed in self-referred women to assess the detection rate of uterine cancer and the validity of different selection criteria for hysteroscopy. Thirty cases of uterine cancer (29 endometrial, 1 carcinosarcoma) were detected. Abnormal uterine bleeding was the indication most commonly associated with cancer (26 of 30 cases, cancer detection rate = 2.1 %), whereas the presence of cervical polyps had no predictive value. Patients age was correlated to cancer detection rate, and the investigation of uterine cancer under the age of 45 was poorly cost effective. Hysteroscopy and endometrial biopsy, performed by Permacurette or Novak curette immediately after hysteroscopy, missed respectively 8 and 2 of 30 cancers. Hysteroscopy should be employed in combination with endometrial biopsy as a standard outpatient investigation whenever endometrial cancer is suspected. These procedures are safe and accurate and rule out more aggressive and costly procedures, such as dilatation and curettage, in most cases.

« T » Category and Operable Breast Cancer Prognosis

The authors report on 4,034 consecutively operated breast cancer cases, evaluating the correlation between clinical T category and long term survival. Age and pathologic nodal status were also considered as independent prognostic factors. Univeriate and multivariate (Cox's) analysis confirmed N status as the most powerful single prognostic indicator and did not reveal any prognostic correlation with age. T category was a strong prognostic indicator, independently of N status, the 10 year overall survival of T1, T2 or T3-4 cases being 0.86, 0.76 and 0.73 in N– and 0.73, 0.56 and 0.35 in N+ subgroups respectively. T category should be carefully considered not only in deciding the extent of surgical excision but also in planning adjuvant postoperative treatment.

The Role of Fine Needle Aspiration Cytology in the Differential Diagnosis of Suspected Breast Cancer Local Recurrences

The authors report on 228 cases of suspected breast cancer local recurrences studied by fine needle aspiration cytology (FNAC). The nature (malignant = 133, benign = 95) of suspected lesions was assessed on histology (no. = 46) or according to unequivocal follow-up (no. = 182). Inadequacy rate was 0.20, 0.09 or 0.35 in total, cancer or benign cases, respectively, and was particularly high (0.50) for benign chest wall lesions. Accuracy was determined on adequate smears; dubious reports were assumed as positive. Sensitivity and specificity were 0.96 and 0.97, respectively. The routine use of FNAC is recommended since it helps in the differential diagnosis of suspicious cases and may bypass surgical biopsy of positive cases not eligible for surgical treatment.

Telethermography and Breast Cancer Risk Prediction

The authors report on 4,624 noncancer women classified by telethermography (TH1-2 vs TH3) and followed for an average of 6.6 years (range, 2–12). Breast cancer occurring beyond the sixth month from TH were recorded according to a Cancer Registry, and the association between breast cancer incidence and thermographic class or patient age was evaluated. Univariate analysis showed a significant association of age and thermography with further cancer incidence, but multivariate analysis (Cox's model) confirmed a significant association only for age. Thermography (TH3) showed a nonsignificant odds ratio of 1.6 with respect to TH1-2 cases. Thus thermography did not show any practical role as a breast cancer risk indicator. Possible biases affecting previous reports suggesting the use of thermography as a breast cancer risk indicator are discussed.

Training in Colposcopy: Experience with a Videocolposcopy Test

The authors evaluate the results of a videocolposcopy test (330 total cases, 12 cases of histologically confirmed CIN2 or more severe lesions) taken by 9 accredited and 17 unaccredited colposcopists during 1995. Seven of 9 accredited and 4 of 13 unaccredited colposcopists reached the requested standard (sensitivity >90%, biopsy rate «60%). Performance was definitely better when the test was not blind to the cytologic report (4 of 13 reached the requested standard) with respect to blind reading (none of 17). The study confirmed that colposcopy at unaccredited practices is poorly accurate. Colposcopy assessment of patients with abnormal smears should be centralized in accredited practices, which should undergo periodic quality control to guarantee screening efficacy. Tape-recorded videocolposcopy tests are a good, simple, practical and inexpensive method for interobserver quality control of colposcopic performance.

