Screening for breast cancer: some clinical aspects

There is little doubt that screening by palpation and mammography will reduce the mortality from breast cancer. Most of the studies have been designed to test survival difference and, following diagnosis, patients were treated by a variety of surgeons and methods. We present clinical and pathological data on 32 asymptomatic patients who were screened and found to have breast cancer. Investigation and treatment was performed by one surgeon according to a defined protocol. We confirm that mammography is a more sensitive diagnostic tool than palpation and describe how a review of the patient with the suspicious mammogram will increase the incidence of palpable tumours. We stress the importance of fine-needle aspiration cytology as a diagnostic and localization method. The low incidence of axillary node metastasis in patients with invasive carcinoma is described. More importantly, no patient in this series required treatment by mastectomy. In our experience patients with breast cancer detected by screening are eminently suitable for treatment by breast conservation.

Ethinyl oestradiol and D-norgestrel is an effective emergency postcoital contraceptive: a report of its use in 1,200 patients in a family planning clinic

We describe a prospective study of 1,200 patients using the Yuzpe regimen of hormonal postcoital contraception. There was an 85% follow-up rate, and of the 1,015 patients followed there were 13 pregnancies, giving a pregnancy rate of 1.3%. The number of expected pregnancies at mid-cycle was reduced by 83%; 12 of the 13 pregnancies went on to abortion. The patients were young: 86% were under 25, and 10% were under 15. The most frequent reason for presentation was that no contraception had been used (57%). All patients received an antiemetic; 57% experienced no side-effects, 28% had some nausea and 9.6% some vomiting. It is concluded that this is a safe form of emergency contraception, which is an effective way of reducing the number of unwanted pregnancies, especially in the very young.

Histopathology of benign non-palpable breast lesions identified by mammography

Over four years the histological features of benign breast diseases, diagnosed after biopsy of non-palpable mammographic abnormalities, were reviewed and correlated with the mammographic appearances. The histological features were compared with those from all other benign biopsy specimens taken during the same period. The incidence of sclerosing adenosis and microcalcifications was considerably higher in the group of non-palpable mammographic lesions; fibrous disease of the breast and radial scar (infiltrating epitheliosis) were also more common. There was no difference in the incidence of epithelial hyperplasia between the two groups. Correlation with the mammographic appearances showed that microcalcification was most often associated with blunt duct adenosis and that stromal distortion or masses were most often caused by fibrous disease.

Patterns of axillary lymphadenopathy demonstrated by mammography: implications for the asymptomatic woman in a breast screening programme

Carcinoma of the breast is the commonest cause of mortality due to malignancy in women in England and Wales. Mammographic screening, with or without clinical examination, is being used increasingly to detect lesions at an earlier stage. In order to test the claim that an asymptomatic woman with axillary lymph nodes on mammography and no demonstrable underlying carcinoma has a greater than two-fold increased risk of developing subsequent breast cancer, a retrospective analysis was performed on 217 mammograms selected from approximately 40,000 screened women using a cluster sampling technique. A group of women with histologically proven breast carcinoma and two control groups were analysed. The incidence, site and pattern of axillary lymph nodes was compared in the three groups. The relative risk of the asymptomatic woman with axillary lymph nodes developing breast cancer was 1.08 times that of the asymptomatic woman without axillary lymph nodes. From these data we conclude that the presence of lymph nodes does not constitute a risk factor for the development of subsequent ipsilateral mammary cancer and should not influence the assessment of screening mammograms.

The management of stage II supradiaphragmatic Hodgkin's disease at St. Bartholomew's Hospital. A retrospective review of 114 previously untreated patients over 14 years

