X-ray and Ultrasound Localization of Non-Palpable Breast Lesions and Difficulties in Management

Seventy-four patients who have had biopsy of a non-palpable breast lesion are reviewed. A double-dye localization technique was used in 88% while in 12% localization of the lesion was best achieved by ultrasound mammography. Biopsy was successful in 70 patients (95%) at the first attempt. The overall incidence of malignancy was 20%, being greater in asymptomatic patients (32%) than in patients with mastalagia (16%). Re-excision of the biopsy site in these patients showed residual cancer in 33%. It is suggested that both careful examination of the operative specimen and postoperative mammography may be necessary to ensure that the original lesion has been removed. Re-excision of the biopsy site appears to be necessary when the histology is malignant.

After Surgery for Breast Cancer: Which Mode of Surveillance?

Five hundred and ten women attending a specialized breast clinic for follow-up after surgery of early breast cancer (Stage I and II) have been studied. Recurrence was found most often (58%) in symptomatic women who returned to the clinic earlier than planned. Only 3% of asymptomatic patients had recurrent disease. It is concluded that counselling in symptoms of recurrent breast cancer would allow more efficient follow-up.

Mortality in a University Surgical Unit: What is an Avoidable Death?

Between January 1978 and December 1987 there were 23 557 surgical admissions to the University Surgical Unit in Southampton. During this period there were 543 deaths, an overall death per admission rate of 2.3%. During the 10-year period the number of admissions per year had risen from 1884 in 1978 (death per admission=3.6%) to 3467 in 1987 (death per admission rate=1.7%).

At the monthly audit meeting an attempt was made to classify each death as ‘avoidable’ or ‘unavoidable’. During this 10-year period it was considered that there were 89 ‘avoidable’ deaths. This represents an avoidable mortality rate (AMR) of 0.38%.

These ‘avoidable’ deaths were due to a wide variety of causes and this paper discusses the lessons learnt from a review of surgical mortality and outlines how units might compare results.

Evaluation of a ‘DIY’ Test for the Detection of Colorectal Cancer

A new type of faecal occult blood test, EZ-Detect™, has been evaluated in 404 patients presenting with symptoms suggestive of colorectal disease. The test avoids handling of stools and gives a result which patients can read themselves - factors which may increase patient compliance. In comparison with the Haemoccult™ test, EZ-Detect has the same sensiti-vity for blood in laboratory conditions. In clinical use 98% of patients expressed a preference for EZ-Detect but it detected significantly fewer patients with cancer than did Haemoccult (P = < 0.05). In its present form, this type of test would be unsuitable for population screening for colorectal cancer even if improved compliance is achieved.

Tumour grade on core biopsy and evidence of axillary involvement on ultrasound predicts response in elderly co-morbid patients treated with primary hormone therapy for oestrogen receptor positive breast carcinoma

INTRODUCTION

Treatment of women with oestrogen-receptor positive breast cancer who are high risk for general anaesthetic remains controversial. Current guidance is based on studies pre-dating aromatase inhibitors (AIs) which may have also included hormone-receptor negative patients. Such studies have demonstrated improved disease-free survival and local disease control following surgery when compared with primary hormone therapy (PHT) alone. However uncertainty persists regarding benefit of surgery over optimal hormone treatment in patients with significant co-morbidity.

METHOD

Retrospective cohort study comparing efficacy of PHT in oestrogen-receptor positive breast cancer patients considered unsuitable for surgery. Co-morbidity was scored retrospectively using the Charlson Index. Overall survival and disease specific survival were noted and multivariate analysis performed to identify predictors of treatment failure.

RESULTS

106 patients treated for breast cancer at Southampton University Hospital with PHT without surgery were identified (Mean age 84.1 years, range 48-101). 94.3% had a probability of 10 year survival of 2.25% or less according to the age-weighted Charlson score. Kaplan-Meier analysis demonstrated a four-year survival of 30% and breast cancer specific survival of 60%. Cox proportional hazards model demonstrated high-grade disease (grade III vs. grade I/II: HR = 2.007; 95% Confidence Interval (CI) = 1.004-4.014. P = 0.049) and ultrasound axillary staging (indeterminate/definite lymphatic involvement vs. no involvement: HR = 1.944; 95% CI = 1.010-3.742. P = 0.047) independently predicted early failure of PHT.

CONCLUSION

A high proportion of elderly and comorbid patients die with breast cancer rather than from breast cancer. Elderly comorbid patients who initially respond to primary hormone therapy have a less than 30% incidence of delayed treatment failure during their life time; however patients with grade III disease or an abnormal axillary ultrasound are twice as likely to fail first choice PHT.

