O052 A retrospective analysis of a single-centre experience with administration of neoadjuvant chemotherapy prior to surgical removal of breast tumour

Introduction

Neoadjuvant chemotherapy (NACT) is increasingly used to aid breast preservation surgery for patients with non-conservable disease at presentation. NICE guidelines recommend offering primary systemic therapy to patients with ER- disease and/or HER2+ disease and for those with ER+ disease to reduce tumour size. This retrospective study aimed to analyse the incidence of local and systemic recurrence post NACT.

Methods

A retrospective analysis of NACT usage was conducted from January 2011 to December 2020 at the breast surgery unit. Clinical data of patients who received NACT were collected using the local Breast Unit database, Electronic Patient Record (EPR) and Systm1. Data included patient demographics, type of breast and axillary surgical procedure, histopathology of breast tumour, pathological response to NACT and time to local and/or systemic recurrence.

Results

202 patients received NACT for breast cancer between January 2011 to December 2020. Analysis showed an increasing use of NACT ranging from 2.19% of all cancers in 2013 to 14.5% in 2020. 89/202 patients underwent breast preservation surgery. 1 patient developed local recurrence at median follow up of 26 months. 42 patients developed systemic recurrence, and 40 of them had residual disease found at surgery post NACT at median follow up of 24 months.

Conclusion

Our unit has been increasingly using NACT over the last 8 years in line with guidance. Breast conserving surgery post NACT is associated with a low risk of local recurrence. The risk of systemic disease progression post NACT is very low for patients who have complete pathological response.

Take-home message

Breast conserving surgery post NACT is associated with a low risk of local recurrence. The risk of systemic disease progression post NACT is very low for patients who have complete pathological response.

There are calls for a national screening programme for prostate cancer: what is the evidence to justify such a national screening programme?

INTRODUCTION

Prostate cancer is the commonest cancer in men and a major health issue worldwide. Screening for early disease has been available for many years, but there is still no national screening programme established in the United Kingdom.

OBJECTIVE

To assess the latest evidence regarding prostate cancer screening and whether it meets the necessary requirements to be established as a national programme for all men.

METHODS

Electronic databases and library catalogues were searched electronically and manual retrieval was performed. Only primary research results were used for the analysis.

RESULTS

In recent years, several important randomised controlled trials have produced varied outcomes. In Europe the largest study thus far concluded that screening reduced prostate cancer mortality by 20%. On the contrary, a large American trial found no reduction in mortality after 7-10 years follow-up. Most studies comment on the adverse effects of screening - principally those of overdiagnosis and subsequent overtreatment.

DISCUSSION

Further information about the natural history of prostate cancer and accuracy of screening is needed before a screening programme can be truly justified. In the interim, doctors and patients should discuss the risks, benefits and sequelae of taking part in voluntary screening for prostate cancer.

Control of HIF-1{alpha} and vascular signaling in fetal lung involves cross talk between mTORC1 and the FGF-10/FGFR2b/Spry2 airway branching periodicity clock

Lung development requires coordinated signaling between airway and vascular growth, but the link between these processes remains unclear. Mammalian target of rapamycin complex-1 (mTORC1) can amplify hypoxia-inducible factor-1α (HIF-1α) vasculogenic activity through an NH(2)-terminal mTOR binding (TOS) motif. We hypothesized that this mechanism coordinates vasculogenesis with the fibroblast growth factor (FGF)-10/FGF-receptor2b/Spry2 regulator of airway branching. First, we tested if the HIF-1α TOS motif participated in epithelial-mesenchymal vascular signaling. mTORC1 activation by insulin significantly amplified HIF-1α activity at fetal Po(2) (23 mmHg) in human bronchial epithelium (16HBE14o-) and induced vascular traits (Flk1, sprouting) in cocultured human embryonic lung mesenchyme (HEL-12469). This enhanced activation of HIF-1α by mTORC1 was abolished on expression of a HIF-1α (F99A) TOS-mutant and also suppressed vascular differentiation of HEL-12469 cocultures. Next, we determined if vasculogenesis in fetal lung involved regulation of mTORC1 by the FGF-10/FGFR2b/Spry2 pathway. Fetal airway epithelium displayed distinct mTORC1 activity in situ, and its hyperactivation by TSC1(-/-) knockout induced widespread VEGF expression and disaggregation of Tie2-positive vascular bundles. FGF-10-coated beads grafted into fetal lung explants from Tie2-LacZ transgenic mice induced localized vascular differentiation in the peripheral mesenchyme. In rat fetal distal lung epithelial (FDLE) cells cultured at fetal Po(2), FGF-10 induced mTORC1 and amplified HIF-1α activity and VEGF secretion without induction of ERK1/2. This was accompanied by the formation of a complex between Spry2, the cCBL ubiquitin ligase, and the mTOR repressor, TSC2, which abolished GTPase activity directed against Rheb, the G protein inducer of mTORC1. Thus, mTORC1 links HIF-1α-driven vasculogenesis with the FGF-10/FGFR2b/Spry2 airway branching periodicity regulator.

