Primary endocrine therapy in locally advanced breast cancers--the Nottingham experience

INTRODUCTION

There are trials comparing different neoadjuvant chemotherapy regimens for locally advanced primary breast cancer (LAPC). Few studies have evaluated alternative therapeutic approaches towards LAPC. A previous trial from our institute in LAPC patients unselected for oestrogen receptor (ER) status, comparing primary endocrine therapy versus multimodal treatment, showed no difference in breast cancer related deaths or overall survival. We report our experience of primary endocrine therapy in ER+ LAPC.

METHODS

Between 1988 and 2007, 195 ER+, non-inflammatory LAPC patients were treated with primary endocrine agents in our institute, due to patient choice, being unfit for chemotherapy, or recruitment into the above mentioned trial. All patients had disease assessable by UICC criteria.

RESULTS

Median age was 69 years. The median follow-up was 61 months. 154 patients (79%) received endocrine treatment alone. 185 patients (95%) derived clinical benefit (complete response/ partial response/ stable disease) for > or =6 months from primary endocrine therapy. Overall 5-year survival was 76% and 5-year breast cancer specific survival was 86%.

CONCLUSION

In selected group of ER+ LAPC patients, primary endocrine treatment achieves excellent survival outcome and is a viable alternative to other modalities of treatment.

Wegener's granulomatosis: a rare presentation

Wegener's granulomatosis (WG) is a necrotizing granulomatous vasculitis involving the nose, paranasal sinuses, lungs, and kidneys. There are two types of WG-systemic, which is characterized by focal segmental necrotizing glomerulonephritis and limited in which the kidneys are spared. Without proper immunosuppression, WG can be aggressive and often fatal. There are very few reports on WG presenting as parotitis and lacrimal gland involvement. We report a lady who presented recurrent parotitis, focal segmental glomerulosclerosis, and orbital cellulitis, in whom the final diagnosis was revealed after an open lung biopsy.

Ultrasound-guided, vacuum-assisted excision in the diagnosis and treatment of clinically benign breast lesions

INTRODUCTION

Ultrasound-guided, vacuum-assisted biopsy has a definitive role in the diagnosis of breast lesions. Its role in the treatment of benign breast lesions like fibroadenomas has not been established.

PATIENTS AND METHODS

This is a retrospective review of patients undergoing ultrasound-guided, vacuum-assisted biopsy for clinically benign breast lesions. The procedures were performed in all cases by two consultant radiologists with special interest in breast radiology between February 2002 and January 2004. Patients were followed up in the clinic 6 weeks after the procedure.

RESULTS

Seventy-six patients had ultrasound-guided, vacuum-assisted excision of clinically benign breast lesions during this 2-year period. Mean age of the patients was 31 years. Altogether, 86 procedures were performed. Six patients with larger lesions (> 2 cm) had two procedures on separate sitting and 4 patients had separate lesions excised on a later date. Fifty-six patients were identified to have fibroadenomas and had complete excisions as evidenced on scan. Three out of nine patients identified with equivocal disease on fine needle aspiration cytology (FNAC) were found to have cancer following ultrasound-guided, vacuum-assisted excision. One patient who was diagnosed with cancer on FNAC, proved to be fibroadenoma on final histopathology. Four patients developed haematomas following ultrasound-guided, vacuum-assisted excision and all were managed conservatively.

CONCLUSIONS

Our study shows that ultrasound-guided, vacuum-assisted excision can play an efficient role in the diagnosis of benign breast lesions and is a safe and successful alternative in treatment of fibroadenomas.

The histology of acute autochthonous hepatitis E virus infection

AIM

To document the histological appearances of liver biopsies in autochthonous hepatitis E virus (HEV) infection.

