The role of magnetic resonance imaging in the assessment of local recurrent breast carcinoma

Experience with magnetic resonance imaging (MRI) of the breast remains limited. MRI studies to date have shown that differentiation of carcinoma from certain benign breast changes can be difficult. The problem of suspected tumour recurrence in patients with known but treated breast carcinoma is considered. Forty-five patients were studied, all having been treated by lumpectomy combined with radiotherapy and/or chemotherapy. Suspicion of recurrence was suggested by X-ray mammography or clinically by the presence of a current breast mass, breast pain, or nipple discharge. The principle differential diagnosis rested between post-treatment fibrosis and recurrent tumour. Axial and sagittal images were obtained using T1-and T2-weighted pulse sequence. Images were enhanced with intravenous gadolinium DTPA in cases where there was a mass. The tomographic format and inherent high soft tissue contrast provided by MRI are of particular value in this situation. The morphological appearances of recurrent tumour, fibrosis, and other post-radiation affects are described and compared. MRI allowed accurate differentiation in the majority of case. In equivocal cases enhancement of mass lesions with gadolinium DTPA provided excellent confirmatory evidence of recurrent tumour.

Threat and loss in breast cancer

The psychological well-being of forty-four breast cancer patients was assessed shortly before and after surgery, and at three and twelve months post-operatively. Regression analysis revealed type of treatment, control over treatment and concern for appearance as significant predictors of nature of subsequent mood state. Results are discussed with reference to the theoretical position that type of severe life event can predict the nature of ensuing psychological disorder.

Viral involvement in breast cancer

Particles containing reverse transcriptase activity have been detected in metastatic cells. This suggests that there may be viral particles within the primary tumour. The concept that this virus is oncogenic, and is an aetiological agent in breast cancer is attractive, although presently, there is no evidence of this nor of the mode of viral transmission.

A randomised controlled trial of adjuvant hormono-chemotherapy in Stage II breast cancer

From 1979 to 1984 women with histologically proven Stage II breast cancer were entered into a randomised controlled trial of adjuvant hormono-chemotherapy following mastectomy. Adjuvant therapy was started within 2 weeks of surgery and was given for 6 months as continuous 'Tamoxifen' and 6-monthly cycles of vincristine, adriamycin and cyclophosphamide (VAC). Of the 157 women randomised 82 were assigned to the control group and 75 to the adjuvant group. Comparing the two groups by life table analysis the rate of recurrence was found to be significantly greater in the control group (n = 46) than in the adjuvant group (n = 25) (Peto log rank test chi 2 = 7.46 P less than 0.01). Although there were more deaths amongst the control patients (n = 31) than in those randomised to receive adjuvant therapy (n = 18), this difference did not achieve statistical significance (chi 2 = 2.80 P less than 0.1). This analysis has shown that although adjuvant hormono-chemotherapy may significantly delay recurrence the trial has failed to demonstrate any significant improvement in the survival of women with Stage II breast cancer following mastectomy.

Postoperative glucose metabolism in patients with gastrointestinal malignancy

Patients with gastrointestinal malignancy demonstrate impaired postoperative glucose disposal (17.5 +/- 1.4 mumol/kg min vs 28.9 +/- 2.5 mumol/kg min; P less than 0.001) and a reduced insulin response, during steady state hyperglycaemia, when compared with control. Analysis of glucose disposal when compared with insulin concentration suggested insulin resistance as a factor in the causation of impaired glucose disposal. In the control group both glucose disposal and insulin response demonstrated a negative correlation with malnutrition score (as assessed by a 13 factor, three grade scoring system), whereas in the cancer group only the insulin response was related to malnutrition score. However, the insulin response in the cancer group was quantitatively different from control subjects. The possible clinical implications of these findings are discussed.