Guideline on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. A United Kingdom Haemophilia Center Doctors' Organisation (UKHCDO) guideline approved by the British Committee for Standards in Haematology

Evidence-based guidelines are presented on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. They include details of therapeutic products available in the UK and they update and replace previous United Kingdom Haemophilia Centre Doctors' Organisation guidelines.

Limiting the use of gastrointestinal decontamination does not worsen the outcome from deliberate self-poisoning

AIM

To review the current epidemiology of patients with deliberate self-poisoning presenting to Christchurch Emergency Department, and to compare this with 1996, 1992, and 1989 data.

METHODS

A retrospective analysis of computer and case records over the twelve-month period of 1999 was conducted and compared with published data from 1996,1992 and 1989.

RESULTS

There were 561 presentations of deliberate self-poisoning to Christchurch Hospital, representing 0.87% of total presentations (compared with 1.1% in 1996, 1.2% in 1992, and 1.0% in 1989). The female to male ratio was 2.2:1.0 (compared with 1.9:1.0, 1.5:1.0, and 2.1:1.0). The principal drugs ingested were antidepressants 30.8% (compared with 20.1%, 24.4%,15.7%), paracetamol 23.5% (compared with 16.7%, 16.9%, 10.6%), benzodiazepines 23.0% (compared with 11.1%, 23.6% 22.8%) and antipsychotics 17.8% (compared with 10.7%, 16.1%, not reported). Gastrointestinal decontamination was performed in only 14.4% of patients (compared with 61%, 73%, 61%). Activated charcoal was given alone in 13.2% (compared with 54%, 46%, 0.4%), activated charcoal and gastric lavage in 0.7% (7%, 26%, 53%), a whole bowel irrigation in 0.5% (not recorded in previous papers). 70.4% were admitted (compared with 69%, 59%, 64%), 7% to intensive care (10.2%, 10.6%, 18%). There were two deaths (compared with 6, 2 and 2).

CONCLUSIONS

Over the time periods studied the drugs ingested and admission rates remain similar, although a large proportion are now being observed in the emergency short stay ward, reducing admission rates to the ward and intensive care. Trends in gastrointestinal decontamination have changed dramatically over the four time periods, but there has been no worsening in the outcome of patients with deliberate self-poisoning.

A trial of a test-and-treat strategy for Helicobacter pylori positive dyspeptic patients in general practice

Computer models of different strategies for the management of dyspepsia in primary care indicate that a 'test-and-treat' approach is likely to be associated with the lowest costs and acceptable clinical outcomes. We present information on computer modelling studies and report the findings of a randomised trial comparing a Helicobacter pylori test-and-treat strategy with referral to direct access endoscopy in the management of dyspepsia in general practice. We compared costs and clinical outcomes in patients managed for one year in study (test-and-treat) and control (endoscopy) practices in south London. Patients aged less than 45 years presenting with persistent dyspepsia without alarm symptoms (141 study patients, 91 control patients) were studied. In the one-year follow-up period there were 17 endoscopies in the study group: all the control patients underwent initial endoscopy and five further endoscopies were performed. None revealed peptic ulcer or cancer. Forty-three (30%) of the study patients compared with 16 (17%) of the controls were referred to hospital clinics (p < 0.025). The cost of management per patient for one year in the study group was 205.67 Pounds, compared with 404.31 Pounds in the control group (p < 0.0001). Clinical outcomes in both groups at one year were comparable. An H. pylori test-and-treat strategy for dyspeptic patients aged less than 45, employing office-based serology testing, appears to be associated with substantially lower costs than initial endoscopy and with similar clinical outcomes.

Blood ordering practices in elective and emergency surgical procedures

A retrospective study of preoperative blood ordering practices for 20 commonly performed elective and emergency general surgical procedures was carried out in a Glasgow teaching hospital. It was found that 50.6% of cross-matched blood was returned unused. This practice contributes to the wasteful outdating of blood held in cross match status but never used. As a result, the Minimum Blood Ordering Schedule has been developed to guide blood ordering in those operations where there is a realistic probability of transfusion (<30 %), and a group and screen is advocated for the remainder of procedures. In this way significant savings can be made in blood, laboratory technician's time and resources.