METHODS AND RESULTS

Four patients were serologically positive for HEV; three had no traditional risk factors, the fourth had recently returned from China. All four consumed meat products. Liver histology of the three autochthonous (locally acquired) cases showed portal tracts expanded by a severe mixed polymorph and lymphocytic inflammatory infiltrate, with a geographical distribution of polymorphs at the interface and lymphocytes centrally. Moderate to severe interface hepatitis and cholangiolitis were present. There was a striking acinar mixed inflammatory infiltrate made up of polymorphs, lymphocytes and macrophages; frequent apoptotic hepatocytes, focal necrosis, cholestatic rosettes and zone 3 canalicular and cytoplasmic bilirubinostasis were noted. Significant steatosis, megamitochondria and Mallory bodies were not present. There was no evidence of iron, copper or alpha(1)-antitrypsin accumulation. By contrast, the histology of the imported case of HEV infection showed less intense portal and acinar inflammation, no cholangiolitis and no geographical distribution of the portal inflammatory infiltrate.

CONCLUSION

The histological appearances of autochthonous HEV infection are sufficiently distinctive to consider the diagnosis in an acute setting and possibly to differentiate it from the endemic form of the disease.

Lattice strain and lattice expansion of nanoparticles of MgAl2O4 as a function of particle size

Reduction in the physical dimension of a crystalline solid lead to regular changes in the lattice constants. The lattice expansion or contraction in nanoparticles depend on a number of factors like nature of atoms in the interior, surface atoms, surface surroundings, dangling bonds, and oxygen concentration on the surface. XRD patterns of nanoparticles of MgAl2O4 having average particle size 7 nm, 9 nm, and 19 nm show that lattice parameters undergo contraction or repulsion along different planes. The lattice contraction along with lattice expansion is possible since the morphology of the particle is not spherical which is evident from the SEM micrographs. Lattice expansion is observed mainly in nanocrystals having covalent or ionic bonds. The existence of ionic bonds is evident from the IR spectrum. Along planes where there is no deficiency of oxygen, contraction is observed while where there is deficiency of oxygen lattice expansion is observed. As the particle size increases due to heating most of the planes show lattice contraction and on further heating due to the excess oxygen accumulation in interstitial positions lattice expansion is observed along most of the planes. The reason for the observation of lattice strain or lattice expansion may be due to the electrostatic attraction or repulsion between ions along different planes.

Recipient Conditioning with Mesenchymal Stem Cells and Interleukin-10 Prolonged Cardiac Allograft Survival (102.1)

Mesenchymal Stem Cells (MSC) and viral interleukin-10 (vIL-10) have immunosuppressive properties. In this study, we tested their ability to prevent cardiac allograft rejection. Bone marrow derived MSC from Lewis rat were expanded ex vivo and transduced with rvIL-10-retrovirus. Autologous MSC or vIL-10 transduced MSC were injected (~25 x 106; i.v.) into irradiated (4 Gy) rat (RT1.Al). Six weeks later heterotopic heart (RT1.An) transplantation (Tx) was performed. MSC therapy prolonged (P<0.05) cardiac allograft survival (14±1 days; n= 4) compared to untreated controls (7±1 days; n=4). Also, vIL-10-MSC treatment prolonged (P<0.01) graft survival (38±1 days; n=6) compared to empty vector treated group (15±1 days; n=4). In vIL-10-MSC preconditioned animals that received donor bone marrow after heart Tx, graft survival was 22±2 days (n=8). Intragraft expression of co-stimulatory molecule (CD80) and cytokines (IL-2, IFN-γ) as determined by RT-PCR was lower (P<0.03) in vIL-10-MSC treated grafts compared to untreated control grafts. Ex vivo expanded MSC were CD34−, CD45+(5 %), CD29+(90%), CD80 (0%), CD 86 (8%), CD90+(93%), MHC Class I+(23–57%), and MHC Class II- as determined by FACS. Both vIL-10 and empty vector engineered MSC expressed CD29 (>95%) but not other molecules. The vIL-10-MSC produced ~ 6 ng/ml of vIL-10 ex vivo. vIL-10-MSC addition in MLR cultures inhibited lymphoproliferative response (P<0.05). TGF-β expression in stimulated (TNF-α or IL1-β) and unstimulated MSC was 46 – 65% of β-actin. IL-2, IL-4, IL-10, IFN-γ, and TNF-α expression was negligible in MSC (0–7% of β-actin). VEGF and HGF mRNA expression in MSC was 58% and 5% of β-actin, respectively. TgGFP+ MSC were demonstrable in various tissues for >28 days. Both MSC and vIL-10 conditioning to promote allograft survival seems promising.

