Current management of pregnancy-associated breast cancer

Pregnancy-associated breast cancer is the most common malignancy during pregnancy with an expected rise in incidence. The belief in the need for termination of pregnancy and that chemotherapy is contra-indicated during pregnancy is challenged by recent evidence. Patients can consider breast-conserving surgery and sentinel lymph node biopsy with acceptably low fetal risk from radiation exposure. A range of chemotherapeutics is possible in the second trimester in terms of drug class and frequency. Hormonal therapy and monoclonal antibody therapy are contra-indicated during pregnancy and lactation. Fetal outcome after in-utero exposure to chemotherapy appears similar to that in a non-pregnant population. Future pregnancy, in most situations, does not appear to be contra-indicated but a multidisciplinary and patient-centred approach is recommended. Fertility preservation techniques are also being developed with reported success and consequent pregnancies.

Neoadjuvant chemotherapy increases rates of breast-conserving surgery in early operable breast cancer

INTRODUCTION

Neoadjuvant chemotherapy is commonly used in stage III breast cancer for disease down-staging. Its use has now been extended to early breast cancer to increase the rate of breast-conserving surgery. This study aimed to evaluate the effectiveness of neoadjuvant chemotherapy in early operable cancers.

METHODS

A retrospective study was carried out at the Hong Kong Sanatorium & Hospital of 102 patients with stage I to III primary breast cancer. All patients who underwent neoadjuvant chemotherapy followed by definitive breast surgery between January 2004 and July 2013 were included. Their pathological complete response and rate of breast-conserving surgery were studied. Data were compared using Chi squared test and Student's t test.

RESULTS

After neoadjuvant chemotherapy, 23% of patients achieved a pathological complete response, of whom 80% had human epidermal growth factor receptor 2 (HER2)-positive disease or triple-negative disease. Hormonal receptor negativity was associated with a higher pathological complete response rate (P<0.05) that was in turn associated with a higher likelihood of breast-conserving surgery (P=0.028). Patients with stage II disease were more likely to convert from mastectomy to breast-conserving surgery following neoadjuvant chemotherapy.

CONCLUSIONS

Neoadjuvant chemotherapy is a useful treatment to downsize tumour in early breast cancer, thereby increasing the rate of breast-conserving surgery. It is especially effective in patients with HER2-positive/oestrogen receptor-negative disease or triple-negative disease.

Ductal carcinoma in situ of breast: detection and treatment pattern in Hong Kong

INTRODUCTION

The treatment of ductal carcinoma in situ has been widely reported in the western and other Asian countries, but the relevant data in Hong Kong are relatively limited. This study aimed to evaluate the latest detection and treatment pattern for ductal carcinoma in situ in Hong Kong so as to guide planning of future service provision.

METHODS

This was a retrospective case series study. A total of 573 patients who registered with the Hong Kong Breast Cancer Registry, and were diagnosed and treated in Hong Kong from January 2001 to December 2011 were reviewed.

RESULTS

Compared with invasive breast cancer patients, patients with ductal carcinoma in situ were younger (median, 48.6 vs 50.3 years; P<0.001), had a higher education level (P<0.001), had a higher total monthly family income (P<0.001), and more common breast-screening habits (P<0.001). Significantly more patients with ductal carcinoma in situ underwent breast-conserving surgery than their invasive cancer counterparts (55.8% vs 36.7%; P<0.001). The percentage of screen-detected ductal carcinoma in situ was relatively lower than that reported in other studies, but was still much higher than that in invasive breast cancer patients (29.0% vs 4.7%; P<0.001). Screen-detected patients with ductal carcinoma in situ tended to choose a private hospital instead of a public hospital for treatment (P=0.05) and to undergo breast-conserving surgery (P=0.02). With a median follow-up of 3 years, the crude local recurrence rate after mastectomy and breast-conserving surgery was 0.4% and 3.3%, respectively; 44% of recurrent tumours had developed invasive components. No regional recurrence, distant recurrence, or cancer-related deaths were recorded.