A prospective 10-year study of the post-thrombotic syndrome in a surgical population

A total of 564 patients undergoing laparotomy entered a prospective 10-year study to determine the influence of postoperative DVT relative to other thrombotic episodes on the subsequent development of post-thrombotic syndrome (PTS). Pre-existing venous thrombotic disease and postoperative thromboses were assessed at the initial hospitalisation. Subsequent thrombotic episodes and signs of PTS have been monitored at biennial review. Thirty-five patients had PTS by the tenth year but it was already present in 16 before the index operation. Twenty-six patients without previous thrombotic episodes developed spontaneous DVT or phlebitis during the 10-year follow-up. New leg ulcers developed in six patients. Although all thrombotic episodes, irrespective of the relation to the index operation, increased the risk of PTS, most PTS occurred in patients without recognised DVT, although most had lesser venous problems prior to operation. PTS should be seen as resulting from the summation of a number of incidents of damage to the leg veins rather than one postoperative incident. Direction of prophylactic effort to patients with pre-existing venous problems may best reduce PTS among patients undergoing abdominal surgery, but will not make a major impact on the total population incidence of PTS.

Sequential chemotherapy, surgery and radiotherapy in locally advanced breast cancer

Thirty-seven patients with locally advanced breast cancer, 86% of whom had skin involvement, were treated with three to six cycles of vincristine 1.4 mg m-2, doxorubicin 40 mg m-2 and cyclophosphamide 600 mg m-2. A complete response rate of 19%, and overall response rate of 61% were achieved. Fourteen patients had received a trial of hormone therapy, but no patient had been given prior cytotoxic chemotherapy or radiation therapy. In no case was chemotherapy discontinued on account of toxicity. In patients with partial remission where gross disease more than 3 cm remained, mastectomy (10 patients) or local excision (five patients), was carried out increasing the complete remission rate to 49%. Thirty-two patients then received 45 Gy in 24 days to the breast and regional lymphatics with a further 12 Gy boost to the tumour site. The overall response rate achieved was 86% of the 37 patients, with a total, complete response rate of 76%. The median time to relapse in the 28 complete responders was 17 months. Local palliation, defined as absence of pain, ulceration or an enlarging mass was achieved in 92% of the total number of patients, and the projected local palliation rate at 2 years by life table analysis was 60%. Only 50% of the 10 N3 patients were alive at 1 year, compared to 93% of the 27 N0-N2 patients (P less than 0.05). The overall survival in the entire group at 2 years was 50%. This is an effective and tolerable combined modality approach for the control of local disease in a subgroup of breast cancer patients with complex management problems.

Factors associated with mammographic parenchymal patterns

The relationship between mammographic parenchymal patterns and known risk factors for breast cancer was studied in 5319 consecutive women presenting for breast screening. Using a multivariate analysis, correlations were found in pre-menopausal women between breast size, weight, age at first pregnancy, history of biopsy and history of cyclical breast pain and parenchymal pattern. In post-menopausal women the parenchymal pattern correlates with breast size, weight, weight change, age at first pregnancy, a history of biopsy and a history of breast feeding. The DY pattern correlated with age, breast size, weight, history of biopsy and menopausal status. When pre-menopausal women were considered separately the DY pattern correlated only with weight and breast size.

The spontaneous disappearance of breast calcification

The spontaneous disappearance of both coarse and fine calcification in the breast was noted in 11 cases who presented either with breast symptoms or to a screening unit. While fine and coarse calcification occur in benign disease, the spontaneous regression of this finding appears not to have been reported previously.

Particles with properties of retroviruses in monocytes from patients with breast cancer

An agent with the properties of a retrovirus has been detected regularly in monocytes from patients with breast cancer. In 97% of breast cancer patients the cell-free culture medium (CFCM) in which the monocytes had been cultured possessed reverse transcriptase (RT) activity. In contrast, RT activity was detected in the CFCM from only 11% of age and sex matched controls (p less than 0.0001; Wilcoxon rank sum test). The RT activity was associated with particles having a buoyant density of between 1.165 and 1.18 g/ml, similar to that of retroviruses. Treatment of the samples with non-ionic detergent abolished the peaking of the activity in this fraction. Enveloped particles (100-120 nm in diameter) with a fringed surface resembling murine mammary tumour virus were found on negative-stain electron microscopy in CFCM obtained from patients with breast cancer. Retrovirus-like particles were also observed in the cytoplasm of giant cells formed by monocytes from these patients, and also in macrophages in breast cancer tissue; however, no such particles were detected in the tumour cells. These findings strongly suggest the presence of a retrovirus in the monocytes from patients with breast cancer. The importance of these observations in the pathophysiology of carcinoma of the breast remains to be established.