Randomised controlled trial of reminders to enhance the impact of audit in general practice on management of patients who use benzodiazepines

OBJECTIVE

To determine whether reminder cards in medical records enhance the effectiveness of audit with feedback in improving the care of patients taking long term benzodiazepine drugs.

DESIGN

Randomised trial, practices receiving feedback only in one group and practices receiving feedback plus reminder cards in the other group.

SETTING

18 general practices in Leicestershire.

SUBJECTS

Random samples of patients who had been taking a benzodiazepine anxiolytic or hypnotic drug for four weeks or longer.

MAIN OUTCOME MEASURES

Entries in medical records indicating compliance with five criteria of care: assessment of suitability for withdrawal; being told about dependency; withdrawal being recommended; withdrawal or continuing medication; and a consultation with the general practitioner in the past year. Data were collected before and after feedback or feedback plus reminders.

RESULTS

Of a total population of 125,846 registered with the 18 practices, 2409 (1.9%) had been taking a benzodiazepine for four weeks or longer. Of the 742 in the first samples, 543 (73.2%) were women, the mean (SD) age was 68.7 (14.9) years, and they had been taking a benzodiazepine for 10.1 (6.7) years. The number of patients whose care complied with the criteria rose after the interventions to implement change. The increase was greater in practices receiving feedback plus reminders for only two of the five criteria "told about dependency" increasing from 52 (11.1%) to 118 (25.8%) in the feedback only group, and from 27 (10.5%) to 184 (43.0%) in the feedback plus reminders group; odds ratio (OR) 1.46 (95% confidence interval (95% CI) 1.32 to 5.21); and "consulted in the past year" increasing from 434 (93.1%) to 411 (95.8%) in the feedback only group and 255 (96.6%) to 400 (99.8%) in the feedback plus reminders group, OR (95% CI) 13.5 (2.01 to 330.3).

CONCLUSIONS

Reminder cards had only a limited effect and cannot be recommended for routine use. There were improvements in the care of patients of both groups of practices and further studies are indicated to determine the impact of both systematically developed criteria and reminders embedded into restructured medical records.

An evaluation of near-patient testing for Helicobacter pylori in general practice

INTRODUCTION

A knowledge of Helicobacter pylori status is likely to be important in the management of patients presenting in general practice with dyspepsia. Near-patient testing kits for the detection of the H. pylori antibodies in whole blood, which provide results very quickly, are now available.

AIM

To determine the test characteristics of the Helisal Rapid Blood test in general practice and to describe the ways in which general practitioners incorporate the results of H. pylori testing into their management of patients with dyspepsia.

SETTING

Nine general practices in the United Kingdom.

PATIENTS

Consecutive patients presenting with dyspepsia in whom further investigation or referral was considered.

METHODS

A whole blood fingerstick sample was tested for H. pylori antibodies using the Helisal Rapid Blood test and a venous sample was obtained for subsequent laboratory testing using Helisal Serum and Helico G (ELISA) methods. Results of the three tests were compared and analysed. Clinical data were recorded by the general practitioners.

RESULTS

Full serological data were obtained on 123 patients, mean age 44.8 years. The sensitivity and specificity of the Helisal Rapid Blood test, compared with concordant results of the laboratory tests, were 83% and 78%, respectively. The prevalence of H. pylori-positive patients was 57%, with a positive predictive value of 83% and a negative predictive value of 78%. The results of the test had a significant impact on the clinical management of the patients in the study.

COMMENT

The Helisal Rapid Blood test is a useful and convenient method of improving the clinical care of patients with dyspepsia in general practice.

Regional differences in concentrations of regulatory peptides in human colon mucosal biopsy

The study was undertaken to examine regional differences in the concentrations of five regulatory peptides in the human colonic mucosa. Biopsies were obtained during routine colonoscopy from 33 patients whose colonic mucosa was macroscopically and histologically normal. Regulatory peptides were extracted, and measured by specific radioimmunoassays. Concentrations of three peptides that are present predominantly in endocrine cells within colonic mucosa increased significantly towards the rectum: Mean concentrations of peptide YY, enteroglucagon, and somatostatin were about three times greater in the rectum than in the cecum. However, concentrations of two peptides that are present in mucosal nerve fibers diminished significantly towards the rectum: Mean rectal concentrations of vasoactive intestinal peptide and peptide histidine methionine were both about 0.6 of mean cecal concentrations. Concentrations of all five peptides were lower in biopsies taken from colonic polyps than in normal colonic mucosa. Regional differences in colonic mucosal concentrations of regulatory peptides probably reflect differences in the physiological functions of different parts of the colon.