CONCLUSIONS

In the absence of a population-based breast screening programme in Hong Kong, ductal carcinoma in situ is more frequently found in the higher social classes and managed in the private sector. The clinical outcome of ductal carcinoma in situ is excellent and more than half of the patients can be successfully managed with breast-conserving surgery.

Is pain from mammography reduced by the use of a radiolucent MammoPad? Local experience in Hong Kong

INTRODUCTION

Screening mammogram can decrease the mortality of breast cancer. Studies show that women avoid mammogram because of fear of pain, diagnosis, and radiation. This study aimed to evaluate the effectiveness of a radiolucent pad (MammoPad; Hologic Inc, Bedford [MA], US) during screening mammogram to reduce pain in Chinese patients and the possibility of glandular dose reduction.

METHODS

This case series was conducted in a private hospital in Hong Kong. Between November 2011 and January 2012, a total of 100 Chinese patients were recruited to our study. Left mammogram was performed without MammoPad and served as a control. Right mammogram was performed with the radiolucent MammoPad. All patients were then requested to complete a simple questionnaire. The degree of pain and discomfort was rated on a 0-10 numeric analogue scale. Significant reduction in discomfort was defined as a decrease of 10% or more.

RESULTS

Of the 100 patients enrolled in this study, 66.3% of women reported at least a 10% reduction in the level of discomfort with the use of MammoPad. No statistical differences between age, breast size, and the level of discomfort were found.

CONCLUSION

The use of MammoPad significantly reduced the level of discomfort experienced during mammography. Radiation dose was also reduced.

Comparison of clinical and pathological characteristics between screen-detected and self-detected breast cancers: a Hong Kong study

INTRODUCTION

Breast cancer is the leading cause of death of Hong Kong women with increasing incidence. This study aimed to determine any prognostic differences between screen-detected and self-detected cases of breast cancer in a cohort of Hong Kong patients.

METHODS

This was a case series with internal comparison carried out in a private hospital in Hong Kong. Approximately 3000 cases of Chinese patients diagnosed with ductal carcinoma in situ or invasive breast cancer were reviewed.

RESULTS

The screen-detected group showed better pathological characteristics than the self-detected group. Number of lymph nodes involved, invasive tumour size, and tumour grade were more favourable in the screen-detected group. There was also a lower proportion of patients with pure invasive ductal carcinoma and mastectomy in the screen-detected group.

CONCLUSION

This study provides indirect evidence that women in the local population may gain clinical benefit from regular breast cancer screening. The findings need to be validated in a representative population of Hong Kong women.

A 77-year-old woman with sudden onset of blue discolouration of right third toe

We report on a 77-year-old woman with a history of peripheral vascular disease who presented with an acute-onset tender blue toe and deteriorating renal function. A clinical diagnosis of blue toe syndrome was made but the patient deteriorated rapidly and died. This case illustrates the rapidly devastating nature and fatality of blue toe syndrome. There is no effective treatment for this condition.

Fine-needle aspiration cytology of mucocelelike tumors of the breast

Mucocelelike tumors of the breast encompass a spectrum of pathologic lesions, including benign tumor, atypical ductal hyperplasia, carcinoma in situ, and colloid carcinoma. Because the fine-needle aspiration (FNA) cytology of mucocelelike tumors covering this pathologic spectrum is not well defined, a study of 21 cases of mucocelelike tumors was conducted. Benign lesions are likely to be poorly cellular and to contain cohesive clusters of cytologically bland cells arranged in two dimensional sheets in the background of abundant mucoid material. Colloid carcinomas are usually highly cellular and contain loosely cohesive clusters and dissociated cells with nuclei showing minimal to mild atypia. The most discriminating feature between benign and malignant lesions appears to be the presence of many dissociated cells with intact cytoplasm. Cases with atypical ductal hyperplasia, with some bordering on carcinoma in situ as seen in 7 of the 12 benign cases, may be difficult to identify on FNA cytology, possibly because of sampling. As expected, some of the atypical cases have intermediate features of benign and malignant tumors. Because of overlapping features in borderline cases, we recommend excisional biopsy for all mucocelelike lesions. Myxoid fibroadenoma is more cellular than benign mucocelelike lesions and can be distinguished from carcinoma by the absence of dissociation and presence of numerous bare nuclei of bland morphology in the background. The mucoid material of myxoid fibroadenoma stained brightly pink rather than magenta as in mucocelelike tumors using the Diff Quik stain.