The influence of clinicopathological features on the predictive accuracy of conventional breast imaging in determining the extent of screen-detected high-grade pure ductal carcinoma in situ

INTRODUCTION

The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures.

METHODS

A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS(®)) breast density score, DCIS extent and disease location within the breast recorded.

RESULTS

Unexpected invasive disease was found in 35 of 144 patients (24%). Within our unit the re-excision rate for all screen-detected DCIS is currently 23% but for patients included in this study with high-grade DCIS the re-excision rate was 39% (34/87). The extent of DCIS (p=0.008) and lack of expression of the oestrogen receptor (ER) predicted the requirement for re-excision in both univariate (p=0.004) and multivariate analysis (p=0.005).

CONCLUSIONS

High-grade DCIS may be focally uncalcified, leading to underestimation of disease extent, which might be related to ER status. Invasive foci associated with high-grade DCIS are often mammographically occult. Exploration of additional biomarkers and targeted use of further diagnostic techniques may improve the preoperative staging of DCIS.

Screen detected sclerosing lymphocytic lobulitis and amyloid of the breast in the same patient--a possible causal link

Sclerosing lymphocytic lobulitis (SLL) and amyloidosis of the breast are both rare. We report the case of a 59 year old woman who presented with suspicious microcalcifications on routine screening mammography. Wire-guided excision biopsy showed features typical of SLL but also localised amyloid deposits within the specimen. Amyloidosis and SLL may have similar immunological causes. This patient represents the first documented association of these two disorders.

Might patients benefit from oral iron therapy following operative treatment of breast carcinoma?

AIMS

To assess the changes in blood haemoglobin concentration and serum iron indices as a consequence of breast operations for cancer in our unit.

METHODS

Haematological parameters were measured in 109 patients undergoing definitive operative treatment for breast carcinoma.

RESULTS

A mean fall in haemoglobin of 2.1 g (P=0.001) occurred in patients undergoing mastectomy and axillary clearance and of 1.3 g (P<0.001) in patients undergoing wide local excision and axillary clearance. The transferrin saturation (serum iron/total iron binding capacity) in both sets of patients after surgery fell on average to levels that would be expected to impair subsequent red cell production.

CONCLUSION

The changes in iron indices that occurred were unrelated to the degree of blood loss consistent with a possible inflammatory effect of the operation. Oral iron therapy is unlikely to be of benefit to operative breast patients if they have normal pre-operative iron stores.

A comparison of 5-day and 8-day drainage following mastectomy and axillary clearance

AIMS

Mastectomy and axillary clearance are standard operations for the treatment of breast carcinoma. Drainage of the mastectomy site and axilla is often required to allow accumulating blood and inflammatory fluids to escape. However, there is a lack of data relating to how long suction drains should stay in situ after major breast surgery. In our study we have tried to address this deficit by comparing the efficacy of 5-day post-operative drainage with 8-day post-operative drainage.

METHODS

Patients requiring mastectomy and axillary clearance were randomized to having drains removed on day 5 or day 8 post-operatively. The number of lymphoceles, aspirations and total aspiration volumes in chest and axillary drains were compared.

RESULTS

From a total of 121 patients enrolled into the study, 64 patients were randomized to the 5-day group and 57 to the 8-day group. There were significant differences regarding the number of aspirations and total aspiration volumes in chest and axillary drains between the two groups, favouring 8-day drainage. However the number of lymphoceles drained in the 5-day group was significantly higher than the 8-day group.

CONCLUSIONS

Five-day post-operative drainage is as safe as 8-day post-operative drainage in the management of patients undergoing major breast surgery, but results in an increase in lymphocele aspiration and aspiration volume.

Improving the sensitivity of stereotactic core biopsy to diagnose ductal carcinoma in situ of the breast: a mathematical model

Stereotactic core biopsy (SCB) is performed on mammographically suspicious, non-palpable lesions of the breast. Reported sensitivities of SCB for the detection of ductal carcinoma in situ (DCIS) vary from 41% to 93%. We have developed a simple mathematical model to predict the probability of retrieving at least one diagnostic core from a focus of DCIS. We make recommendations of the number of samples needed for different sized areas of microcalcification. The sensitivity of SCB is affected by needle placement accuracy, diameter of the area of microcalcification (d), histological density of DCIS (x) (calculated as 7.5% by previous studies) and number of core samples (n) removed. The probability of achieving at least one representative core sufficient for diagnosis (P(core)) is defined as: P(core) = 1-(1 + p ([1- (x/100)]d - 1 ))n, where rho is the probability of a SCB accurately targeting the area of microcalcification. At least seven core samples should be removed in small foci (<5 mm) of DCIS to achieve a 0.75 probability of an accurate diagnosis. The probability of a diagnostic biopsy of larger areas of DCIS (>10 mm) is 0.95 when five cores are removed. This formula serves as an explanation to patients why SCB may fail to diagnose DCIS, and justifies the retrieval of more core samples to increase the probability of an accurate diagnosis and to reduce the chance of a non-representative core. In the absence of sufficient samples, a wire-guided open biopsy is necessary to exclude DCIS.