Neoadjuvant chemotherapy in locally advanced primary breast cancers: the Nottingham experience

AIM

Of our study was to assess and compare the outcome of patients undergoing anthracycline based neoadjuvant chemotherapy in locally advanced primary breast cancers with patients receiving mitoxantrone, methotrexate and mitomycin (MMM) as neoadjuvant agents.

METHODS

Records of 50 consecutive patients receiving anthrcycline based chemotherapy for locally advanced breast cancers from July 1996 to July 2004 were analysed with regard to locoregional recurrence, metastasis and survival. The MMM group comprised of 56 consecutive patients receiving MMM chemotherapy between 1989 and 1994. The unit protocol for patients receiving multimodal therapy has been neoadjuvant chemotherapy followed by Patey's mastectomy, radiotherapy and endocrine treatment if ER-positive. Patients were followed-up in the clinic until either death or the last clinic visit on or before December 2005 in the anthracycline group and on or before December 1999 in the MMM group.

RESULTS

There was no significant difference between the two groups with regard to number of patients, tumour size, grade, ER positivity and median duration of follow-up from start of chemotherapy. Significantly more patients in the anthracycline group had complete clinical response and 44% of the patients in anthracycline group had node negative disease compared to 4% in the MMM group. Anthracycline group when compared to MMM group had a lower incidence of locoregional recurrence (6% vs 19%), distant metastasis (20% vs 55%) and survival (82% vs 45%) at the end of follow-up, which was statistically significant.

CONCLUSION

Anthracycline based neoadjuvant chemotherapy has better response and significantly better outcome compared to MMM chemotherapy.

Knot in a pulmonary thromboembolus

AIM

To describe an unusual morphological appearance of a pulmonary thromboembolus.

CASE REPORT

An adult male was admitted following a collapse at home and certified dead soon after. There was no past history of thromboembolic predisposition, risk or phenomena apart from a BMI of 34, cigarette smoking and recent discharge from hospital following a chest infection. Postmortem findings were those of death due a pulmonary thromboembolus complicating deep (calf) vein thrombosis. Unusually and unexpectedly, a knot was found in the leading (head) portion of this thromboembolus.

CONCLUSION

We describe the first reported case of a knot in a thromboembolus and speculate that this could only have occurred in the larger veins or during its course through the right side of the heart.

Screening for HIV infection by health professionals in India

BACKGROUND

Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India.

METHODS

We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire.

RESULTS

A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patient's HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document.

CONCLUSION

There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.

Comparative study of lymphoedema with axillary node dissection versus axillary node sampling with radiotherapy in patients undergoing breast conservation surgery

AIMS

Our aim was to compare the incidence of lymphoedema in two groups of patients undergoing breast conservation surgery; one undergoing axillary sampling and radiotherapy to patients with positive axillary nodes, and the other undergoing axillary clearance.

METHODS

Retrospective review of records of two sequential groups of patients; one undergoing axillary sampling between January 1994 and December 1998 (Group 1) and the other undergoing axillary clearance between January 2000 and December 2002 (Group 2). Both groups had minimum of 2 years follow-up.

RESULTS

Three hundred and twelve patients were included in Group 1 and 194 in Group 2. 2.2% of the patients in Group 1 developed lymphoedema compared to 12.3% in Group 2. This was statistically significant with a P value=0.0001. In the node-positive patients, the incidence of lymphoedema in Group 1 was 6.2% compared to 15.4% in Group 2, although the differences were not statistically significant with P=0.17.

CONCLUSIONS

The incidence of lymphoedema in the axillary sampling group was low, although the differences were less pronounced in the node-positive patients. The effectiveness of radiotherapy as an alternative to full axillary dissection among patients with positive nodes is currently under investigation in randomised controlled trials.