The development of the "Cantonese receptive vocabulary test' for children aged 2-6 in Hong Kong

The study aims to develop a Cantonese receptive vocabulary test to assess 2-6-year-old children in Hong Kong. The test consists of 100 test items. Each target item is accompanied by a phonological distractor, a semantic distractor and an unrelated distractor. A sample of 609 normal children from four Maternal and Child Health Centres and nine kindergartens was selected. The results show that there is a significant effect of age on the correct score. ANOVA was performed to look at the age effect on each distractor individually. It was found that the scores of the three distractors decrease in their own patterns as age increases. With strong content validity, strong construct validity and high correlation coefficients in the split-half reliability, this test could be used as a reliable measurement for the Cantonese-speaking population in Hong Kong.

Human whole blood assays for inhibition of prostaglandin G/H synthases-1 and -2 using A23187 and lipopolysaccharide stimulation of thromboxane B2 production

When freshly drawn, heparinized human whole blood is incubated with 50 microM calcium ionophore A23187, platelets are stimulated to produce thromboxane B2 (TxB2) by activation of prostaglandin G/H synthase-l (PGHS-1). TxB2 concentration, as measured by immunoassay, is maximal at 20-30 min and declines thereafter. Addition of acetylsalicylic acid (IC50 = 2.8 microM) or other nonsteroidal antiinflammatory drugs (NSAIDs) 15 min or 4.5h prior to 30 min stimulation with ionophore results in concentration dependent inhibition of TxB2 production. When blood is incubated with 0.01-10 micrograms/ml E. colilipopolysaccharide (LPS), PGHS-2 is induced and TxB2 levels become detectable at 3h and continue to increase through 24h. Using a 5h incubation with 10 micrograms/ml LPS, aspirin (10 microM added at 0 h), which is rapidly metabolized to salicylic acid, had no effect on 10 micrograms/ml LPS-induced TxB2, but inhibited TxB2 production by ionophore A23187 added at 4.5h through acetylation of pre-existing PGHS-1. In a 5h assay, NSAIDs added at 0 h were compared for inhibition of TxB2 production stimulated by addition of ionophore A23187 at 4.5h (PGHS-1), or by addition of LPS at 0 h (PGHS-2). Most NSAIDs were more potent against PGHS-1 than PGHS-2. Diclofenac, naproxen and flufenamic acid were equipotent or slightly selective for PGHS-2. Diflunisal and nimesulide were > 4-fold selective for PGHS-2, and NS-398 was > 30-fold selective for PGHS-2.

