Low antibody levels associated with significantly increased rate of SARS-CoV-2 infection in a highly vaccinated population from the US National Basketball Association

SARS-CoV-2 antibody levels may serve as a correlate for immunity and could inform optimal booster timing. The relationship between antibody levels and protection from infection was evaluated in vaccinated individuals from the US National Basketball Association who had antibody levels measured at a single time point from September 12, 2021, to December 31, 2021. Cox proportional hazards models were used to estimate the risk of infection within 90 days of serologic testing by antibody level (<250, 250-800, and >800 AU/mL1 ), adjusting for age, time since last vaccine dose, and history of SARS-CoV-2 infection. Individuals were censored on date of booster receipt. The analytic cohort comprised 2323 individuals and was 78.2% male, 68.1% aged ≤40 years, and 56.4% vaccinated (primary series) with the Pfizer-BioNTech mRNA vaccine. Among the 2248 (96.8%) individuals not yet boosted at antibody testing, 77% completed their primary vaccine series 4-6 months before testing and the median (interquartile range) antibody level was 293.5 (interquartile range: 121.0-740.5) AU/mL. Those with levels <250 AU/mL (adj hazard ratio [HR]: 2.4; 95% confidence interval [CI]: 1.5-3.7) and 250-800 AU/mL (adj HR: 1.5; 95% CI: 0.98-2.4) had greater infection risk compared to those with levels >800 AU/mL. Antibody levels could inform individual COVID-19 risk and booster scheduling.

World Health Organization and knowledge translation in maternal, newborn, child and adolescent health and nutrition

The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE's recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

SARS-CoV-2 Reinfection: A Case Series from a 12-Month Longitudinal Occupational Cohort

Seven cases of COVID-19 SARS-CoV-2 reinfection from the NBA 2020-2021 occupational testing cohort are described including clinical details, antibody test results, genomic sequencing, and longitudinal RT-PCR results. Reinfections were infrequent and varied in clinical presentation, viral dynamics, and immune response.

Evolution of the World Health Organization's programmatic actions to control diarrheal diseases

The Program for the Control of Diarrheal Diseases (CDD) of the World Health Organization (WHO) was created in 1978, the year the Health for All Strategy was launched at the Alma Ata International Conference on Primary Health Care. CDD quickly became one of the pillars of this strategy, with its primary goal of reducing diarrhea-associated mortality among infants and young children in developing countries. WHO expanded the previous cholera-focused unit into one that addressed all diarrheal diseases, and uniquely combined support to research and to national CDD Programs. We describe the history of the Program, summarize the results of the research it supported, and illustrate the outcome of the Program's control efforts at country and global levels. We then relate the subsequent evolution of the Program to an approach that was more technically broad and programmatically narrow and describe how this affected diarrheal diseases-related activities globally and in countries.

Drivers of the reduction in childhood diarrhea mortality 1980-2015 and interventions to eliminate preventable diarrhea deaths by 2030

BACKGROUND

Childhood diarrhea deaths have declined more than 80% from 1980 to 2015, in spite of an increase in the number of children in low- and middle-income countries (LMIC). Possible drivers of this remarkable accomplishment can guide the further reduction of the half million annual child deaths from diarrhea that still occur.

METHODS

We used the Lives Saved Tool, which models effects on mortality due to changes in coverage of preventive or therapeutic interventions or risk factors, for 50 LMIC to determine the proximal drivers of the diarrhea mortality reduction.

RESULTS

Diarrhea treatment (oral rehydration solution [ORS], zinc, antibiotics for dysentery and management of persistent diarrhea) and use of rotavirus vaccine accounted for 49.7% of the diarrhea mortality reduction from 1980 to 2015. Improvements in nutrition (stunting, wasting, breastfeeding practices, vitamin A) accounted for 38.8% and improvements in water, sanitation and handwashing for 11.5%. The contribution of ORS was greater from 1980 to 2000 (58.0% of the reduction) than from 2000 to 2015 (30.7%); coverage of ORS increased from zero in 1980 to 29.5% in 2000 and more slowly to 44.1% by 2015. To eliminate the remaining childhood diarrhea deaths globally, all these interventions will be needed. Scaling up diarrhea treatment and rotavirus vaccine, to 90% coverage could reduce global child diarrhea mortality by 74.1% from 2015 levels by 2030. Adding improved nutrition could increase that to 89.1%. Finally, adding increased use of improved water sources, sanitation and handwashing could result in a 92.8% reduction from the 2015 level.

