Ultrafast semiconductor laser-diode-seeded Cr:LiSAF regenerative amplifier system

An ultrafast, hybrid mode-locked semiconductor laser-diode system has been used to seed a flash-lamp-pumped Cr:LiSAF regenerative amplifier system, producing subpicosecond pulses with millijoule output pulse energy. This system has the potential to eliminate argon-ion-pumped-based, ultrafast laser systems.

Risk of breast cancer associated with atypical hyperplasia of lobular and ductal types

Epidemiological studies using the histological classification of Page for benign breast disease consistently demonstrate a positive association between atypical hyperplasia and the subsequent development of breast cancer. However, atypical hyperplasia is of either lobular or ductal types, and breast cancer risk in relation to type of atypical hyperplasia has not been studied extensively. Thus, we investigated prospectively the risk of breast cancer associated with histological subtypes of benign proliferative breast disease, including the types of atypical hyperplasia, among participants in the Nurses' Health Study who had biopsy-confirmed benign breast disease. Women who subsequently developed breast cancer were matched by year of birth and year of biopsy to participants who were free from breast cancer. Benign biopsy slides were classified according to the criteria of Page. Odds ratios (ORs) of breast cancer and 95% confidence intervals (CIs), adjusted for the matching variables and other breast cancer risk factors, were computed using unconditional logistic regression with benign nonproliferative breast disease as the referent group. Atypical ductal hyperplasia (OR = 2.4; 95% CI, 1.3-4.5) or atypical lobular hyperplasia (OR = 5.3; 95% CI, 2.7-10.4) in a prior biopsy were associated with increased breast cancer risk. Atypical lobular hyperplasia was more strongly associated with the risk of premenopausal breast cancer (OR = 9.6; 95% CI, 3.3-27.8) than with the risk of postmenopausal breast cancer (OR = 3.7; 95% CI, 1.3-10.2). The association of atypical ductal hyperplasia and breast cancer risk varied little by menopausal status. The magnitude of breast cancer risk seems to vary according to the type of atypical hyperplasia present at biopsy.

Familial aggregation of psychiatric disorders in a community sample of adolescents

OBJECTIVE

To determine whether specific psychiatric disorders and suicide attempts ascertained in a community sample of adolescents show evidence of familial aggregation.

METHOD

Fifty-eight adolescent probands recruited from the community and their relatives were assessed as to the presence of specific DSM-III Axis I disorders and suicide attempt, using a combination of family study and family history methodology.

RESULTS

In first-degree relatives, there was evidence for specific familial aggregation of suicide attempt (odds ratio [OR] = 12.1 95% confidence interval [CI] = 1.3 to 111.0), substance abuse (OR = 2.7, 95% CI = 1.1 to 6.7), and any Axis I disorder (OR = 2.5, 95% CI = 1.3 to 4.6), even after demographic confounders and familial comorbidity were controlled. Similarly, among second-degree relatives, in analyses controlling for potentials confounders, the disorders-specific aggregation of suicide attempt (OR = 12.3, 95% CI = 1.2 to 130.0), substance abuse (OR = 2.8, 95% CI = 1.6 to 4.8), and any Axis I disorder (OR = 1.5, 95% CI = 1.0 to 2.2) persisted.

CONCLUSIONS

The familial aggregation of suicide attempts and psychiatric disorders, particularly of substance abuse and any Axis I disorder, occurs in community samples and is not primarily attributable to referral status.

The relationship between shaved margin and inked margin status in breast excision specimens

BACKGROUND

The presence of tumor at the inked margins (IMs) of breast specimens is associated with an increased risk of local recurrence after breast-conserving therapy for invasive breast carcinoma and ductal carcinoma in situ (DCIS). Given the importance of margin status, some have advocated the use of shaved margins (SMs) as a means of conducting a more complete examination of the specimen margins than could be done with sections taken perpendicular to the IMs. However, it is not known whether these two methods of margin assessment provide comparable information.

METHODS

To address this issue, the authors studied 22 consecutive breast reexcision specimens (10 DCIS, 6 infiltrating ductal carcinomas, and 6 infiltrating lobular carcinomas) in which the specimen surfaces were inked, the margins were shaved, and tumor was present in at least one of the SM sections. A total of 199 SMs were examined. The SMs were originally embedded in a way that permitted histologic sections to be cut opposite the inked surface. Sections of SM stained with hematoxylin and eosin (H & E) were reviewed and scored for the presence and extent (number of low-power fields) of cancer. The remaining tissue from the SM was then removed from the blocks, cut perpendicular to the IM, and reembedded to permit visualization of tumor in relation to the IM. Sections were then cut from two different levels of each reembedded block and stained with H & E. An SM was considered positive if tumor was present anywhere on the section. An IM was considered positive when tumor extended to the inked surface.