Pathologic changes of gastric mucosa colonized by Helicobacter pylori

One hundred eighty-nine consecutive gastric biopsies showing colonization by Helicobacter pylori (HP) were studied. Epigastric pain and bleeding were the clinical presentations in 167 cases (88.4%). Major endoscopic findings were gastritis (n = 72, 38.1%) and ulceration (n = 101, 53.4%). Duodenal ulcer was associated with 32 (44.4%) and 29 (28.7%) cases of gastritis and gastric ulcer, respectively. Histologically, the HP-colonized gastric epithelium showed characteristic degenerative changes that were topographically related to the bacteria but unrelated to the inflammatory infiltrate. Disintegration and loss of apical mucus with formation of epithelial pits was seen in nearly all cases. Other changes included microerosion, conventional erosion, and frank ulceration. Only the disintegration of apical mucus, epithelial pit, and microerosion were specific for HP colonization. These conditions were absent in areas not colonized by HP and in 79 consecutive HP-negative gastric biopsies seen during the same study period. The epithelial degenerative changes in HP-colonized gastric mucosa are easy to recognize in routine hematoxylin-eosin-stained sections and they could serve as histologic guides to the localization of the bacteria. It is proposed that HP-colonized gastric mucosa is a distinct pathologic entity with a pathologic spectrum ranging from active chronic gastritis to erosion and frank ulcer. Damage to the mucin-containing portion of the gastric epithelial cells appears to be the basic cytopathologic effect of HP on the gastric mucosa. As effective specific treatment for HP infection is available, identification of HP colonization in gastric biopsies should be attempted in all cases of gastritis and gastric ulcer.

3-Carboxy-5-methyl-N-[4-(trifluoromethyl)phenyl]-4-isoxazolecarboxamide, a new prodrug for the antiarthritic agent 2-cyano-3-hydroxy-N-[4-(trifluoromethyl)phenyl]-2-butenamide

The title compound 3-carboxyisoxazole 3 was synthesized by cycloaddition of carbethoxyformonitrile oxide to N-[4-(trifluoromethyl)phenyl]-3-pyrrolidino-2-butenamide (6) with spontaneous elimination of pyrrolidine followed by hydrolysis of the ethyl ester. Compound 3 was shown to be absorbed intact after oral administration to rats. Over 24 h, the compound was metabolized to yield plasma concentrations of the antiinflammatory agent 2-cyano-3-hydroxy-N-[4-(trifluoromethyl)phenyl]-2-butenamide (2), similar to those obtained following an equivalent dose of the established prodrug of 5-methyl-N-[4-(trifluoromethyl)phenyl]isoxazole-4-carboxamide (1).

Epithelial damage by Helicobacter pylori in gastric ulcers

On review of 136 consecutive biopsies of benign gastric ulcer, Helicobacter pylori was detected in 78 cases (57.3%). The gastric epithelium colonized by Helicobacter pylori showed a characteristic constellation of changes, including loss of apical mucous portion of individual cells, drop-out of epithelial cells, epithelial pits, erosions and cellular tufts, indicative of cellular injury and regeneration. Among the 58 Helicobacter-negative cases, similar changes were not observed in the ulcer edges, except for two cases which exhibited some cellular tufts. Thus, the topographic association of Helicobacter pylori with epithelial damage in the gastric ulcer edges in more than half of the cases suggests that this organism probably plays an aetiological role in ulcerogenesis, at least in these cases. Furthermore, the epithelial changes are so distinctive that they can serve as a helpful histological indicator for the presence of Helicobacter pylori in gastric biopsies.

Columnar cell carcinoma of the thyroid. Fine needle aspiration findings in a case

Columnar cell carcinoma is a recently described rare tumor of the thyroid. The fine needle aspiration cytologic findings of one example are reported. In the smears, the tumor fragments showed papillary and glandular patterns. The tumor cells were columnar and exhibited pseudostratification of the nuclei. The nuclei were oval to elongated and possessed stippled chromatin and inconspicuous nucleoli; occasional ones exhibited longitudinal grooving. It is important to distinguish this tumor from papillary carcinoma of thyroid because of its much more aggressive behavior, from metastatic adenocarcinoma for obvious treatment considerations, and from medullary carcinoma.

