Intraoperative imprint cytology of sentinel lymph nodes in breast cancer: initial experience and lessons learnt in establishing a new practice

AIMS

The initial 18 months experience of performing intraoperative imprint cytology for patients with breast cancer undergoing sentinel lymph node biopsy is described for a single institution. The learning process is compared with published results from institutions with many years of experience in order to assess progress in reaching those ideal results, and the methodology used by these institutions is reviewed.

METHODS

A retrospective review was undertaken of the intraoperative imprint cytology results from 103 patients with breast cancer (yielding a total of 170 lymph nodes) who underwent imprint cytology of their sentinel lymph node. The intraoperative imprint cytology results were compared with the final histopathological results. Details regarding the primary tumour characteristics and metastatic deposit size were recorded.

RESULTS

The sensitivity for imprint cytology was 31.1%, with a specificity of 100% and overall accuracy of 77.8%. The sensitivity for detecting macrometastases (>2 mm diameter) was 61.9% and the sensitivity for micrometastases (<2 mm diameter) and including isolated tumour cells was 4.2%.

CONCLUSIONS

The differences in sensitivity in comparison with many studies in the literature are multifactorial, and include technical aspects, such as the methodology used in the final histopathological and intraoperative evaluation of the sentinel lymph nodes, interpretative difficulties, and much lower case numbers. Furthermore, these numbers represent early experience and methods to improve sensitivity and overall accuracy are detailed in this paper.

Increase in schizophrenia incidence rates: findings in a Canadian cohort born 1975-1985

BACKGROUND

Results from previous studies on the incidence rates for schizophrenia are inconsistent, with some showing a declining rate [e.g., Suvisaari et al. (1999) Arch Gen Psychiatry 56:733-740] and others showing an increasing rate [e.g., Boydell et al. (2003) Br J Psychiatry 182:45-49].

OBJECTIVE

This study examines (1) whether incidence rates are changing, (2) relationships amongst changing incidence rates and age, period and cohort effects, and (3) the impact of rate changes on rate projections.

DESIGN

A care-based cohort study carried out in British Columbia, Canada, 1989-1998. Bayesian statistical analyses were used to estimate rates and describe secular effects. Classical tests of significance were used to assess the relative importance of age, period and cohort effects.

RESULTS

Between 1989 and 1998, median rates per 100,000 persons changed from 77.1 (90% credible interval (CI): 42.1-137.7) to 89.9 (90% CI: 80.1-100.1) in females, and from 66.6 (90% CI: 38.8-113.3) to 119.6 (90% CI: 107.4-132.4) in males. Age effects were active for both males and females. Period and cohort effects were stronger for males than females.

CONCLUSIONS

In contrast to most previous studies, we found an increasing incidence of schizophrenia. Precise projections of schizophrenia incidence beyond 5 years require large sample sizes over prolonged periods of follow-up.

Understanding the Influence of Polymorphism on Phonon Spectra: Lattice Dynamics Calculations and Terahertz Spectroscopy of Carbamazepine

Rigid molecule atomistic lattice dynamics calculations have been performed to predict the phonon spectra of the four polymorphs of carbamazepine, and these calculations predict that there should be differences in the spectra of all four forms. Terahertz spectra have been measured for forms I and III, and there are clearly different features between polymorphs' spectra, that are accentuated at low temperature. While carbamazepine adopts the same hydrogen bonded dimers in all of its known polymorphs, the calculations show that differences in packing arrangements of the dimers lead to changes in the frequency ranges for each type of hydrogen bond vibration, giving a physical explanation to the observed differences between the spectra. Although the agreement between calculated and observed spectra does not allow a definitive characterization of the spectra, it is possible to make tentative assignments of many of the observed features in the terahertz region for the simpler form III; we can only make some tentative assignments of specific modes in the more complex spectrum of form I. While harmonic rigid molecule lattice dynamics shows promise for understanding the differences in spectra between polymorphs of organic molecules, discrepancies between observed and calculated spectra suggest areas of improvement in the computational methods for more accurate modeling of the dynamics in molecular organic crystals.