CONCLUSIONS

Employing the interventions that have resulted in such a large reduction in diarrhea mortality in the last 35 years can virtually eliminate remaining childhood diarrhea deaths by 2030.

Factors associated with the decline in under-five diarrhea mortality in India: a LiST analysis

BACKGROUND

India has achieved 86% reduction in the number of under-five diarrheal deaths from 1980 to 2015. Nonetheless diarrhea is still among the leading causes of under-five deaths. The aim of this analysis was to study the contribution of factors that led to decline in diarrheal deaths in the country and the effect of scaling up of intervention packages to address the remaining diarrheal deaths.

METHODS

We assessed the attribution of different factors and intervention packages such as direct diarrhea case management interventions, nutritional factors and WASH interventions which contributed to diarrhea specific under-five mortality reduction (DSMR) during 1980 to 2015 using the Lives Saved Tool (LiST). The potential impact of scaling up different packages of interventions to achieve universal coverage levels by year 2030 on reducing the number of remaining diarrheal deaths were estimated.

RESULTS

The major factors associated with DSMR reduction in under-fives during 1980 to 2015, were increase in ORS use, reduction in stunting prevalence, improved sanitation, changes in age appropriate breastfeeding practices, increase in the vitamin-A supplementation and persistent diarrhea treatment. ORS use and reduction in stunting were the two key interventions, each accounting for around 32% of the lives saved during this period. Scaling up the direct diarrhea case management interventions from the current coverage levels in 2015 to achieve universal coverage levels by 2030 can save around 82 000 additional lives. If the universal targets for nutritional factors and WASH interventions can be achieved, an additional 23 675 lives can potentially be saved.

CONCLUSIONS

While it is crucial to improve the coverage and equity in ORS use, an integrated approach to promote nutrition, WASH and direct diarrhea interventions is likely to yield the highest impact on reducing the remaining diarrheal deaths in under-five children.

Immunohistochemical Study of Ten Cases of Argyrophilic Carcinoma (Carcinoid) of the Breast

The significance of argyrophilia in human breast cancer is still a controversial issue. We tested immunohistochemically 10 cases of argyrophilic carcinomas of the breast and found evidence of immunoreactivity with neuroendocrine markers: chromogranin, NSE, gastrin, insulin and bombesin. Argyrophilia was demonstrated in breast cancers of the usual types and was found to be related to the secretory activity of neoplastic cells. Unfortunately, no adequate follow-up data are available to clarify the natural history of argyrophilic breast cancer. A clinical treatment different from that of conventional breast cancer is not at present justified.

Prognostic Significance of the Growth Rate of Breast Cancer: Preliminary Evaluation on the Follow-Up of 196 Breast Cancers

The doubling time (DT) of 196 consecutive breast cancers was studied by means of a double mammographic examination (average time between the 2 mammographies, 30 days) and calculated with the formula of exponential growth. On the basis of DT values the case series was divided into 3 groups of growth: fast (DT from 1 to 30 days), 31 cases (15.8 %), intermediate (DT from 31 to 90 days), 84 cases (42.9 %), slow (DT more than 90 days), 81 cases (41.3 %). No relationship was found between growth rate and size of tumor, or menopausal status of the patient. After mastectomy fast and slow cases were equally distributed in the N− and N+ groups, whereas for the intermediate cases the N−: N+ ratio was 1: 2. One hundred and thirty-four cases were followed for a period of 12 to 52 months. Evaluation was done on the basis of the subdivision into N− and N+, and the latter group into N+ (1–3) and N+ (> 3). For N− tumors the course of the disease was apparently not affected by the growth rate. However, the case of fast growing tumors showed a higher proportion of recurrences with respect to N+ slow growing tumors. This difference was even more noticeable the higher the number of involved lymph nodes, but not statistically significant. The course of slow growing tumors was identical in the N− and N+ groups, but all the N+ tumors were subjected to adjuvant chemotherapy.

