Symptomatic benign breast disease and hormone replacement therapy

The effect of hormone replacement therapy (HRT) on presentation and diagnoses of post-menopausal women has been examined by a retrospective review of patients presenting to a symptomatic Breast Clinic over a 5-year period. Sixty-seven post-menopausal women aged less than 65 years taking hormone replacement therapy for more than 6 months were compared with 144 post-menopausal women aged less than 65 years not taking hormone replacement therapy. There was no difference in the pattern of presentation, rate of intervention or final diagnoses between these two groups. HRT does not appear to effect the pattern of presentation of benign breast disease in post-menopausal women.

Tubular carcinoma of the breast: prognosis and response to adjuvant systemic therapy

BACKGROUND

Tubular carcinoma of the breast is an uncommon and usually small tumour, and is thought to have a favourable prognosis. The present study examined the long-term prognosis of patients with tubular breast carcinoma and the roles of axillary dissection and adjuvant therapy.

METHODS

Eighty-six tubular cases were identified from a large worldwide database of 9520 breast carcinoma patients entered into randomized adjuvant therapy trials run by the International Breast Cancer Study Group from 1978 to 1999. These patients were followed for a median of 12 years.

RESULTS

Forty-two (49%) cases were node-positive, of which 33 (79%) had 1-3 nodes involved. Ten (32%) of the 31 smaller tumours (< or = 1 cm in size) were node-positive. Patients with node-positive tubular carcinoma had a significantly better 10-year relapse-free survival (P = 0.006) and survival (P < 0.0001) compared with non-tubular node-positive cases. Overall survival was similar for node-positive and node-negative tubular carcinoma. Overall, 71 patients (83%) received some form of adjuvant systemic therapy. Of the 86 cases, 43 (50%) received more than one course of chemotherapy. There was an 85% decrease in the risk of death for patients who received more than one course of chemotherapy compared to those who did not (hazard ratio 0.15, 95% confidence interval (CI): 0.03-0.82; P = 0.03).

CONCLUSIONS

Compared to other histological types of breast cancer, tubular carcinoma has a better long-term prognosis. Adjuvant chemotherapy may further improve prognosis and involvement of axillary nodes may not be an indicator for early death due to breast carcinoma.

Axillary dissection and ductal carcinoma in situ of the breast: a change in practice

BACKGROUND

Axillary dissection may be associated with significant morbidity and, while it is necessary in the treatment of invasive breast cancer, is not indicated for the treatment of pure ductal carcinoma in situ (DCIS), although it is being performed in a significant number of cases. The present study examined the incidence of elective axillary dissection in the treatment of DCIS cases detected in a mammographic screening programme over a 4-year period, and whether surgeons have changed their practice in this respect.

METHODS

BreastScreen Victoria records were examined retrospectively for the period from January 1995 to December 1998 to identify patients treated for DCIS. The incidence and indications for axillary surgery were investigated.

RESULTS

There were 579 cases of DCIS and 93 (16%) had some form of axillary surgery, which was thought to be inappropriate in 57 (10%), the latter being performed by 21 city surgeons and 20 rural surgeons. Before surgery, 36 (63%) cases were diagnosed by core biopsy or excision, and 21 (37%) had imaging and cytology alone for diagnosis. The rate of unnecessary axillary dissections dropped steadily from 14% in 1995 to 4% in 1998, a significant reduction (P = 0.01).

CONCLUSION

The incidence of axillary dissection for DCIS has dropped significantly over the last 4 years in Victoria, possibly due to increased awareness through education and guidelines. Surgeons are now more aware that in situ lesions do not need axillary dissection, and that axillary dissection should not be performed for breast cancer unless invasion has been proved histologically.

Characteristics and treatment of breast cancers 10 mm or less detected by a mammographic screening programme

BACKGROUND

Small invasive breast cancers up to 10 mm in size have an excellent prognosis and are being detected in increasing numbers by mammographic screening, yet optimal treatment remains controversial.

METHODS

A review was made of pathology and treatment data relating to 100 consecutive invasive breast cancers up to 10 mm in size detected among 52,126 women who were screened over a 32-month period.