Thyroxine suppressive therapy of benign solitary thyroid nodules: a prospective randomized study

Patients with solitary thyroid nodules that are benign on aspiration biopsy are often treated nonsurgically. To find out if thyroxine therapy is effective, 74 patients were randomized to receive levothyroxine treatment or nothing. There were 8 males and 66 females. Their mean age was 39 years. The mean nodule size was 3.6 cm and the mean nodule duration was 11 months. All patients had normal serum thyroxine and thyroid stimulating hormone (TSH) levels, and positive thyrotropin releasing hormone (TRH) tests. The dose of thyroxine was adjusted until the TRH test was negative. Patients were followed at 6-month intervals in the first 2 years and yearly thereafter, with measurement of the nodule diameter. The mean follow-up period was 1.5 years. In the 37 patients receiving thyroxine therapy, 8 had disappearance of nodules, 6 had greater than 50% reduction in nodule size. In 19, the nodules were unchanged and in 4, the nodules were enlarged. In the 37 patients receiving no drug, 8 had disappearance of nodules, 5 had greater than a 50% reduction in nodule size, 17 had nodules unchanged, and 7 had enlarged nodules (p greater than 0.9). The mean reduction in nodule diameter at various follow-up periods was greater in the thyroxine group, but the difference did not reach statistical significance. Carcinoma was found in 1 patient in each group and both of them experienced nodule enlargement. We conclude that an adequate suppressive dose of levothyroxine does not alter the natural course of benign solitary thyroid nodules. An enlargement of the nodule or a change in its consistency should be further investigated to exclude malignancy.

Right atrial extension of adrenocortical carcinoma. Surgical management using hypothermia and cardiopulmonary bypass

A patient with right adrenocortical carcinoma extending into the inferior vena cava and right atrium is presented. Tumor extension was demonstrated by magnetic resonance imaging (MRI) preoperatively. Successful resection of the adrenal tumor and its intravascular extension was achieved with the help of cardiopulmonary bypass and hypothermia. The patient was maintained on mitotane (o,p'-DDD), and was well for 12 months after surgery. It was concluded that intravascular extension of adrenocortical carcinoma is not a contraindication to radical surgery.

Strategy in reoperative surgery for hyperparathyroidism

Eighty-three patients undergoing reoperations for hyperparathyroidism were studied. Preoperative diagnosis was reviewed, and localization was employed in selected patients. Cervical reexploration was carried out in a systematic manner, and mediastinotomy was required in 11 patients. Sixty patients had had previous parathyroid exploration. Missed adenomas were found in 34, of which 28 were single and 6 were double adenomas. Fourteen single adenomas were in normal locations and 14 were in ectopic locations. Seventeen patients had hyperplasia; 6 were wrongly diagnosed as adenoma, 3 had inadequate excision, 2 had supernumerary glands, and 6 had remnant hypertrophy. Three patients had recurrent carcinoma. Two had wrong diagnoses and 4 had uncertain diagnoses. Reoperation eliminated hypercalcemia in 71 patients (85.5%). Eight patients developed permanent hypoparathyroidism, and 1 had a permanent recurrent nerve palsy. Reoperative parathyroid surgery can be minimized with thorough initial cervical exploration, correct pathologic interpretation, and adequate parathyroid resection.

Carney's complex of primary pigmented nodular adrenocortical disease and pigmentous and myxomatous lesions

A complex of primary pigmented nodular adrenocortical hyperplasia associated with myxomatous masses and pigmented lesions of the skin was recently described by Carney. Herein, we describe three patients with Carney's complex seen at our institution. Two patients presented with Cushing's syndrome and one patient with atrial myxoma. The diagnosis was revealed in all three because of an awareness of the disease in association with primary adrenocortical hyperplasia. Because Cushing's syndrome and atrial myxomas are life-threatening components of the disease and can occur metachronously, an early diagnosis in combination with the appropriate treatment is mandatory, and follow-up measures should be taken to define the natural course of events in the disease.