The role and histological classification of needle core biopsy in comparison with fine needle aspiration cytology in the preoperative assessment of impalpable breast lesions

AIMS

To investigate the role of needle core biopsy (NCB) in the preoperative assessment of impalpable breast lesions, mainly derived from the NHS Breast Screening Programme (NHSBSP) and to assess our own modifications to a suggested system for the classification of breast NCBs.

METHODS

The NCB, fine needle aspiration cytology (FNAC), and radiology scores from 298 women with non-palpable breast lesions presenting between January 1997 and December 1998, together with the open biopsy results (where available) were collated and analysed.

RESULTS

The mean follow up period was 15.8 months (range, 5-28). The 298 NCB specimens were categorised as follows: unsatisfactory/non-representative (B1; n = 61; 20.5%), benign but uncertain whether representative (B2r; n = 52; 17.4%), benign (B2; n = 103; 34.6%), lesions possibly associated with malignancy but essentially benign (B3a; n = 9; 3.0%), atypical epithelial proliferations (B3b; n = 10; 3.4%), suspicious of malignancy (B4; n = 7; 2.3%), and malignant (B5; n = 56; 18.7%). Excision biopsy was performed in 43 cases within the B1 (n = 19), B2r (n = 8), B2 (n = 8), and the B3a (n = 8; data unavailable in one case) categories, revealing malignancy in 18 (42.8%) cases and in 65 cases within the B3b, B4, and B5 categories, revealing malignancy in 64 cases (98.5%). The sensitivity of NCB for malignancy was 87.7%, with a specificity and positive predictive value of 99.3% and 98.5%, respectively. FNAC had an inadequacy rate of 58.7%, a complete sensitivity of 34.5% and a specificity of 47.6%.

CONCLUSIONS

This study confirms the value of NCB in the preoperative assessment of impalpable breast lesions. Two new categories are suggested for the NCB classification; category B2r for benign breast tissue where representativeness is uncertain, and the subdivision of category B3 into B3a for benign lesions potentially associated with malignancy (for example, radial scars and intraduct papillomas) and B3b for more worrisome atypical epithelial proliferations. These will aid the accurate audit of NCB and identify more clearly the intellectual pathway leading to a particular assessment.

Clinical outcome and bromodeoxyuridine-derived proliferation indices in 75 invasive breast carcinomas

INTRODUCTION

In vivo labelling of human breast tumours with bromodeoxyuridine (BrdUrd) and analysis by flow cytometry (FCM) allows the labelling index (LI), S phase duration (t(s)) and the potential doubling time (t(pot)) of the tumour to be estimated.

METHODS

The data for a series of tumour specimens from 75 patients with invasive breast carcinoma were reported in 1991, correlated with their lymph-node status, tumour size and grade.

RESULTS AND CONCLUSIONS

This study reports the follow-up data over 10 years in respect of time to recurrence and death from the disease. There were no significant correlations between proliferation data and outcome measures. No adverse events were identified which could be attributed to the use of the halogenated pyrimidine label in vivo.

Papillary carcinoma-in-situ of the breast presenting as a fungating lesion

We report a case of papillary breast carcinoma-in-situ which presented as a fungating lesion. To our knowledge this is the first such case to be reported in the English language literature.

Primary non-Hodgkin's lymphoma of the female breast masquerading as a breast abscess

We report the case of a primary non-Hodgkin's lymphoma of the breast, masquerading as a breast abscess.

Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery

Antibiotic prophylaxis has been used to good effect in the prevention of post-operative wound infections in patients undergoing gastrointestinal operations. We have assessed the use of a single dose of intravenous antibiotic (Augmentin 1.2 g), given with induction of anaesthesia as prophylaxis, against post-operative wound infection in women undergoing clean, elective breast surgery. Three hundred and thirty-four patients were recruited. Of the 164 receiving antibiotic prophylaxis 29 (17.7%) had wound infections compared with 32 (18.8%) in the placebo group (P=0.79). There were no significant differences in any other post-operative infective complications. Antibiotic prophylaxis is probably not required in clean, elective breast surgery.