RESULTS

Although all 22 excisions had at least 1 positive SM, tumor was present at an IM in only 12 specimens (55%). Among 69 positive SMs, the corresponding IM was positive in only 42 (61%). The likelihood of a positive IM increased with the number of low-power fields of involvement by invasive carcinoma or DCIS on the SM, as follows: 19% with 1 low power-field, 67% with 2 low-power fields, and 97% with > or = 3 low-power fields (all P < 0.02). When the SM was negative, the corresponding IM was negative in 98% of cases.

CONCLUSIONS

Many patients with positive SMs do not have positive IMs. A positive SM more reliably predicts a positive IM when tumor involves > or = 3 low-power fields of the SM. The authors conclude that the clinical implications of a positive SM may not be the same as those of a positive IM. Clinical outcome studies are needed to define further the implications of positive SMs. [See editorial counterpoint on pages 1453-8 and reply to counterpoint on pages 1459-60, this issue.]

Breast-conserving therapy for stage I-II synchronous bilateral breast carcinoma

BACKGROUND

Synchronous bilateral breast carcinoma (SBBC) is an uncommon presentation, and the management of patients with this disease is not well established.

METHODS

In order to evaluate whether patients with early-stage SBBC could be safely and effectively treated with bilateral breast-conserving therapy (BCT), the authors retrospectively reviewed the records of 24 patients with clinical Stage I-II SBBC treated during the period 1977-1989 with bilateral BCT. SBBC was defined as bilateral invasive carcinomas diagnosed no more than 1 month apart. The median age at diagnosis was 56 years (range, 32-85 years), and the median follow-up for surviving patients was 95 months (range, 68-157 months). Pathology slides were available for review in 19 cases. Cosmetic results and complications after BCT were scored. Outcome was compared with that of 1314 patients with unilateral Stage I or II breast carcinoma, within the same age range, treated during the same time period.

RESULTS

There were no significant differences between the SBBC and unilateral groups in actuarial disease free survival (70% and 74%, respectively, at 5 years), overall survival (88% and 87%, respectively, at 5 years), or crude distribution of sites of first failure. Multivariate analysis of overall survival and disease free survival also did not show bilaterality to be a significant factor. The cosmetic results for the SBBC group were not significantly different from those for the unilateral group. Physician assessment of cosmetic outcome was excellent in 57% and good in 43% of SBBC patients evaluated 25-48 months after BCT. Long term complications were rare in both groups.

CONCLUSIONS

Patients with early-stage SBBC can be safely treated with carefully planned, bilateral BCT, with outcome that appears to be comparable to that of patients with early-stage unilateral breast carcinoma.

Expression of the invasive phenotype by MCF-7 human breast cancer cells transfected to overexpress protein kinase C-alpha or the erbB2 proto-oncogene

Transfection of the estrogen dependent and poorly invasive MCF-7 cell line to overexpress erbB2 was reported to increase athymic nude mouse mammary fat pad tumor growth; similar PKC-alpha overexpression produced a rapidly growing and metastatic transfectant. We investigated the invasive capacities of the two transfectants in vitro, their secretion of the proteolytic enzymes metalloproteinase (MMP)-9 and -2 and urokinase-type plasminogen activator (uPA), and plasminogen activator inhibitor-1 (PAI-1), together with membrane uPA receptor (uPAR) levels as determined by ELISA. Compared with the MCF-7 cells, the erbB2 transfectant was more invasive and secreted higher levels of MMP-9 and uPA; also there was a greatly enhanced PAI-1 secretion and cellular uPAR expression. The PKC-alpha transfectant cells secreted extremely high levels of uPA and some MMP-9 and MMP-2, with an intermediate increase in uPAR; however, they were so poorly adherent that it was not possible to assess invasiveness in vitro. Thus, erbB2-overexpressing MCF-7 cells possessed several features associated with the invasive phenotype. The reportedly aggressive metastatic phenotype induced by PKC-alpha overexpression, however, was notable only for its uPA hypersecretion.

Suicidal behavior runs in families. A controlled family study of adolescent suicide victims

BACKGROUND

While previous studies have shown an increased rate of suicidal behavior in the relatives of suicide victims, it is unclear if this is attributable merely to increased familial rates of psychiatric disorders. Therefore, we conducted a family study of adolescent suicide victims (suicide probands) and community control probands (controls) to determine if the rates of suicidal behavior were higher in the relatives of adolescent suicide probands even after adjusting for differences in the familial rates of psychiatric disorders.