Insulin resistance in patients with colorectal cancer

The euglycaemic glucose clamp technique has been used to assess insulin resistance in patients with colorectal adenocarcinoma. Ten cancer patients were studied and compared with control subjects matched for age, sex and nutritional status. Forty-one euglycaemic clamps were performed at one of five different insulin infusion rates (20, 30, 40, 100 or 200 milliunits min-1 m-2). Glucose disposal was significantly decreased in the cancer group at all insulin infusion rates, whilst attained insulin levels and metabolic clearance rates of insulin were comparable in the control and cancer groups. Analysis of dose-response data allowed assessment of sensitivity (insulin concentration of half maximal glucose disposal) and responsiveness (maximal glucose disposal). Responsiveness was significantly reduced in the cancer group (40.3 versus 71.5 mumol kg-1 min-1; P less than 0.001), whilst sensitivity was similar (93.7 milliunits l-1 in controls versus 90.8 milliunits l-1 in cancer patients), suggesting a postreceptor defect in insulin action in the cancer group.

Alteration in monocyte function in patients with breast cancer

Migration, phagocytosis and lysozyme production of peripheral monocytes from 36 patients with breast carcinoma was compared with a group of 36 healthy controls. A significant reduction in monocyte random migration and migration towards a chemotactic agent (P less than 0.001) was observed in patients with breast cancer. Furthermore monocyte phagocytic activity was also significantly decreased (P less than 0.001) in breast cancer patients compared to the controls. In contrast lysozyme production by peripheral monocytes was significantly increased in patients with breast cancer compared to controls (P less than 0.001). The changes in monocyte function in patients with breast carcinoma were not due to abnormal blood biochemistry or to direct continuous serum inhibitors, suggesting that the defect may be intrinsic. This defect in monocyte function may play an important role in the control of malignancies by cellular immune processes.

Factors which influence the occurrence of vascular calcification in the breast

Breast arterial calcification, as seen on mammography, increases in frequency with advancing age, especially after menopause. No association was found with systemic hypertension. The number of diabetics in the series was too small for comparative purposes. An early menopause and a history of pregnancy were factors which influenced incidence. Oral contraception was associated with a lower incidence of calcification before, but not after menopause. On the other hand, hormonal preparations taken for menopausal symptoms were associated with a lower incidence of calcification in postmenopausal women.

The biopsy of impalpable lesions of the breast

It is not necessary to undertake special techniques for localization if impalpable lesions of the breast are noted on mammography before biopsy. A simple technique using measurements from the nipple to locate the lesion is described. This method reduces patient discomfort by eliminating preoperative manipulation without increasing the size of the specimen needed for biopsy of the breast. Any impalpable lesion excised must be submitted to serial section after paraffin embedding and must not be submitted to frozen section.

Cyclical mastalgia: clinical and mammographic observations in a screened population

The incidence of cyclical mastalgia in well women presenting for breast screening was 69 per cent. The incidence of cyclical mastalgia increases with age up to the menopause. There was a higher incidence of 'high risk' mammographic patterns and a lower incidence of 'low risk' patterns, according to the Wolfe classification, in women with cyclical mastalgia compared with the rest of the screened population. This finding correlated with the severity, duration and need for treatment. The differences in breast pattern did not persist after the menopause. The question of whether or not cyclical mastalgia can be regarded as a risk factor for breast cancer is uncertain and needs further evaluation.

Glucose metabolism in patients with gastrointestinal malignancy but without excessive weight loss

Patients with gastrointestinal malignancy demonstrate impaired glucose disposal during steady state hyperglycaemia, 20.5 +/- 1.4 mumol/kg min when compared with controls 28.2 +/- 2.2 mumol/kg min. This appears to be unrelated to antecedent weight loss, but is related to the presence of metastatic spread (P less than 0.05). Insulin response to hyperglycaemia is normal, but analysis of glucose disposal with time suggests insulin resistance as a factor in the causation of impaired glucose disposal. Free fatty acid levels fail to suppress in cancer patients but their role in the causation of insulin resistance remains unclear.