Improved sensitivity of sputum smear microscopy after processing specimens with C18-carboxypropylbetaine to detect acid-fast bacilli: a study of United States-bound immigrants from Vietnam

The goal of this study was to evaluate the effect of the specimen-processing method that uses the detergent C18-carboxypropylbetaine (CB-18) on the sensitivity of acid-fast bacillus (AFB) staining. Vietnamese immigrants with abnormal chest radiographs provided up to three sputum specimens, which were examined for acid-fast bacilli by use of direct auramine and Ziehl-Neelsen staining. The remaining sputum was split; half was cultured, and the other half was incubated with CB-18 for 24 h, centrifuged, and examined for AFB by both staining methods. CB-18 processing improved the sensitivity of AFB staining by 20 to 30% (only differences in auramine sensitivity were statistically significant) but reduced specificity by approximately 20% (P < 0.05). These findings have direct utility for overseas migrant tuberculosis screening programs, for which maximizing test sensitivity is a major objective.

Differential chemosensory function and receptor expression of splanchnic and pelvic colonic afferents in mice

Lumbar splanchnic (LSN) and sacral pelvic (PN) nerves convey different mechanosensory information from the colon to the spinal cord. Here we determined whether these pathways also differ in their chemosensitivity and receptor expression. Using an in vitro mouse colon preparation, individual primary afferents were tested with selective P2X and transient receptor potential vanilloid receptor 1 (TRPV1) receptor ligands. Afferent cell bodies in thoracolumbar and lumbosacral dorsal root ganglia (DRG) were retrogradely labelled from the colon and analysed for P2X3- and TRPV1-like immunoreactivity (LI). Forty per cent of LSN afferents responded to alpha,beta-methylene adenosine 5'-triphosphate (alpha,beta-meATP; 1 mm), an effect that was concentration dependent and reversed by the P2X antagonist pyridoxyl5-phosphate 6-azophenyl-2',4'-disulphonic acid (PPADS) (100 microm). Significantly fewer PN afferents (7%) responded to alpha,beta-meATP. Correspondingly, 36% of colonic thoracolumbar DRG neurones exhibited P2X3-LI compared with only 19% of colonic lumbosacral neurones. Capsaicin (3 microm) excited 61% of LSN afferents and 47% of PN afferents; 82% of thoracolumbar and 50% of lumbosacral colonic DRG neurones displayed TRPV1-LI. Mechanically insensitive afferents were recruited by alpha,beta-meATP or capsaicin, and were almost exclusive to the LSN. Capsaicin-responsive LSN afferents displayed marked mechanical desensitization after responding to capsaicin, which did not occur in capsaicin-responsive PN afferents. Therefore, colonic LSN and PN pathways differ in their chemosensitivity to known noxious stimuli and their corresponding receptor expression. As these pathways relay information that may relate to symptoms in functional gastrointestinal disease, these results may have implications for the efficacy of therapies targeting receptor modulation.

Results of tuberculosis screening in applicants for migration in Vietnam and Cambodia

SETTING

Pre-migration medical screening programmes in Ho Chi Minh City, Vietnam and Phnom Penh, Cambodia.

OBJECTIVE

To compare the rates of newly diagnosed bacteriologically confirmed tuberculosis (TB) in a cohort of migration applicants in Vietnam and Cambodia with current estimates of the TB burden in these countries.

DESIGN

Interviews and medical screening of 5108 Vietnamese and 910 Cambodian migration applicants who applied for an Australian visa.

RESULTS

On initial testing, the rate of bacteriologically confirmed TB among the Vietnamese cohort was 157 per 100,000 population compared to 989/100,000 among the Cambodian cohort. When cases detected during follow-up testing were included, the rate in the Vietnamese cohort was 489/100,000 compared to 1209/100,000 in the Cambodian cohort.