METHOD

The relatives of 58 adolescent suicide probands and 55 demographically similar controls underwent assessment for Axis I and II psychiatric disorders, lifetime history of aggression, and history of suicidal behavior (attempts and completions) using a combination of family study and family history approaches.

RESULTS

The rate of suicide attempts was increased in the first-degree relatives of suicide probands compared with the relatives of controls, even after adjusting for differences in rates of proband and familial Axis I and II disorders (odds ratio, 4.3; 95% confidence intervals, 1.1-16.6). On the other hand, the excess rate of suicidal ideation found in the relatives of suicide probands was explained by increased familial rates of psychiatric disorders. Among suicide probands, higher ratings of aggression were associated with higher familial loading for suicide attempts.

CONCLUSIONS

Liability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders. The transmitted spectrum of suicidal behavior includes attempts and completions, but not ideation, and the transmission of suicidal behavior and aggression are related.

Factors affecting hospital admission and length of stay of poisoned patients in the north east of England

1. Poisoning is a common reason for presentation to hospital and hospital admission but there is no agreed policy for managing these patients. This study examined the management of patients presenting with poisoning and the factors affecting the probability of hospital admission and prolonged stay. 2. Data on all cases of poisoning presenting to six Accident and Emergency departments in the North East of England over 12 weeks in 1994 was collected prospectively from A&E notes. Length of stay and outcome were recorded from hospital computer records. 3. Overall, 73% of patients were admitted to a medical ward. Probability of admission was not independently affected by age or gender but was increased in those with intentional poisoning (Odds Ratio (OR) 3.3 [95% CI 1.8, 6.1]), a history of self harm (OR 1.7, [1.0, 2.9]) or potentially hazardous poisoning (OR 3.7 [2.1, 6.6]). There were significant variations between hospitals (50-80%) which could not be attributed to case mix. 4. Prolonged stay (> 2 nights) was more common in patients over 65 years (OR 6.8 [2.9, 16.1]), those with intentional poisoning (OR 2.7 [1.1, 6.6]) and those with potentially hazardous poisoning (OR 2.6 [1.4, 4.9]). Mean hospital stay was 1.5 days and varied significantly between hospitals from 0.8 to 2.1 days and this was independent of case mix. 5. There are appreciable variations in the management of poisoning between hospitals which are not explained by patient characteristics. Savings would occur if rates of admission and duration of stay were reduced by those hospitals where admission is more frequent or hospital stay is longer. However, the impact of this on long term morbidity is unknown.

Pathologic margin involvement and the risk of recurrence in patients treated with breast-conserving therapy

BACKGROUND

The relationship between the microscopic margins of resection and ipsilateral breast recurrence (IBR) after breast-conserving therapy for carcinomas with or without an extensive intraductal component (EIC) has not been adequately defined.

METHODS

Of 1,790 women with unilateral clinical Stage I or II breast carcinoma treated with radiation therapy as part of breast-conserving therapy, 343 had invasive ductal histology evaluable for an extensive intraductal component (EIC), had inked margins that were evaluable for an review of their pathology slides, and received > or = 60 Gray to the tumor bed; these 343 women constitute the study population. The median follow-up was 109 months. All available slides were reviewed by one of the study pathologists. Final inked margins of excision were classified as negative > 1 mm (no invasive or in situ ductal carcinoma within 1 mm of the inked margin); negative-1 mm, or close carcinoma < or = 1 mm from the inked margin but not at the margin); or positive (carcinoma at the inked margin). A focally positive margin was defined as invasive or in situ ductal carcinoma at the margin in three or fewer low-power fields. The first site of recurrent disease was classified as either ipsilateral breast recurrence (IBR) or distant metastasis/regional lymph node failure.

RESULTS

Crude rates for the first site of recurrence were calculated first for all 340 patients evaluable at 5 years, then separately for the 272 patients with EIC-negative cancers and the 68 patients with EIC-positive cancers. The 5-year rate of IBR for all patients with negative margins was 2%; and for all patients with positive margins, the rate was 16%. Among patients with negative margins, the 5-year rate of IBR was 2% for all patients with close margins (negative < or = 1 mm) and 3% for those with negative > 1 mm margins. For patients with close margins, the rates were 2% and 0% for EIC-negative and EIC-positive tumors, respectively; the corresponding rates for patients with negative margins > 1 mm were 1% and 14%. The 5-year rate of IBR for patients with focally positive margins was 9% (9% for EIC-negative and 7% for EIC-positive patients). The 5-year crude rate of IBR for patients with greater than focally positive margins was 28% (19% for EIC-negative and 42% for EIC-positive patients).