How to draw the skin ellipse for a mastectomy

The size of the skin ellipse for a mastectomy varies between patients and the accurate marking and tailoring of the skin flaps is often learnt by the surgical trainee only with increasing experience. Within the Breast Unit, a mathematical model was calculated to predict the required width of the skin ellipse for a successful mastectomy. Measurements of the straight-line distance from mid-clavicular point to the infra-mammary fold and maximum vertical height of the nipple above the infra-mammary fold were taken with the patient relaxed and supine. A close correlation (r = 0.85) was noted. Further analysis demonstrated a linear relationship between the pre-operative height to which the nipple could be suspended above the infra-mammary fold and the required maximum skin ellipse width (r = 0.87, P < 0.001). This linear relationship is easy to remember and is a useful check to ensure that the skin flaps intended will be just right. This same technique may be applicable to skin ellipses elsewhere.

Analysis of somatostatin receptor subtype mRNA expression in human breast cancer

Somatostatin is a widely distributed inhibitory peptide with growth-inhibitory effects in several human tumours, including breast cancer, raising the possibility that it may have therapeutic potential. The effects of somatostatin are mediated via a family of cell-surface receptors that differ in their tissue distribution, pharmacological properties and intracellular response mediators, suggesting that they mediate different functions of the peptide. We have analysed the expression of somatostatin receptor subtype (SSTR1-5) mRNA in normal and malignant breast tissue. Receptor expression was analysed by reverse transcription-polymerase chain reaction (RT-PCR) using receptor subtype-specific primers and by in situ hybridization (ISH) with riboprobes synthesized by in vitro transcription of cloned PCR products. A total of 51 breast carcinomas, 36 samples of matched normal tissue, two axillary node metastases and eight normal/benign breast tissue samples were analysed. SSTR2 expression was ubiquitous in both normal and malignant breast tissue. Expression of SSTR5 was detected in approximately one-third of tumour and normal tissue, but fewer than 13% of all tissues expressed SSTR1, 3 and 4. These data suggest that SSTR2 gene expression is ubiquitous in breast cancer. Although this is unlikely to have diagnostic or prognostic significance, SSTR2-specific somatostatin analogues may have therapeutic potential in breast cancer.

Patterns of clinical metastasis in breast cancer: an analysis of 100 patients

Many patients diagnosed with breast cancer will develop metastases and these have diverse presentations. We have reviewed 100 consecutive patients who have died with metastatic breast cancer, to determine the frequency, sites and mode of presentation of recurrent disease. The commonest site of failure was loco-regional (n = 61), this usually presented with a mass, but a minority of patients also complained of pain. Bone metastases developed in 60 patients and produced bone pain, pathological fracture (n = 6) or cord compression (n = 5). Pulmonary metastases producing shortness of breath were diagnosed in 34 patients and were asymptomatic in a further 10. Intra-abdominal metastases were found at some time in 23 patients, most commonly in the liver (n = 20) and the majority complained of epigastric pain (n = 17). Brain metastases occurred in 23 patients and produced a wide range of symptoms including those of a space-occupying lesion (n = 10), cranial nerve palsy (n = 7), diabetes insipidus (n = 3), focal limb weakness (n = 2) and meningitis (n = 1). Three patients had choroid metastases producing reduced visual acuity. Recurrent breast carcinoma can present in a variety of ways, therefore any new symptom or sign should be considered to represent recurrence until proved otherwise.

Management of ductal carcinoma in situ of the breast

The advent of mammographic breast screening has increased the detection of ductal carcinoma in situ (DCIS), which now accounts for 15-20% of all breast cancer. While symptomatic DCIS has been treated satisfactorily by mastectomy, this may be an overtreatment of smaller screen-detected lesions. Although local excision, with or without radiotherapy, is associated with a significant risk of local recurrence of DCIS or invasive cancer, salvage surgery is usually successful. The long-term breast-specific mortality rate of treatment by mastectomy and local excision are similar. Whereas mastectomy is still appropriate for women with lesions > 30 mm in diameter or centrally placed and for those women who demand the best possible disease-free survival, local surgery should otherwise be considered.

Management of fibroadenoma of the breast

Fibroadenoma is a common cause of discrete breast lumps in young women. There is agreement that fibroadenomas can be diagnosed preoperatively with a high degree of confidence and that some of the lesions thus diagnosed will resolve, possibly obviating the need for excision. There is, however, wide disagreement over the proportion of fibroadenomas that resolve spontaneously and therefore the benefit that accrues from an expectant policy. The aim of this study was to audit the management of fibroadenomas on one unit and clarify their natural history over a 5-year period. A cohort of 70 women with 87 fibroadenomas diagnosed using a triple assessment of clinical examination, cytology and imaging (sonomammography) have been followed for a minimum of 5 years. In all, 53 of the 'fibroadenomas' have been excised. In four cases the histology revealed benign disease other than fibroadenoma; there were no neoplasms. The sensitivity of cytology and sonomammography for the diagnosis of fibroadenoma were 84% and 98% respectively. Thirty-four fibroadenomas have not been excised. Of 25 fibroadenomas that have been reassessed after at least 5 years of follow-up, 13 (52%) have reduced in size, 4 (16%) are unchanged in size and 8 (32%) have grown. No patient has developed a carcinoma at the site of the presumed fibroadenoma. This study confirms that an expectant management policy of fibroadenomas has not resulted in misdiagnosis of carcinomas. Further, since a significant proportion of fibroadenomas remain static or reduce in size over a 5-year period many women can avoid excision.