Flow cytometric measurements of nuclear DNA and ploidy analysis in Hürthle cell neoplasms of the thyroid

Nuclear DNA content and nuclear DNA ploidy were measured in 36 Hürthle cell neoplasms (HCNs) to better define their potential roles in predicting the clinical behavior of these lesions. An EPICS V flow cytometer (Coulter Electronics, Hialeah, Fla) was used. Measurements were taken from paraffin-embedded tissue. Isolated nuclei were stained with propidium iodide. The study was conducted in a blinded fashion. Observed NDC and PDY patterns were classified as diploid, aneuploid, or suspicious. Twenty-nine lesions (81%) were diploid and seven (19%) were aneuploid. Twelve (33%) HCNs were malignant, 23 (64%) were benign, and one (3%) was indeterminate. Eight (67%) of 12 malignant HCNs were diploid and four (33%) of 12 were aneuploid. In comparison, 20 (87%) of 23 benign lesions were diploid and three (13%) of 23 were aneuploid. The indeterminate neoplasm was diploid. There were three deaths in this group of patients; all three had aneuploid neoplasms, and all had locally recurrent disease with distant metastases. There was a significant cross correlation between histologic features and DNA content with regard to outcome. These preliminary data suggest that NDC and PDY are not helpful in distinguishing histologically benign from malignant HCNs; however, they may be useful in determining prognosis.

Frank rectal bleeding: a prospective study of causes in patients over the age of 40

In order to determine the frequency of tumours in patients presenting with frank rectal bleeding, a prospective study was carried out in 337 patients over the age of 40 attending our Proctology Clinic. After making a clinical diagnosis, flexible sigmoidoscopy followed by barium enema was performed. Excluding 7 digitally palpable rectal cancers, there were 30 cancers (9.1%), 34 polyps (10.3%), 7 proctocolitis (2.1%) and 25 diverticula (7.6%) detected, giving a total diagnostic yield of 29.1%. A clinical diagnosis of bleeding sources other than haemorrhoids was made in 80% of the cancers. Flexible sigmoidoscopy detected 93.3% of the cancers and 88.2% of the polyps. Barium enema diagnosed the remaining cancers and polyps but there was a false-positive rate of 3.8%. From our results, we conclude that patients with frank rectal bleeding should be screened routinely for left-colon cancer irrespective of the clinical diagnosis. The flexible sigmoidoscope is a quick and useful tool. However, barium enema should be recommended to individuals with strong clinical suspicion of rectal bleeding other than haemorrhoids.

Primary hyperparathyroidism: its clinical pattern and results of surgical treatment in Hong Kong Chinese

Primary hyperparathyroidism has been increasingly diagnosed among whites since the advent of the biochemical autoanalyzer. However, the condition remains uncommon among Orientals. Our experience with 31 patients at the Queen Mary Hospital, University of Hong Kong, in the periods before and after we began to use the biochemical autoanalyzer was reviewed. The prevalence of primary hyperparathyroidism rose slightly from 3.1 to 3.7 per 100,000 hospital population. In both periods skeletal manifestation was the major clinical presentation, followed by hypercalcemic symptoms and urologic disease. Asymptomatic hypercalcemia occurred in three of 31 patients despite the use of the biochemical autoanalyzer. Preoperative localization was carried out in 27 patients and was helpful in nine (33.3%) of them. The surgeon explored all four parathyroids, removed the diseased gland(s), and examined a biopsy specimen of one normal-appearing gland. There were 27 adenomas, two carcinomas, one four-gland hyperplasia, and one sarcoidosis. Twenty-eight patients had transient hypocalcemia after parathyroidectomy and required calcium supplements for variable periods. Before and after we began to use the biochemical autoanalyzer, there was minimal change in the prevalence and clinical pattern of primary hyperparathyroidism seen in our hospital. In our experience, successful parathyroidectomy depends more on the surgeon's operative technique than on preoperative localization.