Unexpected Breast Cancer Detection after Outpatient Biopsy for Benign Lesion

At the Istituto Nazionale Tumori of Milan, in its Outpatient Department, 1302 breast surgical biopsies were carried out in 1978. Fibroadenomas occurred in 44.2% and benign dysplasias in 39.3%. Sixty-two cancers (4.8%) and 23 atypical hyperplasias (1.8%) were unexpected findings, with an increasing incidence in women over 50. Seventy-nine duct resections were performed for significant nipple discharge and revealed 5 unexpected carcinomas and 28 papillomas or papillomatosis. In our opinion and experience, this procedure of performing breast biopsy in the presence of a solid lump in women over 30 without hospitalization improves early detection of cancer, lowers costs, cuts down admission waiting lists and increases the number of women who better accept a surgical diagnosis and treatment.

Partnership Conference

BACKGROUND

The Duke Global Health Institute (DGHI) was founded in 2006 with a goal to foster interdisciplinary global health education and research across Duke University and Duke Medical Center. Critical to achieving this goal is the need to develop and sustain strong international partnerships.

OBJECTIVE

To host a conference with multiple international partners and strengthen existing relationships.

METHODS

After a deliberate year-long planning process, DGHI convened a Partnership Conference with its international partners on the Duke University campus in conjunction with its 10th Anniversary Celebration. The Partnership Conference sought to promote an exchange of novel ideas in support of global health education and research, explore new collaborations in South-South relationships, and identify and facilitate pursuit of new educational and research opportunities.

FINDINGS

A total of 25 partners from 10 countries and 46 DGHI faculty members participated in the 3-day event in October 2016. Activities included workshops on preselected research topics, educational symposia on novel teaching methods and harnessing technological advances, introduction of the Health Humanities Laboratory to prepare students and trainees for fieldwork, and discussions of research infrastructure and training needs. Surveys from visiting partners revealed a high degree of satisfaction. Proposed action items include methods to realize improved communications, enhancement of mutual education opportunities, support and mentoring to build local research capacity, and more exchange of faculty and students between partnering institutions.

CONCLUSIONS

With careful planning from all parties, a multilateral partnership conference including both university and medical center faculty can be a productive forum for exchange on global health education and research. Sustaining such partnerships is vital to the success of global health scholarship.

Strategies used in the detection of acute/early HIV infections. The NIMH Multisite Acute HIV Infection Study: I

Acute/early HIV infection plays a critical role in onward HIV transmission. Detection of HIV infections during this period provides an important early opportunity to offer interventions which may prevent further transmission. In six US cities, persons with acute/early HIV infection were identified using either HIV RNA testing of pooled sera from persons screened HIV antibody negative or through clinical referral of persons with acute or early infections. Fifty-one cases were identified and 34 (68%) were enrolled into the study; 28 (82%) were acute infections and 6 (18%) were early infections. Of those enrolled, 13 (38%) were identified through HIV pooled testing of 7,633 HIV antibody negative sera and 21 (62%) through referral. Both strategies identified cases that would have been missed under current HIV testing and counseling protocols. Efforts to identify newly infected persons should target specific populations and geographic areas based on knowledge of the local epidemiology of incident infections.

Government-NGO collaboration and sustainability of orphans and vulnerable children projects in southern Africa

Given current donor attention to orphans and children made vulnerable by HIV/AIDS, and the need for a new framework that recognizes the complementary roles of nations and non-governmental organizations (NGOs), this analysis reviews NGO-operated community-based orphans and vulnerable children (OVC) projects in Botswana, Lesotho, Namibia, South Africa, and Swaziland. There has been a lack of attention within the field of evaluation to inter-organizational relationships, specifically those with government agencies, as a factor in sustainability. We analyzed evaluations of nine OVC projects funded by the Bristol-Myers Squibb Foundation for the influence of government-NGO collaboration on project sustainability. For eight of the nine projects, evaluations provided evidence of the importance of the government partnership for sustainability. Government collaboration was important in projects designed to help families access government grants, initiate community-based solutions, and advocate for OVC rights through legislation. Government partnerships were also critical to the sustainability of two projects involved in placing children in foster care, but these showed signs of tension with government partners. In addition to the more common factors associated with sustainability, such as organizational characteristics, donors and NGOs should concentrate on developing strong partnerships with local and national government agencies for the sustainability of their projects.