RESULTS

The most common radiological finding was a stellate lesion (44%). Thirty-three cases had an extensive in situ component in addition to the invasive tumour, and included among these were seven ductal carcinoma in situ (DCIS) cases with microinvasion. Of 79 patients who had axillary dissections, seven (9%) were node-positive. Tumours < or = 5 mm were as likely to be node-positive (11%) as those 6-10 mm in size (8%). Positive nodes were found only in patients with more than five nodes excised. Breast conservation surgery was performed in 84% of patients treated by surgeons associated with the programme, and 63% of patients were treated by other surgeons (P = 0.054, exact test). Breast radiation after breast conservation surgery was used in 44% of the cases, but was almost twice as likely to be used if the tumours were > 5 mm (51%) than if the tumours were < or = 5 mm (29%). Adjuvant tamoxifen was given to 61% of the cases.

CONCLUSIONS

We found that small invasive breast cancers are commonly treated by breast conservation, which usually includes axillary dissection. Even the smallest may be node-positive, and there is uncertainty about the place of adjuvant radiation therapy and tamoxifen.

Pilonidal sinus: experience with the Karydakis flap

A personal series of 141 patients with postanal pilonidal sinus was treated by the Karydakis operation. Each sinus was totally excised with a vertical eccentric elliptical excision. A thick flap was created by undercutting the medial edge and advancing it across the midline so that the whole suture line was lateralized to reduce the risk of recurrence. Follow-up was achieved in 114 patients for 1-108 months; 79 (69 per cent) were followed for more than 18 months. Overall there were five recurrences (4 per cent) which required further surgery. Thirty-three patients (23 per cent) were referred following recurrence or failure of healing after previous surgery elsewhere; all were cured by this method. The Karydakis operation has a low recurrence rate because it produces a shallow midline furrow free from scar or suture holes which is less vulnerable to hair penetration than a midline wound.

Changes in the investigation and management of primary operable breast cancer in Victoria

OBJECTIVES

To investigate the surgical practice and adjuvant therapies used in the treatment of primary operable breast cancer in Victoria in 1990 and compare them with results of a similar study in 1986.

DESIGN

All 856 cases of primary operable breast cancer registered by the Victorian Cancer Registry between 1 April and 30 September 1990 were identified. Each patient's surgeon was sent a standard questionnaire covering diagnosis, investigations, operative procedures, adjuvant therapies and reasons for certain management choices. Data were collected on 89% of the patients from 176 participating surgeons.

RESULTS

Most patients (82%) were referred to surgeons by general practitioners. Mammographic screening detected 14% of the cancers. The proportion of women receiving breast-conserving operations rose from 22% in 1986 to 42% in 1990. Surgeons operating on more than 20 breast cancers per annum were most likely to perform breast-conserving operations. The most common reasons given for non-conservative operations were the size of the tumour (37%), its central location (25%) and/or patient concern about the risk of recurrence if the breast was to be conserved (22%). Among these patients, reconstruction was done at the time of primary treatment in 13%, subsequently in 2%, and was planned by another 5%. Of all patients, 33% were referred to a radiation oncologist and 24% actually received radiotherapy (similar to 1986). Medical oncologists saw 33% of the patients and 20% of all patients received chemotherapy (similar to 1986), which was given by a medical oncologist in 83% of the cases. Use of endocrine therapy increased from 20% in 1986 to 40% in 1990.

CONCLUSIONS

There has been a strong trend towards more conservative breast surgery in Victoria, with surgeons who are most active in breast cancer surgery most likely to perform breast-conserving operations. Apart from a significant increase in the use of endocrine therapy, use of adjuvant therapies was unchanged from 1986.