Male Breast Carcinoma: Review of a Multicenter Series of 150 Cases

The authors report on a consecutive retrospective series of 150 male breast cancers. Clinical, diagnostic and therapeutic features are compared over time and with respect to a large consecutive series of female breast cancers. Both age at diagnosis and tumor stage were more advanced in males than in females. Poor alertness of both men and doctors for this unfrequent disease may account for such a delay in diagnosis. The use of mammography increased over time and sonography or cytology were frequently and successfully employed in the last decade. Unfortunately no improvement of tumor stage at diagnosis was observed over time in the present series. A time trend was also evident for the type of surgical and postoperative treatment. Modified radical mastectomy and adjuvant chemo- or hormone therapy were increasingly adopted, although Halsted operation and postoperative radiotherapy were still common in the last decade due to the relatively high proportion of locally advanced T3-4 cancers. Both disease-free and overall survival were worse in men than in women, even after adjustment by stage at diagnosis. This study suggests that male breast cancer has a worse prognosis with respect to female breast cancer and provides no complete explanation of this finding, except for an intrinsic higher aggressivity. No evidence was found which may justify a different diagnostic or therapeutic approach with respect to female breast cancer.

A First Survey of Organized Cervical Cancer Screening Programs in Italy

In Italy, where no national screening program for cervical cancer exists, organized programs have developed on a local basis. We performed the first survey of existing organized programs by mailing a standard questionnaire to a large network of possibly involved services. For the present survey, a program was defined as organized if personal invitations were sent. We identified 29 already active organized programs and 4 others in a starting phase. The target population of active programs included 2,074,820 women in the age range 25-64 years, corresponding to 13.5% of the Italian female population of the same age. The situation is rapidly evolving since many regional programs are being implemented. Most programs followed Italian and European recommendations as regards the age limits, interval between screening rounds, presence of a fail-safe system for women referred for colposcopy, presence of protocols for diagnostic workup and treatment, and presence of referral centers for such phases. However, many programs did not meet national guidelines as regards the size of laboratories interpreting smears, which were frequently small. Second-level referral centers also frequently had a very small activity. The average (weighted for size of the invited population) compliance to invitation and coverage (proportion of women with at least one test in the last 3 years) was 32.6% and 66.0%, respectively, therefore needing to be improved. Compliance to colposcopy (weighted for number of referred women) was 81.4%. We found a very high variability in the proportion of women referred for colposcopy that could only be partly explained by different referral protocols and could depend on different criteria of smear interpretation: the average (weighted for number of tested women) was 2.01%. A need for improvement in the process of evaluation and for homogenization of criteria of cytology interpretation was identified: work in this regard is on-going.

Comparing two Modalities of Management of Women with Cytologic Evidence of Squamous Or Glandular Atypia: Early Repeat Cytology or Colposcopy

Early repeat cytology is recommended in most screening programs for cervical cancer in subjects with squamous or glandular abnormalities not amounting to neoplasia (atypical squamous cells of undetermined significance, ASCUS), but immediate colposcopy is also recommended in some countries, especially those where there is easy access to colposcopic facilities. We evaluated the cost-effectiveness of the two procedures in a prospective study of women with cytologic ASCUS, invited to cytocolposcopic assessment after 6 months. Colposcopy-directed biopsy was assumed as the gold standard, and the accuracy of colposcopy at 6 months was assumed to be equal to that of immediate colposcopy. Out of 874 compilers, punch biopsy was performed in 303 cases (34.7%), and 19 CIN2+ lesions were detected (CIN2 = 12, CIN3 = 6, microinvasive carcinoma = 1). Detecting 13 CIN2+ lesions at colposcopy required 874 colposcopies and 303 directed biopsies: the cost per CIN2+ lesion detected with the procedure was 2,749 US$. Detecting 15 CIN2+ lesions at repeat cytology required 874 cytologic examinations, 137 colposcopies, 64 directed biopsies, and 6 diagnostic large-loop resections, the latter being performed in subjects with high-grade squamous intraepithelial lesion and less severe lesions at punch biopsy: the cost per CIN2+ lesion detected with the procedure was 1,961 US$. The policy of repeat smear was more cost-effective than immediate colposcopy. According to such results, the protocol of the Florence screening program has been modified since October 1996.