A social cognitive model of health for HIV-positive adults receiving care in India

In-depth interviews were conducted with 50 HIV-positive adults (23 women, 27 men) with access to care at a non-governmental organization in Chennai, India to gain a broad understanding of how they managed their HIV infection. Using a Social Cognitive Model of Health, we identified factors within the model's three domains--Personal, Environmental, and Behavioral--that are applicable to this socio-cultural context. The Personal domain's factors were a positive self-concept, family-focused goals, and treatment optimism; the Environmental domain comprised family-based support, treatment availability, access and quality, and HIV stigma and discrimination; and the Behavior domain's factors were medication adherence and health habits, sexual behavior, and social relationships and emotional well-being. Significant differences for many of the factors within the three domains were observed across married men and women, widowed women, unmarried men, and female sex workers. Implications for an enhanced intervention for HIV-infected individuals in similar treatment settings are discussed.

Living with HIV infection: perceptions of patients with access to care at a non-governmental organization in Chennai, India

Through interviews, we examined explanatory frameworks of living with HIV infection among 50 HIV-positive individuals (23 women, 27 men) receiving care at a non-governmental organization in Chennai, India. Results were analysed according to three sets of issues, all of which were found to differ by gender: causal beliefs about HIV, impact of HIV, and care/treatment of HIV. HIV-positive participants attributed their infection to biological, moral and social causes, and the physical, financial and relationship dimensions of their lives were impacted upon by the infection. Furthermore, HIV-related stigma evoked fears about isolation and discrimination. Regarding care/treatment, men were most usually first initiated into the healthcare system while women often entered as a consequence of their partner's condition. Non-adherence to medication was reported by 32% of the participants due to financial constraints or side-effects. Although all participants were hopeful about a cure for HIV, women were less positive than men about treatment. Results highlight the importance of a gender-sensitive approach to HIV care, nuanced to accommodate an individual's gender, marital status and social background.

Improving home-based care in southern Africa - an analysis of project evaluations

No abstract available.

Sentinel node biopsy in the surgical management of breast cancer: experience in a general hospital with a dedicated surgical team

The aims of this study were to analyse the feasibility and accuracy of the sentinel lymph node biopsy (SLNB) procedure as performed in a general hospital compared with the literature results; to report on the organizational aspects of planning surgical time with higher accuracy of pathological analysis; and to verify that there is a real advantage of SLNB in the surgical management of breast cancer. From October 1999 to September 2000, 371 consecutive patients with T1-2N0 breast lesions underwent SLNB. The immunoscintigraphic method of sentinel node identification was the main one used, the blue dye method being used only when the lymphoscintigraphic method was unsuccessful in identifying sentinel nodes. SLNB was done under either general or local anaesthesia, depending on how the surgical procedure was organized and clinically planned. SLNB was successful in 99% of these T1-2N0 breast cancer cases, and in 71% no metastases were found in the sentinel node. In 47% of cases with axillary metastasis only the sentinel node was involved. Nodal involvement was not present in any case of microinvasive or in situ carcinoma. In T1 cancers nodal involvement was present in 21%; in T2 cases the corresponding rate reached 51%. The results obtained with the SLNB procedure at Bergamo Hospital are similar to the literature data. When a dedicated surgical team, the nuclear medicine department and the pathology department work together, a general hospital can provide breast cancer patients with appropriate surgical treatment.

Population-based sentinel lymph node biopsy in early invasive breast cancer

INTRODUCTION

Sentinel lymph node biopsy (SLNB) has been proposed as a reliable method for staging of early invasive breast cancer (EIBC). In the present study we analyse the impact of this procedure when systematically applied to all unselected women of a community-based Breast Cancer Unit (BCU).

METHODS

All consecutive women with unifocal cT1-2 (<or=3 cm) cN0 EIBC diagnosed at our BCU were considered for radiocolloid sentinel node localisation and biopsy.

RESULTS

Only 387 of all consecutive 542 patients met eligibility criteria for SLNB. Reasons for ineligibility included tumour size, palpable axillary nodes, plurifocality and/or multicentricity, and refusal to undergo the procedure. Successful SLNB was performed in 362 patients (94% of those eligible), but in 108 of these axillary dissection (AD) had to be performed anyway, mainly because of SLN-positivity. Therefore, SLNB ultimately allowed sparing axillary dissection in 256 patients out of the entire population of women with EIBC.

CONCLUSIONS

Radiocolloid-guided SLNB, when appropriately applied in the context of a population-based service, can help in sparing unnecessary AD, with its related costs and morbidity, in approximately half of all women presenting with EIBC. In absolute terms, in the EU this could result in approximately 100,000 unnecessary AD avoided each year.