A comparison between radioligand and immunohistochemical assay of hormone receptors in primary breast cancer

The detection of oestrogen and progesterone receptor (ER and PgR) levels in human breast carcinoma has traditionally been performed using a biochemical radioligand binding method. This method has several disadvantages including the requirement for generous tissue samples, the production of radioactive waste products and the inability to exclude non-malignant cellular material from the assay process. An alternative method for detecting hormone receptors is available with the use of a monoclonal antibody specific for the ER or PgR receptor using immunocytochemical assay (ER-ICA or PgR-ICA). Although designed for use on frozen section material, with modifications this method can be used on paraffin sections of routinely fixed and processed tissue, on archival material and on very small specimens. Further, an objective assessment or scoring of staining intensity is possible using computerized video-image analysis. Forty-three cases of primary breast carcinoma, treated from 1989 to 1991 at Goulburn Valley Base Hospital, Shepparton were assessed for ER and PgR content using both the radioligand method and immunohistochemistry with video-image analysis, and the results were compared. Of the 43 cases, ER-ICA and ER had a concordance of 81% (P < 0.001, r = 0.58) and in 39 cases, PgR and PgR-ICA had a concordance of 87% (P < 0.001, r = 0.54). Because the sample for radioligand assay is of uncertain composition and the immunohistochemical stain can be scored specifically for malignant epithelium, a degree of discordance is thought to be mostly attributable to the limitations of the radioligand assay.

Management of sub-areolar abscess and mammary fistula

Sub-areolar abscess is a form of chronic non-lactational mastitis often presenting in young women at the areolar margin as a recurring discharge or painful infection. Incision and drainage is inadequate and will be followed by recurrence unless the major duct leading from the abscess to the nipple is identified and laid open. Three cases are presented to illustrate this problem and its management.

Oestrogen receptor assay of breast cancer by immunocytochemistry of fine needle aspirates

Sixty-five patients with operable breast cancer were studied to assess the reliability of immunocytochemical analysis of oestrogen receptor (ER-ICA) in specimens obtained by percutaneous fine needle aspiration. Results obtained with the commercially available ER-ICA kit were compared with those obtained by the routine biochemical radioligand assay of oestrogen receptor (ER) on excised tumour specimens. Fifty-two of 65 percutaneous aspirates were evaluable. Of these, thirty-five (67%) were ER positive by the radioligand method. ER-ICA was found to be a reliable method for oestrogen receptor assay, with a high concordance (90.4%) between it and the radioligand essay. The ER-ICA assay had a sensitivity of 89%, specificity of 94%, positive predictive value of 97% and negative predictive value of 80%. ER-ICA assay performed on material obtained by fine-needle aspiration is a reliable method of ER assay. It can replace formal biopsy for patients with inoperable primary tumours or accessible metastases.

Breast cancer and pregnancy

Although breast cancer is a rare event in pregnancy, the consequences of a delay in its detection and of late-stage disease are tragic for the young woman who presents in her childbearing years. Therefore, all pregnant women with breast problems should undergo a careful assessment. Pregnancy is not a contraindication to orthodox investigations for breast cancer, provided that special care is taken to reduce the risk to the developing fetus. Management is also orthodox, and breast cancer in pregnant or lactating women is thought to behave no differently from breast cancer in non-pregnant women, when age, stage and histological type are similar. For women who have developed early breast cancer during pregnancy, termination of the pregnancy does not appear to have a beneficial influence on the disease. There is no convincing evidence that a subsequent pregnancy has any effect on the outcome of a breast cancer that has been managed successfully previously. The prevention of subsequent pregnancy is not an indication for a prophylactic oophorectomy. A decision for further pregnancies must be made by the patient and the family after sound advice is given as to the prognosis and consideration of the social, economic and spiritual factors. There is no evidence that the termination of a subsequent pregnancy will affect beneficially or adversely the prognosis of a patient with breast cancer.

Effect on immunologic and other indices of adjuvant cytotoxic chemotherapy including melphalan in breast cancer