Colposcopy as a Primary Screening test for Cervical Cancer

Aim and background

To evaluate the cost effectiveness of screening by colposcopy compared to conventional cytology.

Methods

A prospective study was performed in the Florence District screening center on 3,000 consecutive women, self referring, who were examined by cytology and colposcopy in a blind fashion. Further assessment was based on cytologic report or on colposcopy-directed punch biopsy. Actual costs of the whole screening process were known. The cost effectiveness of different possible simulated screening scenarios was then determined.

Results

Overall, 18 high-grade lesions (CIN3 = 9, CIN2 = 9) were detected. Four different screening scenarios were compared, namely a) cytology alone, b) cytology + repeat smear for ASCUS (atypical squamous cells of undeterminate significance) cases, c) colposcopy + cytology for cases of condyloma at punch biopsy, and d) colposcopy alone. Although they had a higher cost per examined woman (a) = 17.98, b) = 19.40, c) = 23.86, d)= 22.10 US$), scenarios c) and d) had a higher relative sensitivity (a = 44.4, b = 61.1, c = 100, d = 88.8%) and a lower cost per high-grade lesion detected (a = 6,743, b = 5,291, c = 3,977, d = 4,144 US$).

Conclusions

Screening by colposcopy is a feasible procedure which is more sensitive and more cost effective than conventional cytologic screening. At least in those settings where access to cytopathology may be difficult, screening by colposcopy should be considered as a possible alternative.

Lower protection of cytological screening for adenocarcinomas and shorter protection for younger women: the results of a case-control study in Florence

The efficacy of cytological screening in preventing adenocarcinoma of cervix uteri as compared to squamous cell cancer has been evaluated by means of a case-control study in the province of Florence. The odds ratios of women who had a Pap test within the 3 years before the index date was 0.65 (95% confidence interval (CI) 0.26-1.64) and 0.15 (95% CI 0.07-0.31), for adenocarcinoma and squamous cancer, respectively. The duration of the protective effect was shorter in women below the age of 40 years than in older women.

Measurement of the Cost of Screening for Cervical Cancer in the District of Florence, Italy

AIMS AND BACKGROUND

To estimate the cost per woman examined and per CIN II or more severe lesion detected in a population-based cytologic screening program for cervical cancer prevention. An organized cytologic screening program has been ongoing in the Florence District since 1973, and a call-recall system using mail invitation has been ongoing since 1980. Smear reading and assessment of screening positives is centralized at the screening unit.

METHODS AND STUDY DESIGN

All relevant resources (costs) consumed by the program were listed and measured. The unit cost per examined woman and per each CIN II or more severe lesion detected was estimated for each screening phase (recruitment, screening, assessment).

RESULTS

The cost per examined woman was $24.60, whereas that per CIN II or more severe lesion detected was $13,600. Staff accounted for 80% of total amount.

CONCLUSIONS

Although the cost for a single procedure is low, the cost per detected lesion is quite remarkable due to the low detection rate in a population screened for a long time. Different approaches and longer interval screening tests are discussed.