CONCLUSIONS

Patients with negative margins of excision have a low rate of recurrence in the treated breast, whether the margin is > 1 mm or < or = 1 mm and whether the carcinoma is EIC-negative or EIC-positive. Among patients with positive margins, those with focally positive margins have a considerably lower risk of local recurrence than those with more than focally positive margins, and could be considered for breast-conserving therapy.

Widespread loss of gelsolin in breast cancers of humans, mice, and rats

Down-regulation of gelsolin, an actin-binding protein, is frequently found in several types of transformed cells and tumors. The present study demonstrates that gelsolin protein and RNA were absent or markedly reduced in human breast cancer cell lines relative to "normal" mortal human mammary epithelial cells and benign, immortalized cell lines. Moreover, actin filaments were usually attenuated coincident with the reduction in gelsolin. Gelsolin was also missing or greatly decreased in 70% of 30 human sporadic, invasive breast carcinomas examined by immunocytochemistry and in 100% of virally induced mouse and chemically induced rat mammary carcinomas evaluated by Northern analysis. Southern analysis revealed no major mutations in the gelsolin gene of human breast cancer cells. Our results show that partial or total loss of gelsolin expression is common to the majority of breast cancers of diverse etiologies in three animal species and point to gelsolin as a candidate suppressor of breast cancer.

149 consecutive thyroid operations--indications, technique and outcome

One hundred and forty nine patients underwent thyroid and parathyroid surgery over a nine year period. The most common indications for surgery were the presence of a solitary thyroid nodule (56%) or the onset of pressure symptoms (30%). Carcinoma was found in 7.4% of cases. Wound complications occurred in 5%. The permanent nerve injury rate was 0.67%. The incidence of permanent hypothyroidism after surgery was 4%. No patients developed permanent hypoparathyroidism.

Asymmetric competition between plant species

Despite extensive interest in the role of plant size in competition, few formal attempts have been made to quantify the magnitude of asymmetric competition, particularly for interactions between members of different species. This paper introduces the concept of asymmetric interspecific competition at the population livel (i.e. mean plant performance) in mixtures of species. It proposes an index of interspecific competitive asymmetry which allows for a progressively greater asymmetric effect as the average size differences between competing species increase, and allows for such an effect whether individuals of focal species are larger or smaller, on average, than competitors. This index of competitive asymmetry is evaluated in the study of interactions between two widely coexisting annuals of disturbed habitats, Stellaria media and Poa annua. An experiment was conducted in which the density, relative frequency and relative seedling sizes (emergence times) of Poa and Stellaria individuals were varied. The relative growth rate (RGR) for both species was measured over a 22-day period. An inverse linear model was fitted for each species, relating the RGR of the focal species to the initial biomass of each species. Each response model included an asymmetry coefficient (β) to assess whether the impact of a unit of initial biomass of the associate species changed with the relative sizes of seedlings of the two species. A zero value of β implies symmetric competition between the two populations; i.e. the competitive effect of a unit of associate species biomass does not change with its initial seedling size. If β is positive the smaller the initial relative size of seedlings of the associate species, the smaller their per unit biomass effect on the response of the focal species. The model fitted our data for Stellaria and Poa well and was validated by an alternative modelling approach. Asymmetry coefficients were estimated as 0.508 (P<0.05) for the effect of Poa in the Stellaria model, and 0.0001 (NS) for the effect of Stellaria in the Poa model; i.e. the effect of Poa on Stellaria was asymmetric while the effect of Stellaria on Poa was symmetric. Differences in interspecific species asymmetric competitive effects are discussed within the context of shoot architecture, and the relative importance of competition for light versus soil resources. Finally, we discuss the relationship of this model to earlier models of competitive asymmetry, and consider the implications of interspecific competitive asymmetry for a number of current theories of plant competition and community organisation.

Relationship of tumor grade to other pathologic features and to treatment outcome of patients with early stage breast carcinoma treated with breast-conserving therapy

BACKGROUND

Although histologic grade has previously been described as a predictor of distant failure, it is uncertain whether histologic grade should be used to decide which patients should undergo axillary lymph node dissection and whether grade should be considered as a selection factor for breast-conserving therapy.