Cystic carcinoma of the breast: a trap for the unwary

Cystic breast masses are a common presentation to breast clinics. While the majority of cysts can be managed by simple aspiration, a small proportion are malignant. Histology records for a 10-year period have been examined to identify patients with cystic breast carcinomas. In all, 31 patients were identified. Of these, 18 had cystic degeneration of high-grade tumours, while 13 had intracystic papillary carcinoma. Both of these tumour types were diagnosed by a combination of cyst fluid cytology and breast imaging. The prognosis of high-grade tumours was poor, while that of intracystic papillary carcinomas was excellent. After cyst aspiration, bloodstained fluid should be sent for cytology and breast imaging arranged in all patients. Patients in whom a cyst refills within 2 week of aspiration require a careful re-evaluation. Cysts in postmenopausal women should be viewed with suspicion. Excision should be performed in patients with positive cytology or imaging.

Prospective study of outcome in women presenting with nipple discharge

In this study, 56 women who presented to the breast clinic with nipple discharge have been reviewed. Patients were selected for surgery by a triple assessment of clinical examination, discharge cytology and breast imaging. Surgical intervention was required in 17 women. Significant pathology was found in 11 cases including five with carcinoma (in situ or invasive). Those women who did not have carcinoma detected at their initial presentation have been reviewed after a minimum of 5 years. None has gone on to develop breast cancer. We conclude that women with nipple discharge, but no positive findings on triple assessment, are not at an increased risk of the development of carcinoma. In addition, nipple discharge spontaneously resolves in 73% of women over a 5 year period.

Randomized comparison of fine-needle aspiration cytology and Biopty-Cut needle biopsy after unsatisfactory initial cytology of discrete breast lesions

In a minority of patients with a discrete breast lump the initial cytological assessment is either unsatisfactory or at variance with the results of other methods of diagnosis. A randomized comparison of repeat cytology and needle-core biopsy provided clinically useful information in 14 of 31 patients receiving repeat cytology and in 26 of 29 randomized to core biopsy. Nineteen patients had carcinoma: ten who received repeat cytology, which indicated malignancy in only three (diagnostic of malignancy in one, suspicious in two), while all nine patients who underwent core biopsy had a correct diagnosis (only suspicious of malignancy in one). The sensitivity for the definitive diagnosis of carcinoma on repeat cytology and core biopsy was 10 and 89 per cent respectively. Patients with a discrete breast lump and unclear cytology results require needle-core biopsy. This has more diagnostic value than repeat cytology.

The Impact of the First 3 Years of Breast Cancer Screening on the Overall Presentation of Breast Cancer

We have assessed the effect of the first round of the Breast Cancer Screening Programme on the presentation of breast cancer in the Southampton Health District with respect to number of cases and pathological characteristics. A retrospective comparative survey of the presentation of breast cancer in the 3 years prior to breast cancer screening (1985–1988) with the presentation of breast cancer during the prevalent round of breast cancer screening (1988–1991) was performed.

During the period of study 1536 cases of breast cancer presented. Six hundred and sixty presented in the years prior to screening and 864 during the first round of screening. All patients lived within the Southampton Health District.

The study was designed to assess the changes in breast cancer presentation with regard to age, pathological characteristics, and treatment.

Even allowing for the increases in the local population there was a significant increase in the number of cases of breast cancer diagnosed (χ2=23.7, df=1, P< 0.001). The majority of this increase was in the 50–64 age group. There was also a significant shift towards an earlier stage at diagnosis and a significant reduction in tumour size when all cases were included (mean 26 mm versus 34 mm P< 0.001). Screening also created the opportunity for less invasive treatment. Consequently there was a rise in the number of excisions by localization biopsy from 1% to 13% during the screening period.

In conclusion, the National Breast Cancer Screening Programme (NBCSP) has had a significant impact on the presentation of breast cancer. This has resulted in a greater awareness of the disease with earlier presentation, smaller tumours, and a higher local excision rate in the study group.