Estimating the cost of unmet HIV-prevention needs in the United States

BACKGROUND

Although new HIV infection cases have dropped from over 160,000 per year in the mid-1980s to 40,000 per year in the 1990s, HIV incidence has been relatively unchanged for a decade. This number of annual incident infections suggests that substantial, unmet HIV-prevention needs continue to fuel the HIV epidemic in the United States.

OBJECTIVES

This study estimates the cost of addressing the unmet HIV-prevention needs in the United States and establishes a performance standard by estimating the number of HIV infections that would have to be prevented in order for these programs to be considered cost saving to society.

METHODS

Standard methods of cost and threshold analysis were employed in this study. Interventions needed to address unmet behavioral risks include services to reduce sexual risk of HIV infection, services to provide access to sterile syringes for people who cannot stop injecting drugs, HIV counseling and testing, and intensive preventive services to help HIV-seropositive people avoid transmitting the virus to others.

RESULTS

If brief interventions are utilized to address sexual behavior risk, the total program cost (over and above current resource levels) is just over $817 million; and if more expensive multisession, small-group interventions are used, the costs increase to over $1.85 billion. However, even the higher-cost program has a threshold of only 12,000 infections that must be prevented in order for the program to be considered a cost saving to society.

CONCLUSIONS

Addressing the remaining unmet HIV-preventive needs in the United States will require a substantial commitment of resources. However, even a greatly expanded HIV-preventive program in the United States could pay for itself through savings in averted medical care costs.

Electropotential measurements as a new diagnostic modality for breast cancer

BACKGROUND

Proliferative changes in breast epithelium are an intrinsic aspect in the development of breast cancer, and result in regions of epithelial electrical depolarisation within the breast parenchyma, which can extend to the skin surface. Diagnostic information might be obtained from a non-imaging and non-invasive test based on skin-surface electropotentials.

METHODS

In 661 women, scheduled for open biopsy at eight European centres, we studied whether measurements of breast electrical activity with surface sensors could distinguish benign from malignant breast disease. A depolarisation index was developed.

RESULTS

We found a highly significant trend of progressive electrical changes according to the proliferative characteristics of the biopsied tissue. Discriminatory information was obtained in both premenopausal and postmenopausal women, and the index was not related to age. The best test performances were for women with palpable lesions. The median index was 0.398 for non-proliferative benign lesions, 0.531 for proliferative benign lesions, and 0.644 for cancer (ductal carcinoma-in-situ and invasive). A specificity of 55% was obtained at 90% sensitivity for women with palpable lesions when a discriminant based on age and the depolarisation index was used.

INTERPRETATION

This new modality may have diagnostic value, especially in reducing the number of unnecessary diagnostic tests among women with inconclusive findings on physical examination. Understanding and control of the biological variability of these electrical phenomena will be important in the improvement of this test. Studies in populations with a lower cancer prevalence are needed to assess further the diagnostic value of this approach.

Enhancing awareness of hospice through physician assisted living: public health perspectives

The provision, management, and financing of care for patients with irreversible diseases has become increasingly complex in this era of advanced medical technology. With enhanced capabilities of medicine to prolong life, clinical practice has taken on legal and ethical dimensions that reach beyond the traditional scope of medicine. This paper demonstrates that hospice represents a major area of public health practice and research. It argues for enhanced involvement of public health practitioners and academics in the design and evaluation of efforts to encourage appropriate use of hospice for patients with irreversible diseases. The physician assisted living intervention in Connecticut represents one such effort. However, ongoing educational efforts targeted at both the public and health care providers are needed to ensure that all those with irreversible diseases fully understand and have access to hospice care at the end of life.

[Therapeutic alternatives in the treatment of class T1N0 squamous cell carcinoma of the penis: indications and limitations]

At INT of Milan between 1964 and 1990, 204 consecutive native patients suffering from penile cancer have been treated. 101 (59%) patients out of 171 with invasive cancer (23 affected with Tis were excluded) have been classified T1N0M0. 74 patients have been treated with penis conserving methods, such as circumcision, radiotherapy, laser excision and primary chemotherapy + conserving surgery. Overall local failure and/or nodal relapses occurred in 27% (20/74). Relapses are significantly related with grading but there isn't any relationship with macroscopical aspect or size of the tumor. The conservative treatment had been possible in 80% of patients. In our experience T1N0 clinical stage conservative therapy does not worsen the prognosis.