The complementary role of fine needle aspiration cytology and Tru-cut needle biopsy in the management of breast masses

Fine needle aspiration cytology (FNA) and Tru-cut needle biopsy (TNB) have been used for the pre-operative diagnosis of cancer in breast masses as alternatives to open breast biopsy. The accuracy of clinical examination, fine needle aspiration biopsy and Tru-cut needle biopsy was assessed in 230 patients with palpable breast masses and the value of using both biopsy methods in the management was prospectively evaluated. Clinical diagnosis had a sensitivity of 89.2% and specificity of 78.4% (32.7% false positive, 6.5% false negative). Aspiration cytology was diagnostic in 78.4% of cancers and 71.6% of benign lesions [excluding non-diagnostic samples (27.4%), sensitivity was 96.6% and specificity was 100%]. Tru-cut needle biopsy identified 82.9% of cancers and 61.7% of benign lesions [excluding non-diagnostic samples (33.3%), sensitivity was 96.7% and specificity was 100%]. There were no false positive errors with either aspiration cytology or needle biopsy. Statistical comparison showed that there was no significant difference between aspiration cytology and needle biopsy. The combined result of both biopsies was superior to clinical examination when non-diagnostic samples were excluded. With the routine use of both biopsy techniques, frozen section was avoided in 73% of all cancers and unnecessary operations were avoided in 33.5% of patients which included breast cysts, benign mammary dysplasia and inflammatory lesions.

Diagnosis and treatment of functioning and nonfunctioning adrenocortical neoplasms including incidentalomas

The most important functional tumors of the adrenal cortex are those that secrete cortisol or aldosterone in excess. Biochemical testing when appropriately utilized can diagnose and differentiate the cause of Cushing's syndrome, and when an adrenal adenoma is found, surgical excision is curative. The diagnosis and surgical treatment of primary aldosteronism are straightforward today, and localization of the usual small cortical tumor producing the syndrome can be achieved by CT and NP-59 scanning or selective venous assays. Adrenocortical carcinomas are relatively rare, are usually incurable when diagnosed, and are an important consideration in the incidentally discovered adrenal mass found by CT scanning.

Effect of hyperparathyroidism on the control of diabetes mellitus

Hyperparathyroidism is associated with abnormalities in glucose tolerance and insulin secretion. To assess the effects of hyperparathyroidism on the control of diabetes mellitus, 56 patients with concomitant hyperparathyroidism and diabetes mellitus were studied before and after parathyroidectomy. Fifty patients (89.3%) had hypercalcemia, and six patients (10.7%) had normocalcemia associated with inappropriately elevated parathyroid hormone. After surgery, three of five patients with insulin-dependent diabetes mellitus showed more than a 50% reduction in insulin requirement. Thirty-nine of 49 patients with noninsulin-dependent diabetes mellitus were followed. Of these, three patients had restoration of normal blood glucose levels without any diabetic treatment including diet restriction. Diabetes control improved in eight parents, remained stable in 18, and deteriorated in 10 patients. In the remaining two patients, impaired glucose tolerance disappeared in one patient and progressed to frank diabetes in the other. Overall 60.7% of the patients improved or remained stable in their diabetes control after parathyroidectomy. We conclude that in patients with hyperparathyroidism, the coexistence of diabetes mellitus might be a further indication for parathyroidectomy. Physicians should be alerted to the possible change in diabetic regimen and the risk of hypoglycemia in patients with diabetes after parathyroidectomy.

Nonfunctioning malignant neuroendocrine tumors of the pancreas

The clinical features of eight women and three men with nonfunctioning islet cell carcinoma of the pancreas were reviewed. The mean patient age was 58 years (range 44 to 75 years). Weight loss and abdominal pain were the most frequent presenting symptoms. An abdominal mass was palpable in five patients. At operation regional or distant metastases were present in 82% of patients. Only 18% of patients underwent resection for potential cure. All tumors proved histologically to be neuroendocrine in origin. Immunohistochemical staining showed positive reactivity for neuron-specific enolase and chromogranin in all tumors studied but was negative for insulin, glucagon, and somatostatin. Focal positivity for pancreatic polypeptide was seen in one tumor. Nine patients with unresectable disease at operation were available for follow-up. Mean survival for the entire group was 23 +/- 7.2 months (range 4 to 72 months). Survival differences between women and men appeared to favor women but were not statistically significant. Postoperative regional or systemic chemotherapy also had no significant effect on patient survival although two of the longest survivors (36 and 72 months) had received adjunctive chemotherapy. Nonfunctioning islet cell neoplasms are locally aggressive, have a propensity for early metastases, and are rarely resectable for cure. Unlike pancreatic exocrine carcinomas, endocrine malignancies may respond favorably to adjunctive chemotherapy.