Trends in cervical cancer incidence in the district of Florence

The trend in cervical cancer incidence in the District of Florence from 1975 to 1989 was investigated. Tuscany Cancer Registry data were available since 1985. Incidence data from 1975 to 1985 were obtained through a retrospective survey of all the Departments of Pathology and Gynaecology in the district. Cytological screening for cervical cancer has been available in the district since 1973, and since 1980 active invitation of residents aged 25 to 59 years has been in use. A significant trend in decreasing incidence was evident for the overall population (P = 0.003) and for 40-49 (P = 0.028), 50-59 (P < 0.001) and 60-69 (P = 0.002) year age groups, whereas no significant trend was observed for the age group 30-39 years. An association between attendance to screening and reduced incidence was evident, in that a greater reduction was evident for those cohorts (ages 50-59 and 60-69) who had a higher compliance to screening 10-15 years before. If the decrease in cervical cancer incidence was spontaneous, a parallel decrease of CIN3, which is commonly assumed to be the precursor of invasive carcinoma, would be expected. On the contrary, the detection rate of CIN3 at first Pap test showed a significant increase in the study period. All these findings suggest that the observed reduction in cervical cancer incidence was mostly due to the effect of screening, and stress the need for optimising the coverage of the invited population.

Subclinical vulvar papillomavirus infection

Eighty-eight cases of subclinical human papillomavirus (HPV) vulvar infection were detected in a consecutive colposcopic series of 968 women. Three patterns of acetowhite lesions had a 72% predictive value (88/122) for histologically assessed HPV. The prevalence of subclinical vulvar HPV in self-referred patients was 7.9% (73/918); it was 9% (88/968) in the overall series and significantly higher in younger patients (age less than 25 years: 21/106, or 19.8%) or in those with cervical HPV or cervical intraepithelial neoplasia (CIN) (40/100, or 40%). Routine inspection of the vulva after acetic acid lavage in association with a Papanicolaou test might help identify Papanicolaou-test-negative patients at high risk of developing cervical HPV or CIN. Treatment with beta-interferon (2,000,000 IU daily intramuscularly for 10 days) was given to 30 consecutive patients, but the results were poor: regression was observed in only 2 cases.

Colposcopic survey of Papanicolaou test-negative cases with hyperkeratosis or parakeratosis

A colposcopic survey was performed in 269 consecutive women with negative cytology showing hyperkeratosis or parakeratosis. A colposcopy-guided biopsy specimen of cervical abnormalities was taken in 88 cases, and human papillomavirus infection (HPV) was detected histologically in 25 cases. No cervical intraepithelial neoplasia (CIN) was detected. The detection rate of HPV was not significantly different from that observed in a consecutive series of 1073 Papanicolaou test-negative subjects self-referred for colposcopy. Colposcopic screening of subjects showing hyperkeratosis or parakeratosis with otherwise negative smears is not recommended because it does not allow detection of cytologically false-negative CIN.

"Nonclassic" cytologic signs of cervical condyloma. A case-control study

The association between "nonclassic" cytologic signs of condyloma and human papillomavirus (HPV) infection in women with negative Papanicolaou smears was analyzed via a case-control study. The cytologic signs considered were mild koilocytosis, mild dyskeratosis, binucleation or multinucleation, cleared cytoplasm and nuclear hyperchromatism. The Papanicolaou smears of 166 cases that showed colposcopic and histologic evidence of HPV infection (but whose smears lacked the classic cytologic signs of condyloma) and 166 controls that were negative colposcopically were randomly admixed and blindly reviewed by a panel of cytologists. A significant association to HPV infection was observed for all of the nonclassic signs studied, but multivariate analysis showed a weakly independent association only for mild koilocytosis. The sensitivity (0.46) and the specificity (0.87) of these nonclassic signs were not satisfactory. The utility of selecting women with negative Papanicolaou smears for colposcopy on the basis of these signs is discussed.

Routine colposcopic survey of patients with squamous atypia. A method for identifying cases with false-negative smears

Routine colposcopy was performed on 376 women with cervical squamous atypia (originally reported as "inflammatory atypia"). Colposcopy showed no abnormalities in 240 cases and a lesion in 136 cases; the latter were sampled by colposcopy-guided biopsy. The biopsy samples showed evidence of human papillomavirus (HPV) infection and/or grade I cervical intraepithelial neoplasia (CIN I) in 42 cases (11.1%), CIN II in 4 cases (1.1%) and CIN III in 5 cases (1.3%); the other 85 biopsied cases were histologically negative. Most cases of HPV/CIN I (35 of 42) and all of the cases of CIN II-III occurred in women under the age of 40. The detection rates were 4.4% for CIN II-III in women under the age of 40, 4.0% for HPV/CIN I in women 40 and older and 17.2% for HPV/CIN I in women under the age of 40 (P less than .001). It thus appears that women under the age of 40 who show cytologic evidence of squamous atypia would benefit from colposcopic examination.