Determination of Ki67 growth fraction and oestrogen receptors in screen-detected breast cancer using cytological preparations

Oestrogen receptor (ER) status of 77 cases of screen-detected breast cancer has been determined using cytological preparations. In 48% ER status was positive, which was the same proportion as that formed in a control group of age-matched patients with symptomatic breast carcinoma. Since the screen-detected group contained more low grade tumours, the percentage of ER-positive cases would be expected to be higher. The reasons for the discrepancy are discussed. Ki67 score has been determined for 41 cases of screen-detected cancer. Ki67 score showed a positive correlation with histological tumour grade and a negative correlation with ER status. However, there was no correlation with tumour size or lymph node status. The Ki67 scores in the screen-detected cancers were essentially similar to those found in an age-matched symptomatic group, but the very low scores were only found in the screened group.

Axillary nodal status in women with screen-detected breast cancer

A prospective study of the axillary nodal status of women found to have an invasive breast cancer within the prevalence screening round is reported. Thirty-one per cent of patients were lymph node positive. Twenty-two per cent of patients with an impalpable tumour and 41% of those with a palpable tumour had involved axillary lymph nodes. Only 6% of patients with a tumour of less than 10 mm had diseased axillary nodes. Of the factors examined only the size of the invasive component of the primary tumour was related to the axillary lymph node status. This proportion of patients with positive lymph nodes is higher than might be expected and is likely to represent those patients with potentially symptomatic breast tumours detected by breast screening in the first round.

Metastatic carcinoid of the breast: an unusual screen-detected breast cancer

The breast is a rare site of metastasis. This case report is of a rare case of metastatic carcinoid tumour to the breast. The differentiation from primary breast carcinoid is discussed.

Breast size and prognosis in early breast cancer

The influence of breast size on the prognosis of 196 patients with early breast cancer diagnosed in the period 1984-1985 was studied. Breast size was based on the volume from mammography. This method was validated against the volume of the mastectomy specimen determined by water displacement in 18 patients and found to be accurate (r = 0.93, P < 0.01). The median breast volume was 833.5 cm3 (interquartile range 522.8-1153.3 cm3). Breast size was significantly associated independently with age (Spearman's rank r = 0.24. P = 0.001), menstrual status (z = -4.81, P < 0.001), body weight (Spearman's rank r = 0.61, P < 0.001), T stage (z = -1.91, P = 0.05) but not N stage (z = -1.64, P = 0.10) or hormone receptor status (z = -0.80, P = 0.42). In an analysis of breast size and other known prognostic factors, based upon Cox's proportional hazards regression, N stage was the only significant factor for both breast cancer survival and disease-free survival. Even though women with larger tumours at presentation had larger breasts, breast size was not a significant prognostic factor in early breast cancer.

Loco-Regional Recurrence and Survival after Wide Local Excision, Radiotherapy and Axillary Clearance for Early Breast Cancer

After breast conservation for early breast cancer which comprised wide local excision, axillary clearance and radiotherapy to the breast, 145 women have been followed prospectively for a median of 42 months. Local recurrence occurred in 11 (7%) and axillary recurrence in three (2%). Distant recurrence has occurred in 32 and accounted for 80% of all first recurrences.

Local treatment failure has occurred in three women and would not have been prevented by mastectomy. Loco-regional recurrence in the absence of preceding or synchronous distant disease was unusual and did not pose a significant clinical problem.

Assessment of morbidity from complete axillary dissection

The importance of axillary dissection as part of the primary surgical procedure in the treatment of operable cases of carcinoma of the breast is established. The morbidity of this procedure, however, is less well documented. A study of 126 women who had had full axillary dissection as part of their initial surgical treatment was undertaken to assess their degree of morbidity in terms of numbness, pain, weakness, swelling, and stiffness. Seventy per cent of cases complained of numbness, 33% of pain, 25% of weakness, 24% of limb swelling, and 15% of stiffness. Objective measurements confirmed decreased sensation in 81%, weakness in 27%, swelling in 10%, and stiffness in 10%. In no case were these symptoms described as severe, though they did have an effect upon the daily lives of 39%. The side effects of full axillary dissection are common and all women should be warned of them prior to surgery; however they are usually mild and therefore should not preclude this procedure as a part of definitive surgical treatment.

Breast liver metastases--incidence, diagnosis and outcome

Breast liver metastases are uncommon and have not been well reported. We studied the clinical outcome of 47 patients who developed liver metastases out of 912 breast cancer patients treated between 1982 and 1987, an incidence of 5.2%. The median disease free interval prior to clinical liver metastases was 20.2 months (range 4-192 months). The most frequent clinical presentations were hepatomegaly (70%) and abdominal pain (34%). The diagnosis was confirmed on ultrasound scan in 72.7% patients. Thirty-one patients (70.5%) received specific treatment with both hormone and chemotherapy but only six showed any evidence of objective response, the majority of whom had metastases only in the liver. The median survival of treated patients was 4 months and absence of jaundice, response to treatment and liver metastases only were associated with significantly better survival. In conclusion breast liver metastases usually present as a manifestation of disseminated disease and have an appalling prognosis. When they occur as an initial site the prognosis is better but very few patients overall respond to conventional treatment.