Fifty cases of primary hyperaldosteronism in Hong Kong Chinese with a high frequency of periodic paralysis. Evaluation of techniques for tumour localisation

Fifty consecutive Chinese patients with primary hyperaldosteronism were studied. All were considered to have an adrenal cortical adenoma, this being proven by surgery in 46 cases. In contrast to other reports, periodic paralysis was a presenting feature in 42 per cent of patients. Other notable symptoms were palpitations (30 per cent) and syncope (12 per cent). Vascular complications were present in 20 per cent of cases. Mean serum potassium level at presentation was 2.1 +/- 0.1 (mean +/- SEM) and sodium 145.0 +/- 0.1 mmol/l. Serum potassium was significantly lower and plasma aldosterone higher in patients with periodic paralysis. Adrenal venography in order to localise the tumour was unreliable and was misleading in two cases. Adrenal venous sampling for steroid analysis was much more helpful, despite the difficulty of obtaining right adrenal venous blood. The side of the adenoma could be predicted in 97 per cent of cases from measurements of left adrenal venous and vena caval aldosterone levels. The use of high resolution CT gave 100 per cent accuracy in all 18 patients who underwent surgery, the smallest detected tumour being 0.8 cm in diameter. Surgery corrected hypokalaemia in all cases, and 37 of the 46 patients required no further antihypertensive treatment.

Bilateral amyloid tumours of the breast

An 82 year old woman with bilateral amyloid tumours of the breast is described. Clinically, the breast masses were hard and were suspicious of carcinoma. Investigation revealed no evidence of systemic amyloidosis or amyloid related illness. Microscopically there was no neoplasia. Instead there was extensive fibrosis with amyloid deposition in perivascular periductal areas and also in the intervening stroma. The presence of amyloid was confirmed by special stains and by electron microscopy.

Evaluation of the posterior approach for subfascial ligation of perforating veins

A posterior midline incision was used for subfascial ligation of incompetent medial and lateral perforating veins in 32 patients. The indications for surgery were recurrent ulceration in 31 limbs and stasis dermatitis in six limbs. Incompetent perforating veins were found on the medial aspect of the leg in all cases and lateral aspect of the leg in 69% of cases. Postoperative mild skin edge necrosis and wound infection each occurred in seven limbs. Follow-up of these patients from 5 months to 4 years showed that there were 11 recurrent ulceration, 10 mild leg oedema and three recurrent varices. This operation was successful in preventing further leg ulceration in 70% of patients, and a further 21.6% had benefited from the operation in that ulcers which recurred in the follow-up period were small in size compared to the original ones, and healed quickly.

Colorectal carcinoma in the young

Four hundred and five patients with colorectal adenocarcinoma were seen over a five year period in the Department of Surgery, University of Hong Kong. These patients were divided into two concurrent groups according to the age of 40. Thirty patients (7.4%) were below age of 40 at the time of presentation. This young group of patients had both a higher combined proportion of C and D tumors (76.6% to 50%) and a higher proportion of poorly differentiated tumours (20% to 5.5%). The curative and palliative resections rates were similar. Life tables of patients who underwent curative resections showed young patients to have a significantly poorer overall disease-free interval as well as overall determinant survival. In comparing only the Dukes C patients, the young patients still showed a higher recurrence rate.