CONCLUSIONS

Although it has been suggested that the rate of newly diagnosed bacteriologically confirmed TB among migration applicants would underestimate the prevalence of TB in the Vietnamese and Cambodian populations, the rates found were substantially higher than current point estimates of the prevalence of TB, particularly for Vietnam. Our findings suggest that current published estimates of the tuberculosis burden in Vietnam and Cambodia may be conservative.

Treatment outcome of multidrug-resistant tuberculosis among Vietnamese immigrants

OBJECTIVE

To review the outcome for MDR-TB treatment among potential migrants from Vietnam.

SETTING

All cases of documented MDR-TB treated by the International Organization of Migration (IOM) in Vietnam from 1989 to 2000 were reviewed.

METHODS

MDR-TB was defined as isoniazid- and rifampicin-resistant Mycobacterium tuberculosis. All cases of TB treated by the IOM and recorded in the computerised database were reviewed to identify MDR-TB cases. Demographics, chest radiograph results, drug resistance, drug use and dosage, duration of treatment, and outcome were analysed.

RESULTS

Forty-four cases of MDR-TB were identified. Treatment consisted of ambulatory directly observed treatment with an 8-drug protocol: isoniazid, rifampicin, pyrazinamide, ethambutol, capreomycin, ethionamide, ofloxacin and cycloserine. This initial protocol was modified due to drug availability or drug intolerance. Patients were treated with a median of 8 drugs (range 6-12). Mean duration of treatment for MDR-TB was 23.0 (SD+/-11.4) months. Thirty-eight (86%) patients were cured and emigrated, one failed treatment (2%), three were lost to follow-up (7%) and two died (4%).

CONCLUSION

Treatment for MDR-TB provided by the IOM was effective in preparing a low-income population for migration.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Bleomycin, vincristine, cisplatin/bleomycin, etoposide, cisplatin chemotherapy: an alternating, dose intense regimen producing promising results in untreated patients with intermediate or poor prognosis malignant germ-cell tumours

Patients with poor and intermediate prognosis metastatic germ-cell tumours (MGCTs) are at a significant risk of relapse after standard platinum-based chemotherapy. Novel treatment regimens are required to improve survival. Dose intense, alternating combinations of drugs with known activity in germ-cell tumours represents one approach. In all, 43 patients with IGCCCG intermediate/poor prognosis MGCT were treated with a dose intense regimen alternating bleomycin, vincristine, cisplatin (BOP) with bleomycin, etoposide, cisplatin (BEP) to a maximum of three cycles. Data were collected on the maintenance of dose intensity, toxicity, response, progression-free (PFS) and overall survival (OS). The complete response rate was 58%; a further 7% of patients being rendered disease free by resection of viable residual tumour. With a median follow-up of more than 4 years in surviving patients, 3-year OS and PFS rates of 81% (95% CI: 66–91%) and 72% (95% CI: 56–83%) are seen, respectively. Bleomycin, vincristine, cisplatin (BOP)/bleomycin, etoposide, cisplatin (BEP) was well tolerated, with 86% of patients completing all planned courses. Toxicity was predominantly haematological with common toxicity criteria grade III neutropenia in 90% of patients. Cisplatin neuropathy and bleomycin-induced pulmonary toxicity represented the most significant nonhaematological toxicity. Bleomycin, vincristine, cisplatin (BOP)/bleomycin, etoposide, cisplatin (BEP) represents a practicable, well-tolerated, dose intense chemotherapy regimen with significant activity in intermediate and poor prognosis MGCT.

The Auckland Breast Cancer Register: a special project of the Auckland Breast Cancer Study Group

AIMS

The Auckland Breast Cancer Register (ABCR) has been established in response to the need for a comprehensive database of breast cancer cases from the Auckland area.

METHODS

The database records patient demographics, diagnosis, treatment options, prognosis and long-term outcome (annual follow up). Data from 1204 cases, recorded between June 2000 and June 2002 are reported.