Ultrasonic attenuation in fibroadenoma of the breast

Fifteen patients are described who attended out Breast Screening Programme, and were found to have sclerosed fibroadenomas, the imaging of which raised the possibility of carcinoma. In six of these a reflective zone between a mass lesion and distal acoustic shadowing might have been used to infer the benign diagnosis.

Incidence of arm swelling following axillary clearance for breast cancer

Arm swelling was measured using volume determination in 118 patients following mastectomy (n = 60) or wide excision (n = 58), both with axillary clearance. The mean age was 60.5 years and the median follow-up was 22.5 months. Axillary clearance removed level III nodes. Axillary irradiation was given to only three patients with extensive (more than 75 per cent) nodal involvement. The incidence of early postoperative complications was 18.6 per cent. The incidence of lymphoedema was 7.6 per cent (nine patients). Three of these patients had early lymphoedema within 6 months of treatment. Arm circumference differences correlated poorly with volume differences. The incidence of lymphoedema following axillary clearance is low and comparable to that for sampling or no axillary surgery.

ERICA predicts response to tamoxifen in elderly women with breast cancer

Oestrogen receptor status has been determined by an immunocytochemical assay using fine-needle aspiration samples of primary breast cancers in elderly patients. In a prospective study 56 patients were treated with tamoxifen only. Satisfactory assays were achieved in 49 patients. Disease was controlled by tamoxifen in 32 of 35 (91%) patients with oestrogen receptor positive tumours, compared with only 1 (7%) of 14 who were receptor negative. Immunocytochemical assay on fine-needle aspiration samples is relatively non-invasive and simple to perform, it accurately predicts response to tamoxifen in elderly patients and can be used to select patients for tamoxifen only therapy.

Impact of an Extensive in Situ Component on the Presence of Residual Disease in Screen Detected Breast Cancer

This study investigates the histopathological characteristics of a consecutive series of 100 screen detected breast cancers in relation to residual disease. Tumour type, size, grade, resection margins and extent of primary or associated in situ disease were all assessed by one pathologist. Thirty-seven women underwent further surgery (wider excision or mastectomy) and the resected specimen was examined for residual in situ or invasive cancer.

In total, 36 cancers had an extensive in situ component, of which 69% were predominantly intra-duct carcinoma of comedo type. Of the 37 women who underwent further resection, 21 (57%) women had residual cancer. Of those with initial disease at the resection margin, 16/25 (64%) had residual disease. Five of 12 (42%) with disease close to (within 2–3 mm) but not at the margin had residual disease. Of those with an extensive in situ component, 18/25 (72%) had residual disease, whereas only 2/12 (17%) women with none or some in situ disease had residual cancer.

In screen detected breast cancer, residual cancer was present in 72% of women with an extensive in situ component at initial surgery. These women comprise a group in whom conservation surgery may be inappropriate if completeness of excision is considered a prerequisite for breast conserving surgery.

Technique and results of localization biopsy in a breast screening programme

The techniques of ultrasonographic and hookwire localization biopsy of impalpable breast lesions detected by a large breast screening unit during its first year of operation are described. Hookwire localization (HL) was performed using mammography. Ultrasonographic localization (UL) was used for lesions readily detectable by ultrasonography by marking the skin directly over the lesion and calculating its depth below the surface. UL is not appropriate when microcalcification is the sole mammographic abnormality. Localization was required for 150 of the 191 (78.5 per cent) screen-detected lesions. HL was used for 94 (62.7 per cent) and UL for 56 (37.3 per cent). Four lesions were missed by HL, none by UL; 35 per cent of lesions removed by HL and 39 per cent by UL were malignant, giving benign: malignant biopsy ratios of 1.8:1 and 1.5:1 respectively. Only 22 percent of the patients required overnight hospital stay. Localization biopsy plays a major role in the surgery for screen-detected lesions and, where applicable, UL is the technique of choice.

Poor response of breast cancer to tamoxifen

Fifty eight (58) patients with early breast cancer (mean age 78.3 years) and 37 patients with advanced breast cancer (mean age 65.9 years) were treated with tamoxifen orally 20 mg daily or twice daily. The mean follow-up time was 19.1 months in the early group and 18.4 months in the late group. The drug was extremely well tolerated. All patients had cytological or histological evidence of breast cancer. A complete or partial response was found in only 36% of the patients with early breast cancer and only 13% in the advanced group. We conclude that tamoxifen was disappointing as a primary therapy in our patients. Although because of its lack of toxicity it can be seen as initial therapy for patients with breast cancer, it may have to be supplanted rapidly by other forms of therapy in the substantial proportion of patients in whom a response will not occur.