In situ ductal carcinoma of the breast--analysis of clinical presentation and outcome in 156 consecutive cases

We report on 156 consecutive cases of in situ ductal carcinoma (DCIS) of the breast observed from 1968 to 1988. The relative frequency of DCIS was much higher in screened, with respect to self-referred, women and a significant association of DCIS with younger age was observed. The combined use of mammography and physical examination identified 138 of 156 total DCIS cases as suspicious. Mammography, physical examination or cytology (of nipple discharge or needle aspirate) were the only tests to provide suspicious evidence in 35, 22 and four cases respectively. DCIS was a relatively unexpected surgical finding in 13 apparently benign cases. Different surgical options were recorded in the study period but a temporal trend in favour of conservative surgery was evident. Subsequent ipsilateral or contralateral breast cancer was recorded in seven and six cases respectively. Death from breast cancer occurred in five cases, all of whom had contralateral or subsequent ipsilateral infiltrating cancer. This figure confirms the high curability of DCIS if local control is achieved.

Referral policy and positive predictive value of call for surgical biopsy in the Florence Breast Cancer Screening Program

The authors evaluate the referral rates and the predictive value (PV) of call for diagnostic work up or biopsy in a population based breast cancer screening program in the 1979-1986 period. The presence of mammographic abnormalities either benign or suspicious proved to be the only reliable referral criterion (recall rate = 7.9%, recall PV = 3.8%, biopsy call PV = 39%). When mammography was normal the presence of breast complaints other than pain or of a radiologically dense breast were aspecific referral criteria, and since the latter was abandoned, (a) referral rates dropped especially in younger women, (b) referral or biopsy PV improved, whereas (c) cancer detection rate was almost unaffected. Younger age was associated with higher referral rates and with lower PV of both referral or biopsy. Whenever comparison with previous examination was possible, mammography accuracy was higher; this explains the decrease in referral rates and the increased predictivity observed at further rounds with respect to first screening round.

Prognosis of nonpalpable infiltrating carcinoma of the breast

A consecutive series of 185 instances of histologically confirmed nonpalpable infiltrating carcinoma of the breast is presented. Histologic nodal involvement was found in 12 per cent and was dependent on the size of the tumor. Conservative surgical treatment was the predominant method used during the study period. The ten year over-all survival was studied and compared with that of 4,217 instances of palpable carcinoma of the breast observed during the same period. The ten year survival rates were, by far, better for nonpalpable (94 per cent) than for palpable carcinomas (65 per cent). A better prognosis for nonpalpable carcinomas was confirmed also by multivariate analysis (Cox) with adjustment for potential confounders, such as age, stage or nodal involvement. The possible confounding effect of over diagnosis and length or lead time bias is discussed. Although this difference in survival might be partially explained by the aforementioned confounders, the chance of increasing life expectancy and conservative surgical treatment encourages preclinical detection of carcinoma of the breast.

Risk of breast cancer subsequent to proven gross cystic disease

3809 women in whom breast cysts were aspirated were followed up to evaluate the observed/expected ratio of subsequent breast cancer. Breast cancer at cyst aspiration was excluded by physical examination and mammography. The first year of follow-up was censored to avoid a prevalence screening effect. Subsequent breast cancers were found either directly or by means of a cancer registry which also provided the expected age and residence specific incidence rates. The number of expected cancers was assessed in person-years (15,915 in the total series). The observed/expected subsequent breast cancer ratio was 1.77 (34/19.15; 95% confidence interval 1.23-2.48, P less than 0.05). The presence of gross cysts was associated with a moderately though significantly increased risk of subsequent breast cancer. Increased surveillance in such patients is not justified.