RESULTS

The major findings are that 34% of women had breast cancer detected by screening only (47% in the group eligible for free screening within the Breast Screen Aotearoa screening programme); 84% of patients had invasive carcinoma; 13% had ductal carcinoma in situ (DCIS); and 3% fine needle aspiration only. Forty nine per cent of invasive tumours were < or =2 cm. Grade 3 tumours were found in 53% of patients under 40 years old compared with 26.8% 40 years or older. Mastectomy was performed in 56% of patients with invasive cancer and 33% of those with DCIS. Axillary surgery was performed in 94% of patients with invasive cancer and 39% had involved nodes. Seventy nine per cent of patients were referred for an opinion from an oncologist. Radiotherapy was given to 77% of these patients, chemotherapy to 33%, and hormone therapy to 57%.

CONCLUSIONS

The ABCR will provide essential healthcare information that will lead to better understanding of breast cancer in Auckland and more effective delivery of the clinical resources available in the Auckland region.

Community based program to improve firearm storage practices in rural Alaska

OBJECTIVE

To develop and evaluate a pilot program to reduce unauthorized access to firearms by youth by distributing gun safes and trigger locks to households.

DESIGN

Pilot intervention with pre/post-evaluation design.

SETTING

Two Alaska Native villages in the Bristol Bay Health Corporation region of southwest Alaska.

SUBJECTS

Forty randomly selected households with two or more guns in the home.

INTERVENTION

Initially, a focus group of community members who owned guns was convened to receive input regarding the acceptability of the distribution procedure for the gun storage devices. One gun safe and one trigger lock were distributed to each of the selected households during December 2000. Village public safety officers assisted with the distribution of the safes and provided gun storage education to participants.

MAIN OUTCOME MEASURES

Baseline data were collected regarding household gun storage conditions at the time of device distribution. Three months after distribution, unannounced onsite home visits were conducted to identify if residents were using the gun safes and/or trigger locks.

RESULTS

All selected households had at least two guns and 28 (70%) of the 40 households owned more than two guns. At baseline, 85% of homes were found to have unlocked guns in the home and were most often found in the breezeway, bedroom, storage room, or throughout the residence. During the follow up visits, 32 (86%) of the 37 gun safes were found locked with guns inside. In contrast, only 11 (30%) of the 37 trigger locks were found to be in use.

CONCLUSIONS

This community based program demonstrated that Alaska Native gun owners accepted and used gun safes when they were installed in their homes, leading to substantial improvements in gun storage practices. Trigger locks were much less likely to be used.

Using administrative data to analyze the prevalence and distribution of schizophrenic disorders

OBJECTIVE

In order to effectively plan and implement psychiatric services, a clear estimate of the prevalence and distribution of the population in need is required. The authors examined the use of administrative data as a means of estimating the prevalence and distribution of schizophrenic disorders.

METHODS

Administrative health services data for residents of the Canadian province of British Columbia in the age range 15 to 65 years (total population in 1997-1998 of 2,703,588) were examined over a three-year period. Potential cases of schizophrenic disorder were identified on the basis of the presence of a diagnostic code of 295 in one or more of three databases. One-year prevalence rates were estimated for each of the province's geographic regions, and associations with low income and unemployment were examined.

RESULTS

One-year prevalence rate estimates were.45 cases per 100 population in 1996-1997 and 1997-1998 and.42 cases per 100 in 1998-1999. The prevalence estimates of all 88 local health areas in the province were consistent across the three-year period; Pearson correlations were determined to be approximately.9. One-year contact prevalence rates for schizophrenic disorders were significantly correlated in all three years to the percentage of persons with low income in the individual geographic regions but were not correlated with unemployment rates.

CONCLUSIONS

In areas with well-developed health services, analyses of administrative data appear to provide cost-effective means of examining the prevalence and distribution of schizophrenic disorders.