Demonstration of oestrogen receptor in symptomatic breast carcinoma, using fine needle aspiration cytology

Oestrogen receptor immunocytochemical assay (ER-ICA) was used to determine oestrogen receptor (ER) content of cells in fine needle aspirate (FNA) specimens from 88 breast carcinomas. In 49 of these the radioligand binding assay for oestradiol was available for comparison. The predictive value of ER-ICA staining for a positive radioligand binding assay (greater than 10 fmol/mg protein) was 95%. Although the predictive value of negative staining was only 66%, 34 out of 37 ER-ICA negative tumours had radioligand binding assays below 60 fmol/mg protein. ER-ICA staining showed a strong positive correlation with age of the patient, positivity being rare before the menopause. There was a weak inverse correlation with tumour grade but none with tumour size or lymph node status. The assessment of ER by immunocytochemistry using FNA cytology is a rapid technique, which may easily be repeated and provides a pre-operative assessment of ER status. It allows confirmation that tumour cells are present in the sample and an assessment of tumour heterogeneity.

The Southampton teaching triad: an audit of operative surgical instruction

Clinical audit and regular morbidity and mortality meetings are required of all units involved in surgical training. Agreed standards of training are under discussion in the face of new examinations and have not at present been formally evaluated. In order to quantify the level of operative surgery instruction in this unit, a prospective 'Teaching Audit' has been undertaken, using an extension of the existing surgical audit. Results, which are presented as a standardised diagram, reflect the relationship between trainer and trainee. Problems, such as missed teaching opportunities, were identified. The method can be applied to any specialty, and may be useful in planning teaching resources and surgical training programmes.

Faecal occult blood testing in symptomatic patients: comparison of three tests

This study examines three faecal occult blood tests, Haemoccult, Fecatwin and E-Z Detect, each with different sensitivities, to determine which is best suited for use in symptomatic patients--both for the detection of cancer and of non-malignant mucosal disease of the large bowel. A test was completed by 1025 patients before double-contrast barium enema and the performance of each test was determined from the result of this investigation. The study was completed by 969 patients. There were 49 patients with colorectal cancer, 92 patients with a cancer or a polyp greater than 5 mm, and 130 with some mucosal abnormality. The test most sensitive for blood, Fecatwin, detected 14 of 15 (93 per cent) cancers and 29 (69 per cent) of 42 patients with mucosal disease (including inflammatory bowel disease) but gave three times as many false positive results as the Haemoccult test, which is less sensitive for blood. The chance of a patient with a positive Haemoccult result having mucosal disease on barium enema was 24 of 47 patients (51 per cent) (two-thirds of these having colorectal cancer). A negative Haemoccult result, however, was unreliable and should not influence patient management. A test less sensitive for blood than Haemoccult was found to be of little value in symptomatic patients.

Through the colonoscope--a radiologist's view

A series of 1578 consecutive colonoscopies performed by radiologists in training is reviewed, with specific reference to patients with colorectal neoplasms. The contribution of the radiologist to the practice of colonoscopy is discussed. This input to the colonoscopy service of a hospital carries several benefits, including the following: a link is established between radiologists and gastroenterologists which improves the standard of both barium enema and colonoscopic examinations; informed discussion is made possible about the suitability of a barium enema lesion for endoscopic removal; the endoscoping radiologist acquires an impartial view of each examination and is able to choose the more appropriate investigation; direct visualisation of the colonic mucosa and its abnormalities may facilitate the interpretation of barium radiographs and enhance the quality of the radiological training that can be offered. In our experience, participation in a weekly colonoscopy session has had no adverse effect on the routine work of the radiology department.

Varicose vein surgery using a pneumatic tourniquet: reduced blood loss and improved cosmesis

A prospective controlled randomised study has been performed of 100 consecutive patients undergoing varicose vein surgery. One group underwent saphenofemoral flush ligation and multiple lower leg avulsions with the leg exsanguinated with a Rhys-Davies cuff, and ischaemia maintained with a pneumatic tourniquet. The other group underwent identical surgery but with a 30 degree head down tilt only. Blood loss was significantly less (13.5 +/- 12 ml vs 133 +/- 78 ml; P less than 0.01) and postoperative cosmesis was significantly improved in patients in the tourniquet group. Operating time was similar (27 +/- 11 min vs 30 +/- 13 min) in the two groups.