METHODS

The authors retrospectively analyzed data from 1081 patients with American Joint Committee on Cancer Stage I or II infiltrating ductal carcinoma treated with breast-conserving therapy at the Joint Center for Radiation Therapy between 1970 and 1986. All patients had pathology slides reviewed by one of two study pathologists. Using the Elston modification of the Bloom-Richardson grading system, patients were divided by histologic grade into 3 groups (219 with Grade I, 482 with Grade II, and 380 with Grade III). The median follow-up time for 716 survivors was 134 months. The incidence of various pathologic features was examined with respect to histologic grade. In addition, the 10-year crude rates of failure (by first site) were examined as they related to grade. A polychotomous logistic regression model was used to determine the effect of grade on local and distant failure.

RESULTS

High grade tumors tended to be larger, to exhibit more mononuclear cellular reaction and necrosis, and were more likely to be estrogen receptor negative. Patients with high grade tumors were also younger than those with lower grade tumors. The incidence of an extensive intraductal component and lymphatic vessel invasion did not vary significantly by histologic grade. The incidence of pathologic lymph node metastases also did not vary by grade, even when stratified by tumor size. In both univariable and multivariable analyses, the 10-year crude rate of local recurrence was not related to histologic grade (P = 0.44). Distant recurrence rates, however, were significantly higher as grade increased (p = 0.002).

CONCLUSIONS

Higher histologic grade predicted an increased incidence of distant recurrence, but not a greater likelihood of axillary lymph node metastases or local recurrence after breast-conserving therapy. The authors conclude that grade should not be used to make decisions regarding local management.

Histological and immunohistological study of the developing and involuting superficial cervical thymus in the koala (Phascolarctos cinereus)

The thymuses of 44 koalas, ranging from less than 30 d to more than 14 y of age, were examined histologically and immunohistologically. The thymuses from 17 of these koalas dying acutely through trauma were regarded as not being significantly affected by disease and formed the basis for study of the normal thymus. Most other koalas had chronic illness and, consequently, disease affected (involuted) thymuses. Histologically, thymuses showed obvious corticomedullary differentiation with small Hassall's corpuscles visible in koalas more than 8 mo of age. Most cortical and medullary lymphocytes stained for CD3 and CD5 (T lymphocyte markers) while some cells (predominantly medullary) stained for CD79b (B lymphocytes and plasma cells), IgG (plasma cells) or MHC class II (reticular epithelium, macrophages and possibly lymphocytes). Adults of up to 5-6 y of age which had died through trauma had little evidence of involution and had prominent Hassall's corpuscles and medullary epithelial thymocytes. Thymic eosinopoiesis was an inconsistent finding. In traumatised animals over this age, involution was obvious with fibrous replacement of lobules, loss of Hassall's corpuscles and the development of dilated ducts lined by nonciliated epithelium. However, loss of lymphocytes was gradual and pockets of lymphocytes, centrally located in lobules, were still present in the oldest koala examined. In these involuted thymuses, remaining lymphocytes stained for CD3 and lesser numbers of CD5 and CD79b. Plasma cells were common and often stained both for IgG and MHC class II. Thymuses of chronically diseased koalas showed accelerated involution when age matched with thymuses from traumatised koalas. Chronically ill koalas as young as 18-24 mo showed advanced involution, but the morphological and immunohistological characteristics of involuted thymus from diseased koalas could not be distinguished from those of involuted thymuses derived from traumatised koalas. It was concluded that development of the koala thymus is completed at 8 mo of age and that for normal koalas involution is a gradual process which starts not at but after sexual maturity. Immunohistological characterisation of the thymus was comparable to that reported for a variety of eutherian mammals.

Cosmos 2229 mission. Overview

The Cosmos 2229 unmanned biosatellite was launched from the Plesetsk Cosmodrome in northern Russia on December 29, 1992. This was the 10th Russia-sponsored international mission dedicated to space biology and marked the 8th mission with United States participation. The payload, which orbited the Earth for 11 days 16 h, included two rhesus monkeys; the papers that follow report studies on these monkeys.