Thirty patients with histologically proven node-positive early breast cancer (Stage II) were treated by total mastectomy and axillary clearance and adjuvant chemotherapy regimens including melphalan for 1 year. These patients were studied sequentially, at 3-month intervals, for up to 2 years to assess effects of cytotoxic drugs on immune function, and to determine whether any changes in immune function were related to recurrence. All indices were in the normal range before chemotherapy. The most marked and long-lasting effects of chemotherapy were on numbers of circulating T-cells and B-cells. Mean counts +/- one standard error (X 10(6)/ml) for T-cells before and 12 months after stopping chemotherapy were 1.537 +/- 0.118 and 0.874 +/- 0.120 (P less than 0.01), and for B-cells 0.345 +/- 0.060 and 0.207 +/- 0.030 (P less than 0.01). Functional indices of T-cell and B-cell competence were less compromised than values for cell counts and, in contrast, recovery occurred either during or within 3 months of stopping chemotherapy. This held for both T-cell function measured by delayed-type hypersensitivity (DTH) responsiveness to five recall antigens and mitogenic responsiveness to phytohemagglutinin, and for B-cell function measured by titration of blood group isohemagglutinins. After 4 years the 30 subjects were divided into groups according to whether there was recurrence of cancer (14) or no recurrence (16); the only index predictive of recurrence was depression of DTH to recall antigens. Thus it was found that cytotoxic chemotherapy with melphalan appears to cause long-lasting depression of cell counts but only short-lasting depression of functional indices of immunocompetence, and that levels of immunologic indices during chemotherapy are mostly nonpredictive of recurrence of cancer. The results prompt some caution in the use of adjuvant chemotherapy, at least with melphalan.

Pilonidal sinus: excision and primary closure with a lateralised wound - the Karydakis operation

In a personal series, forty-five patients with postanal pilonidal sinus have been treated by the Karydakis operation. The sinus is excised using an eccentric elliptical incision, the medial edge of which is undermined and advanced across the midline to produce a lateral vertical scar and shallower natal cleft. Forty patients were followed up for an average of thirty-three months. There were two wound haematomata, four wound infections and two recurrences, one of which was not in the scar. A low recurrence rate can be achieved by flattening the natal cleft and closing the skin away from the midline.

Recurrence of pancreatic ascites due to a second leak demonstrated radiologically

A case of recurrent pancreatic ascites is reported in which both episodes were investigated by endoscopic retrograde pancreatography.

Node-positive breast cancer: a comparison of clinical and pathological findings and assessment of axillary clearance

The Breast Adjuvant Chemotherapy Study of the Anti-Cancer Council of Victoria was set up to encourage the cooperation of clinicians from many centres who are involved in the management of early node-positive breast cancer in Victoria. Data sheets were completed by participants, and an analysis was made of the first 100 registered patients to determine the reliability of clinical assessment related to pathological findings and to study the extent of axillary node clearance. Although all subjects were histologically node positive, 47 had no palpable axillary lymph nodes, and in only 38 were nodes considered to be clinically involved. Correlation between clinical and pathological measurements of breast tumour size was significantly better (86%) with tumours over 5 cm in extent than with tumours of 5 cm or less (70%). Total mastectomy with total axillary clearance was the most common operative procedure performed. The pectoralis major was preserved in 97 and the pectoralis minor was divided or removed in 71 cases as part of the axillary clearance. In a subgroup (33) the location of involved nodes in the axilla was studied, and of these seven (21%) were found to have involved upper axillary nodes in the absence of lower axillary nodal involvement, emphasizing the inadequacy of axillary sampling in determining nodal status.

Radionuclide pancreatic scanning: a retrospective analysis

Records of 346 patients were studied to determine the reliability and diagnostic value of pancreatic scanning. In 157 the pancreatic diagnosis was established subsequent to scanning. The scan was abnormal in 28 of 34 patients (82%) with pancreatic neoplasm, and in 21 of 26 patients (81%) with chronic pancreatitis. Of 71 with normal scans, 56 (79%) had a normal pancreas, and 15 had pancreatic disease (a false negative rate of 21%). Of the 86 with abnormal scans, the pancreas was diseased in 56 (65%), and of the others, 14 had extrapancreatic conditions known to be associated with a high incidence of scan abnormalities. In obstructive jaundice all 21 patients with pancreatic carcinoma had abnormal scans (and the scan accurately diagnosed all four cases of bile duct carcinoma). A normal scan reliably indicated that the cause of jaundice was outside the pancreas. In chronic abdominal pain an abnormal scan was unreliable, but a normal scan excluded pancreatic disease with reasonable accuracy.