Altered monocyte function in patients with benign breast disease

Monocyte migration, lysozyme production and phagocytosis was studied in 34 patients with fibroadenosis, 28 patients with fibroadenoma and 48 healthy female controls. In patients with fibroadenosis and fibroadenoma, monocyte migration and phagocytic activity were significantly reduced when compared to controls (P less than 0.001). Conversely, lysozyme production by monocytes from patients with benign breast disease was significantly higher than in controls (P less than 0.001). In 20 patients with benign breast disease, there was no significant difference in monocyte function before and 3 months after operation. The observed impairment of monocyte function in fibroadenosis and fibroadenoma would not appear to be the result of abnormal blood biochemistry or due to a direct serum inhibitor, but is probably related to an intrinsic cellular defect. Further studies are required to evaluate the significance of impaired monocyte function in the pathophysiology of benign breast disease.

Elevated fibrinopeptide A levels in patients with clinically localised breast carcinoma

58 patients with clinically localised breast carcinoma, treated by either mastectomy alone or lumpectomy plus local radiotherapy, have now been followed for up to 51 months (median 12 months). 21 of the 58 patients (36.2%) had a persistently elevated or rising fibrinopeptide A level after surgery and 11 of these patients (52%) to date have subsequently developed recurrent breast carcinoma up to 27 months after the fibrinopeptide A level became elevated (median 6 months). Conversely, only 2 (5.4%) of the 37 patients with persistently normal post-operative fibrinopeptide A levels have developed recurrent disease. Elevated fibrinopeptide A levels appear to be a marker of persistent tumour activity and precede clinical recurrence in certain patients with breast carcinoma, but normal values do not exclude recurrent or residual disease.

The effect of colorectal malignancies on monocyte migration, lysozyme production, and phagocytosis

Peripheral monocyte migration, phagocytosis and lysozyme production has been investigated in 46 patients with colorectal malignancies. The diagnosis of colorectal carcinoma was based on clinical, radiological, and endoscopic examinations and confirmed histopathologically after removal of the tumour. The results were compared with a group of 36 normal healthy controls. Monocytes from patients with colorectal malignancies displayed reduced migration towards the chemotactic agent (P less than 0.001), random migration (P less than 0.001), and phagocytic activity (P less than 0.01) compared to normal controls. Lysozyme production by monocytes from patients with colorectal malignancies was significantly increased (P less than 0.01) compared to control subjects. The impairment in monocyte function in patients with colorectal carcinoma was not due to direct serum factors or to abnormal blood biochemistry, suggesting that the defect is intrinsic to the monocytes. These results suggest that an impairment in monocyte function may play an important role in the control of malignancies by cellular immune processes.

An analysis of referral patterns from a breast screening unit

The reasons for referral from a breast screening unit are reviewed, together with the subsequent outcome and biopsy findings. 4.94% of persons attending were referred for assessment in a breast clinic, biopsy being performed on 2.09% with a detection rate of 4.1 cancers per 1000. 24.4% of the cancers were palpable and 36.6% were non-invasive. A rounded ill-defined mass was the commonest mammographic reason for biopsy. Cancer was found in 15.2% of cases with microcalcification. In no case did clinical examination in the screening unit reveal cancer which was not detected on mammography.

Transformation of blood monocytes to giant cells in vitro from patients with breast cancer

Monocytes from patients with breast cancer and from control subjects were cultured under agarose for 6 days. Giant cell formation occurred in 32 out of the 36 patients with breast cancer (89 per cent). In contrast giant cell formation was only observed in two of the control subjects (6 per cent). Menstruation and menopause had no effect on giant cell formation. Furthermore, under the experimental conditions of this study, it seems unlikely that serum factors, lymphokines or phagocytic stimulators induced giant cell formation. The results therefore, suggest that giant cell formation may be initiated by viruses already present in the monocytes from patients with breast cancer. Further studies are required to confirm this hypothesis and to elucidate the significance of giant cell formation in the pathogenesis of breast cancer.