Between January, 1968 and July, 1981, 114 consecutive patients with newly diagnosed supradiaphragmatic stage II Hodgkin's disease were treated at St. Bartholomew's Hospital on the basis of pathologic staging (PS) in 56 (47 IIA, 9 IIB) and clinical staging (CS) in 58 (23 IIA, 35 IIB). Complete remission (CR) was achieved in 104 (91%) patients, of whom 27 have relapsed. Ninety-three patients remain alive, the cumulative predicted survival at 10 years being 81%, with a minimum follow-up of 2 years and a maximum of 15 years. Mantle radiotherapy (RT) was prescribed for 76 patients, of whom 67 (88%) entered CR. The duration of CR correlated inversely with the presence of intrathoracic lymphadenopathy. No patient with PS IIA and a normal chest radiograph has yet relapsed, whereas in contrast, a rising probability of relapse is related to increasing volume of intrathoracic lymphadenopathy. Combination chemotherapy (CT) with mustine, vinblastine, procarbazine, and prednisone (MVPP) was prescribed to 38 patients, 27 with "B" symptoms and 11 stage IIA patients with "unfavorable" features. CR was attained in 32 (84%) patients, of whom 24 subsequently proceeded to mantle irradiation. Only one of these has relapsed, compared to two of eight patients who did not receive adjuvant RT (P = NS). The duration of remission of patients receiving combined modality therapy (CT + RT) or CT alone was significantly longer (P less than 0.05) than that of patients receiving RT alone, in spite of the fact that the CT + RT group comprised predominantly patients with unfavorable features.

Breast screening results from a healthy working population

The early results of a breast screening service in a large retail company have been analysed. Female employees over 35 years of age were offered mammography, thermography and clinical examination, periodically over 51/2 years. One hundred and two cases of proven cancer were found in 21 186 women (4.8 per thousand). Non palpable cancers accounted for 56.9% of the total and 37.3% of these were less than 1 cm in size. Twenty tumours were microscopic. Only 13.7% of cases were known to be node positive and 43% of the cancers occurred in women of less than 50 years of age. The results throughout the whole age range encouraged the original hope that screening and early diagnosis will influence the prognosis of female breast cancer.

The role of computed tomography in the detection of intrathoracic lymphoma

Computed tomographic scanning of the chest in 100 patients with newly diagnosed malignant lymphoma detected mediastinal lymphadenopathy (39%) and parenchymal deposits (15%) with a significantly greater sensitivity and specificity than conventional radiological techniques. This principally affected the staging and treatment of patients with limited stage disease. The stage was changed in 10/61 patients (16%) with Stages I-III prior to CT scan and treatment was altered in 11/29 (38%) patients for whom radiation was the treatment of choice. Complete remissions as defined by CT scan have been more durable than those defined by CXR alone.

Patterns of breast skin thickness In normal mammograms

Measurement of the mammographic skin thickness over different parts of the breast was performed in 150 normal patients. The patients were divided into three groups based on breast size and the skin thickness in these three groups compared. The results showed that skin thickness decreased with increasing breast size and that the upper limit of normal was greater than the previously quoted normal range at 3.0 mm. Measurement over different parts of the breast showed that medial exceeded lateral skin thickness by up to 100%, and similarly for the inferior and superior measurements. These findings in the normal breast are of importance in deciding on the presence or absence of abnormal skin thickening as an indicator of underlying breast disease.

A test object for assessing image quality in mammography

The problems inherent in the design and manufacture of mammographic test objects are discussed and a test object is described which may be used for assessing image quality. Some typical results from both good and bad mammographic machine/film combinations are presented.

Computerised tomographic (CT) abdominal scanning in Hodgkin's disease

Thirty-nine patients with Hodgkin's disease (HD) with little or no clinical evidence of abdominal disease were investigated by abdominal CT scanning. The results were compared with those of bipedal lymphography and laparotomy and splenectomy. In the assessment of para-aortic lymph nodes, CT scanning and lymphography were of equal efficacy in determining the presence or absence of disease (87 and 79% respectively). Although CT scan could occasionally demonstrate disease in nodes in areas other than the retroperitoneum, its value was limited by its inability to detect involvement of nodes which were not significantly enlarged. CT assessment of splenic HD was unreliable, focal deposits being detected in only one of the 11 spleens involved. In this selected group of patients, CT scan had little advantage over lymphography in the description of disease extent. However, CT scan would appear to be the investigation of choice in patients with suspected abdominal relapse because of the more frequent presence of disease in sites not seen on lymphography. When treatment decisions are dependent on accurate knowledge of distribution of disease, CT scanning cannot yet effectively replace staging laparotomy and splenectomy as the means of achieving this information.