Presentation of poisoned patients to accident and emergency departments in the north of England

1. A 12 week prospective survey of all patients of any age with confirmed or suspected poisoning presenting to six accident and emergency departments in the North East of England was performed to establish the local incidence and patterns of presentation of poisoning. 2. 945 episodes of poisoning involving 852 patients were recorded representing approximately 1.2% of all A&E presentations and suggesting an annual attendance rate of 2.7 per 1000 persons per year. 3. Attendance rates varied threefold between hospitals and were similar in males and females overall; between the ages of five and 14 attendances were more common in females (1.9 vs 0.6/10(3)/y) while between 0 and 4 y (3.1 vs 2.4) and 25 and 34 y (3.9 vs 2.9/10(3)/y) they were more common in males. 4. The median interval between poisoning and presentation was 2 h (mean 4.1 h) and only 19% of cases presented within 1 h. Presentation was most common between Friday evening and Tuesday morning and in the late afternoon and evening. 5. 6% of the patients presented more than once with poisoning during the study period and 37% had a past history of deliberate self-harm. The most common poisons involved were paracetamol (43%), opioids (15%) and benzodiazepines (15%). 6. The study illustrates the frequency of presentations of poisoning to A&E departments. The high rate of poisoning in young men and the increasing use of paracetamol are particular causes for concern.

Morphology-dependent resonances of a microsphere-optical fiber system

Morphology-dependent resonances of microspheres sitting upon an index-matched single-mode fiber half-coupler are excited by a tunable 753-nm distributed-feedback laser. Resonance peaks in the scattering spectra and associated dips in the transmission spectra for the TE and TM modes are observed. We present a new model that describes this interaction in terms of the fiber-sphere coupling coefficient and the microsphere's intrinsic quality factor Q(0). This model enables us to obtain expressions for the finesse and the Q factor of the composite particle-fiber system, the resonance width, and the depth of the dips measured in the transmission spectra. Our model shows that index matching improves the coupling efficiency by more than a factor of 2 compared with that of a non-index-matched system.

A prospective study of conservative surgery alone in the treatment of selected patients with stage I breast cancer

BACKGROUND

Randomized clinical trials have clearly demonstrated that the use of radiation therapy (RT) following breast-conserving surgery (CS) substantially reduces the risk of local recurrence. However, the low rate of local recurrence after CS and RT for patients without known risk factors, and the recent increase in the detection of smaller cancers due to mammographic screening have led to the speculation that a subgroup of patients who have a low risk of local recurrence without RT might be identified. In 1986, we initiated a one-arm, prospective clinical trial of CS alone for treatment of highly selected breast cancer patients without known risk factors for local recurrence.

METHODS

The study had a sequential design with a planned accrual of 90 patients. Criteria for entry into the trial were: a unicentric, clinical TI infiltrating ductal, mucinous or tubular carcinoma without an extensive intraductal component or lymphatic vessel invasion; a wide excision with a pathologically-documented negative margin of at least 1 cm; and histologically negative axillary lymph nodes. No adjuvant RT or systemic therapy was administered. Seventy-six per cent of the lesions were detected by mammography alone. The median gross pathologic tumor size was 0.9 cm. The median patient age was 67 years.

RESULTS

Eighty-seven patients were enrolled in the trial before it closed prematurely in 1992 because the predefined stopping boundary was crossed (i.e., the sixth local recurrence was observed). At that time, the average annual local recurrence rate was 4.2%. With a median follow-up of 56 months, there are now 14 patients (16%) with local recurrence as their site of first failure (average annual local recurrence rate: 3.6%). Four patients without local recurrence developed distant metastases. Three patients have died, one of metastatic breast cancer and two of unrelated causes.

CONCLUSIONS

Even in a highly selected group of patients with early-stage breast cancer, there is a substantial risk of early local recurrence for those treated with wide excision alone.

Vasculitis and rapidly progressive glomerulonephritis in the elderly

The proportion of patients with vasculitis and rapidly progressive nephritis aged 70 years or over has risen from about 10% in the 1980s to over 30% in series reported in the 1990s. This study was undertaken to examine the presentation and outcome of such older patients. Seventeen of 56 patients (30%) who presented at two renal units were aged 70 years or over. Mean creatinine level at presentation was 530 mumol/l, and five patients received dialysis at presentation. Outcome was dependent on three factors, namely comorbid pathology, response to immunosuppressive therapy, and the occurrence in three cases of temporary spontaneous partial remission. Overall patient survival at one and two years was 62.5% and 50%, respectively, and 90% and 100% of surviving patients were independent of dialysis at one and two years, respectively. Response to chemotherapy was excellent, with full rehabilitation in many cases and no deaths directly attributable to adverse effects of immunosuppressive therapy. We conclude that diagnosis of vasculitis and rapidly progressive glomerulonephritis by renal biopsy and the subsequent administration of chemotherapy (including cyclophosphamide in many cases) resulted in a worthwhile benefit in these elderly patients.