Positive predictive value of fine needle aspiration cytology of breast lesions

The predictive value of fine needle aspiration (FNA) was assessed in 1,181 consecutive cases of breast lesions in which cytologic abnormalities were reported. The positive predictive value (PPV) of an FNA cytologic report of atypia, suspicious or positive was 0.49, 0.95 or 0.996, respectively. In the presence of a suspicious/positive report by both physical examination and mammography, the PPV of a cytologic report of suspicious was 0.99. The PPV was directly correlated with age, partly due to the incidence of fibroadenomas among younger patients; fibroadenomas were present in 53 of 146 cases with a false FNA report of atypia, in 10 of 19 cases with a false FNA report of suspicious and in 2 of 2 cases with a false FNA report of positive. Overall, 93 cases reported as benign by physical examination and mammography were biopsied on the basis of the FNA cytologic report; cancers were diagnosed in 33 of these 93 cases (6 cancers among 42 women less than 40 years old and 27 cancers among 51 women greater than 39 years old). The widespread use of FNA cytology to study breast lesions is thus recommended, without regard to patient age and even in the presence of clinically benign findings, since the increase in the rate of cancer detection is worth the excess of unnecessary biopsies. The predictive value of a positive report of FNA cytology, or even of a suspicious report in the presence of clinical suspicion, is so high that an intraoperative frozen section biopsy might be spared in such cases.

Chest X-ray survey in the follow-up of breast cancer patients

The authors report on 182 cases of intrathoracic metastases (ITM = lung, pleura or mediastinum) observed as first single recurrences in the course of the follow-up of patients treated for primary breast cancer. ITM were detected on standard two-views chest X-ray (CXR) at regular follow-up visits and in absence of subjective symptoms (102 A cases) or in the interval between two consecutive planned controls because of the onset of subjective symptoms (80 S cases). The average disease-free interval since primary treatment was significantly shorter in A with respect to S cases (40.3 vs. 28.5 months, P less than 0.001) as a consequence of the early detection achieved by CXR survey. On the contrary, prognosis was not influenced by ITM early diagnosis as the 10-year survival since primary treatment did not differ significantly between A or S cases (12% vs. 10%, P = 0.68). Results were confirmed on multivariate (Cox's) analysis, adjusting for potential confounders such as age or nodal status. Periodic CXR survey looks a very questionable policy as it does not seem to have any favourable impact on prognosis. Its routine use in breast cancer patients should thus be carefully reconsidered.

Association of estrogen receptors with parenchymal pattern at mammography

The authors report on a consecutive series of 1,003 breast cancer cases classified on the basis of Wolfe mammographic parenchymal patterns and estrogen receptor content. The association between these two variables was investigated to assess the reliability of parenchymal patterns in predicting the estrogen receptor status. No significant association was observed after adjustment for possible confounders such as age, menopausal status, and T category. Mammographic parenchymal patterns appear to have no role in predicting estrogen receptor status.

Prognostic significance of estrogen receptor determination in primary breast cancer

The authors report on 767 consecutive primary Stage I-II breast cancer cases followed-up from 3 to 8 years. The estrogen receptor (ER) content was determined in all cases and did not influence the treatment choice. A correlation was attempted between ER and menstrual or pathological nodal status (N) or the 5-year disease-free survival (DFS). ER was correlated with menopausal status ER+ cases being more frequent in postmenopausal patients, whereas no correlation was observed between ER and nodal status. In absence of nodal involvement (N-) the prognosis was not influenced by the ER status. A significantly better DFS was evident for ER+ respect to ER- patients in the N+ series but such a correlation is questionable as the adjuvant treatment (hormone or chemotherapy) given to such patients may have influenced the DFS according to the ER status. According to the present study, ER determination should not be used as a discriminant in the performance of adjuvant postoperative treatment based on a prognostic judgment.