Experimental analyses of the source of ABR wave II

Recent reports based on direct recording from various locations along the auditory nerve in humans during neurosurgical procedures have suggested that the auditory nerve-brainstem response (ABR) wave II is generated by the same neurons which generate wave I. In order to analyze this possibility using a different approach, ABR was recorded in ten rats in response to several click intensities and click repetition rates. These studies were also repeated in ten human volunteers. The amplitudes and latencies of ABR waves I, II and III were analyzed in order to determine if wave I and II behaved in a parallel fashion with changes in stimulus intensity and latency, as would be expected from the physiological "all or none law" if both waves were generated by the same axons. Several types of analyses indicate that the amplitudes of ABR waves I and II do not grow in amplitude in a parallel fashion with increases in stimulus intensity and decreases in stimulus rate. This is evidence either for independent sources of waves I and II or for composite sources of wave II both from the auditory nerve and the cochlear nuclei.

Mathematical expression of relationship between auditory brainstem transmission time and age

Brainstem transmission time (BTT) was studied in 71 subjects ranging in age from one day to 29 years in order to find a mathematical expression to best describe the relationship between BTT and age. The mathematical function which relates BTT to age is exponential. Using this data, the BTT confidence limit was calculated for subjects from birth through to eight years. Repeated recordings of auditory brainstem responses were performed in several children as they grew older and these verified the normal maturational processes of the brainstem structures in the developing infant and young child.

Analysis of the effector functions of different populations of mucosal lymphocytes

Lymphocytes separated from the epithelial layer of mouse small intestine, IEL, were tested for their NK cytotoxicity against Yac-1 targets. There was little NK activity in a 4 hour assay, but high activity in an 18 hour assay, and the NK activity of IEL did not parallel that in the spleen in any of the mouse strains tested. Furthermore, IEL exerted a suppressor activity on mouse spleen NK activity. Specific T-cell cytotoxicity appeared in IEL in mice immunized with an intraperitoneal injection of P-815 tumor cells. By contrast with IEL, LPL had little NK or NK suppressor activity, but higher levels of specific T-cell cytotoxicity in tumor-immunized mice than intraepithelial lymphocytes. A high proportion of IEL had granules that stained with Giemsa and Astra blue. Furthermore many IEL carried Lyt-2+ phenotype and no other T-cell surface antigen. Intraepithelial lymphocytes appeared, therefore, to have staining and phenotype characteristics of both granular NK cells and suppressor cells. It was clear that the intestinal mucosa contained populations of immune effector cells that were heterogeneous in nature and function.

Potassium supplements during long-term thiazide therapy for essential hypertension

Increasing doses of a slow-release potassium supplement were given to nine hypertensive patients previously treated for at least 18 months with bendrofluazide 10 mg daily. Serum potassium and total body potassium (TBK) were measured after 2 months on each dose. No significant increase in serum potassium or TBK occurred over a 6 month period of supplementation using doses commonly prescribed in clinical practice.

A functional measure of brain activity: brain stem transmission time

Surface-recorded auditory nerve and brain stem responses are being used routinely for diagnostic purposes in man. When interest is in auditory diagnosis, the electric response threshold is of primary importance. However, when used in neurological diagnosis, the wave form of the response is important. As a measure of one aspect of response wave form, this paper suggests the use of brain stem transmission time (BTT), defined as the time interval between the first earlobe-negative wave (response of the auditory nerve--the 'input' to the brain stem) and the earlobe-positive wave from the region of the inferior colliculus (the 'output' of the brain stem). The paper shows that BTT is longest in neonates, approaches adult values at the age of about 3 years, is relatively independent of click intensity, conductive hearing loss (middle ear lesion), click rate (except for high rates) and click frequency (filtered clicks). The finding that in a given age group, BTT is generally independent of most stimulus conditions, makes it a useful functional test of brain stem activity.

Critique of neonatal hearing evaluation

A commonly employed procedure for routine neonatal hearing screening is analyzed in terms of its rationale, method, and effectiveness. The procedure does not seem to accomplish its objectives adequately and actually creates some problems of its own. A particular weakness of the procedure is that it fails to screen many of the infants who were the main impetus for mass neonatal screening programs—children with deteriorating hearing, and those with mild-to-moderate hearing impairments present at birth. An alternative approach is offered which stresses more careful and objective evaluation of a limited number of children selected on the basis of a high-risk register. An economical and easily learned procedure is suggested to accomplish the evaluation. Stress is also placed on follow-up evaluations in well-baby clinics, in pediatricians' offices, and through mobile hearing testing units.