Another look at osteoarthritis

One hundred consecutive cases of osteoarthritis seen in a medical clinic have been reviewed and contrasted with 100 patients with rheumatoid disease. Osteoarthritis was usually a polyarticular disease and as symmetrical in distribution as rheumatoid; the knees and hands were the most commonly involved sites. Evidence of inflammation was often found in patients with osteoarthritis and included morning stiffness, redness of distal interphalangeal joints, warmth, and effusions in the knees. In many cases there was either radiological or electron microscopical evidence of deposition of calcium salts. These findings do not support the concept of osteoarthritis as a mechanical, noninflammatory 'wear and tear' condition. An active metabolic abnormality of articular cartilage resulting in cartilage destruction, calcification, and inflammation is suggested as being more compatible with the findings.

Osteonecrosis in Hodgkin's disease

Four patients suffering from Hodgkin's disease developed osteonecrosis following therapy and both femoral heads were involved in each case. Retrospective review of abdominal radiographs taken for follow-up lymphography demonstrated that the earliest radiological changes in bone were evident between five and 18 months after treatment was started and between six and 21 months before the onset of symptoms. The clinical implications are discussed.

The radiology of bone changes in rhabdomyosarcoma

Rhabdomyosarcoma usually presents as a soft tissue mass, which may invade adjacent bone. However, the patient presents occasionally with bony metastases. Recognition of these is important for staging and management. Fifty-eight cases have been reviewed; 14 of these had local bone invasion by the soft tissue tumour. All bones involvel were flat bones; 12 showed permeated bone destruction and two showed geographic destruction. Bone expansion was seen in half the involved bones. Twelve of the 58 cases showed secondary bone deposits, which were the presenting feature in five. Although 10 cases had permeated bone destruction, two were very well defined with a wide range of radiological appearances. The radiological differential diagnosis includes neuroblastoma, leukaemic infiltration, lymphoma, histiocytosis X, solitary and multifocal osteosarcoma and other deposits.

Pain in the knee associated with osteoporosis of the patella

Four patients, all of whom complained of pain in the knee, were found to have radiological evidence of osteoporosis particularly marked in the patella. In 3 a neurological lesion at the appropriate spinal segment was present, and the fourth patient, who was frankly hysterical, had an autonomic disturbance. If radiological porosis is isolated to the patella a distant cause such as nerve irritation should be sought.

Intensive investigation in management of Hodgkin's disease

Ninety-eight patients with clinically localised Hodgkin's disease underwent laparotomy and splenectomy to determine the extent of microscopic spread. In 68 patients the procedure was carried out for untreated disease apparently confined above the diaphragm. Abdominal disease cannot be confidently excluded on the basis of non-invasive investigation at presentation. Clinical assessment of splenic disease was unreliable unless gross splenomegaly was present. Pedal lymphography was accurate in assessing para-aortic and iliac disease but of no value in assessing other intra-abdominal lymph node involvement, including that of the mesenteric lymph node. Trephine bone marrow biopsy findings were normal in all patients before surgery, and only one patient was found to have diseased bone marrow by Stryker-saw biopsy at operation. Liver disease was identified at operation in nine patients, some of whom were asymptomatic with clinically undetectable splenic and nodal disease. Detailed clinical staging failed to detect disease in one-third of patients who underwent laparotomy. These studies show that if radiotherapy is to remain the treatment of choice for disease truly localised to lymph nodes a detailed staging procedure, including laparotomy and splenectomy, remains essential. The value of this potentially curative treatment is considerably diminished in the patient who has been inadequately staged.

Pulmonary fungal infection complicating treated malignant disease

Secondary pulmonary fungal infection in patients being treated for malignant disease may be difficult to diagnose. Nine patients are described, illustrating some of the possible radiological appearances. There was pathological support for the diagnosis in seven of these patients. A plea is made for a higher level of suspicion in patients with the predisposing factors who also develop pulmonary complications so that suitable treatment may be given, even though sputum examination is negative.

Hospital topics. Pulmonary function after lymphography

The effects of lymphography on ventilatory function and gas transfer factor were studied in nine patients. Serial measurements made up to one month showed no change in the forced expiratory volume in one second or vital capacity. A small but reversible fall in transfer factor was found. The greatest reduction was at 24 or 48 hours. It was concluded that patients with normal lungs are unlikely to encounter difficulties but that patients with severe lung disease require careful assessment before lymphography.