Chemical composition and antimicrobial activity of essential oil from the rhizomes of Amomum cannicarpum

The essential oil obtained by hydrodistillation of the rhizomes of Amomum cannicarpum was analyzed by GC and GC/MS. Thirty-four compounds were identified, of which the major components were beta-terpineol (13.4%), beta-pinene (9.4%) and alpha-pinene (6.9%). The essential oil showed significant antimicrobial activity.

Villous papyraceous: an unusual cause of tamoxifen-induced postmenopausal bleeding

OBJECTIVE

We describe an unusual histological finding in a woman with postmenopausal bleeding who was being treated with tamoxifen for breast cancer.

METHOD

This patient presented with a history of postmenopausal bleeding, 4 years after her last period. Pelvic ultrasound showed a thickened cystic endometrium and bulky uterus. A diagnostic endometrial aspiration biopsy by Pipelle was performed; at this time, urinary beta-human chorionic gonadotropin was negative.

RESULTS

Histology showed villous papyraceous (sclerosed and mummified chorionic villi) in a background of scanty atrophic endometrium.

CONCLUSION

Tamoxifen has dual estrogenic and antiestrogenic effects; the estrogenic effects have been associated with ovulation induction in premenopausal women. This effect, however, has not been documented in postmenopausal women. We conclude that the presence of chorionic villi is, in this instance, likely to be a tamoxifen-mediated effect.

Surveillance colonoscopy in patients with colorectal cancer: how often should we be doing it?

BACKGROUND

The optimum protocol for colonoscopic surveillance following curative resection for colorectal cancer has not been established. The aim was to assess the incidence of recurrence and metachronous tumours in our less intensive colonoscopic surveillance programme and compare our results with those reported from intensive surveillance programmes.

METHODS

Colonoscopic records of patients who had surveillance colonoscopy following curative resection from April 1998 to March 2003 for cancer were available from the endoscopy department computer database. The variables studied included the tumour site, Duke's stage, number of recurrences, number of metachronous tumours, size and number of polyps and their biopsy results.

RESULTS

There were a total of 105 patients. Two patients were diagnosed with metachronous tumours and three with recurrence. Adenomatous polyps were identified in 24 patients of which nine had multiple/advanced adenomas (equal to or more than 1cm adenomatous polyps, or with severe dysplasia).

CONCLUSION

The risk of development of colonic pathology following curative resection for colorectal cancer is low. More intensive follow-up should be reserved for patients with additional risk of developing further cancers.

Septate fungal invasion in masked mastoiditis: a diagnostic dilemma

Invasive fungal mastoiditis is a rare entity, seen almost entirely in immunocompromized patients. It has been reported primarily in patients with leukaemia and more recently with acquired immunodeficiency syndrome. A literature search revealed only a few reports in diabetic patients, in whom the invasive fungus was identified as mucormycosis in all cases. We report the first case in the English literature of invasive septate fungal mastoiditis in a diabetic patient with intact tympanic membranes.

Complications of acute infective rhinosinusitis: experience from a developing country

INTRODUCTION

Complications of acute infective sinusitis are a therapeutic emergency. The purpose of this study was to determine the clinical presentation, microbiological pattern, treatment modalities and outcome of patients diagnosed to have acute rhinogenic orbital, intra- and extra-cranial complications from a developing country in Asia.

METHODS

A retrospective chart review from October 1999 to January 2004 was conducted.

RESULTS

Among 247 ENT surgical emergencies documented, 13 patients (5.3 percent) were diagnosed to have acute sinusitis with various complications either as in solitary or multiple forms. Orbital complications were the most common (61.5 percent) followed by acute subdural empyema (23.1 percent) and meningitis (15.2 percent). Subdural empyema was the most common intracranial complication. Staphylococcus was reported to be the most common offending organism (45.5 percent). Majority of the patients (84.6 percent) had surgical drainage of the affected sinuses, 38.5 percent being endoscopic drainage while external approach was done for those with coexisting osteomyelitis (30.8 percent). Two patients had combined approach, and one patient had post-operative facial paresis. There was no mortality in our series.

CONCLUSION

Early detection, aggressive medical and prompt surgical treatment by multidisciplinary approach involving ophthalmological, neurosurgical and rhinological procedures, can successfully treat the complications with a significant reduction in the morbidity and no mortality.