Results of a breast-cancer-surgery trial compared with observational data from routine practice

BACKGROUND

The strength of randomised controlled trials (RCTs) is that they allow investigators to draw reliable inferences about treatment differences; physicians can then make a choice between different options. Their weakness is that they are conducted on a set of patients who cannot be regarded as a random sample from the population that will be treated outside the trial. Observational data collected in a prospective clinical database may provide more realistic estimates.

METHODS

At the Istituto Nazionale de Tumori of Milan an RCT was started in 1973 (MI1) in which Halsted mastectomy was compared with quadrantectomy plus axillary dissection and radiotherapy (QUART), a breast conserving treatment, for "early-stage" primary breast cancer. In addition, a prospective clinical database was established to collect, in standard format, information on all women undergoing breast conservation thereafter and followed up at the Institute. 1760 women were treated with QUART, 350 of them being accrued in the years 1973-80 in the context of the MI1 trial. The remaining 1408 received QUART after the MI1 trial, up to December, 1984.

RESULTS

In the years after the trial, the criteria for use of QUART became more liberal. However, after adjustment for baseline characteristics, out-trial patients fared no worse than trial patients in terms of survival or distant metastasis. Out-trial patients did have a slightly higher rate of local recurrence, probably because of subtle and multiple changes in the surgical procedures since the time of the trial.

INTERPRETATION

The results of QUART in out-trial patients resembled those reported from research settings. In this instance, the results of clinical trials did not exaggerate the benefits obtainable in routine practice.

Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events

BACKGROUND

Local disease recurrences are a concern in conservative breast cancer surgery, and many studies have attempted to identify risk factors for these events. It is important to distinguish local recurrences linked to increased risk of distant spread from those due to inadequate local treatment.

PURPOSE

We evaluated the incidence of local and distant recurrences according to demographic, biological, and pathologic variables in a large series of women who were conservatively and uniformly treated for breast cancer, with the aim of identifying women in whom local failure is predictive for distant metastases and who are therefore candidates for aggressive systemic treatment.

METHODS

Medical records of 2233 women who had been hospitalized at the Milan Cancer Institute from 1970 to 1987 were analyzed. All women received quadrantectomy and axillary lymph node dissection followed by radiotherapy for the breast. Quadrantectomy is breast-conserving removal of most of the affected quadrant by a radial incision that includes part of the skin. The end points considered were local failures (including local recurrences and new ipsilateral carcinomas) and distant metastases. Statistical analysis employed the competing risks and multiple failures approaches.

RESULTS

There were 119 local recurrences, 32 new ipsilateral carcinomas, and 414 distant metastases as first events. The timing of local failures and distant metastases differed: The yearly probability for local failures was approximately 1% up to the 10th year and for distant metastases was 5% in the 2nd year and decreased progressively until the 8th year. Young age was an important risk factor, with peritumoral lymphatic invasion also predictive for local and distant recurrences. Tumor size and axillary lymph node involvement were not related to local recurrence but were important predictors of distant metastases. Extensive intraductal component was only a risk factor for local recurrence. Early (< 2 years) local failure predicted for distant metastases compared with later failure. In local failure patients, the 5-year survival rate was 69% from failure.

CONCLUSIONS

Local recurrences and distant metastases are partially independent events that occur at different times; several predicting factors also differ. However, women with local recurrences have increased risk of distant metastases. In particular, women 35 years old or younger at first diagnosis who had initial peritumoral lymphatic invasion and local recurrence within 2 years are at high risk for distant spread. For recurrence in cases with an extensive intraductal component or where initial local surgery was possibly inadequate, women are at lower risk.

Endocrinological and clinical evaluation of two doses of formestane in advanced breast cancer

Formestane is a selective inhibitor of oestrogen synthesis by aromatase enzymes and induces disease regression in breast cancer patients. This phase II randomised study was carried out to determine whether there were any differences in the effects of two different doses of formestane on oestradiol (E2) serum levels and to evaluate the corresponding clinical activity in post-menopausal patients with positive or unknown oestrogen receptor status pretreated or not for advanced disease. Furthermore, possible drug interference with adrenal steroidogenesis was assessed by measuring 17-hydroxycorticosteroid (17-OHCS) urinary levels. A total of 143 patients entered the study and were randomly assigned to receive formestane 250 mg (72 patients) or formestane 500 mg (71 patients), both given i.m. every 2 weeks. In comparison with baseline, E2 serum levels decreased by an average of 40% after only 15 days and remained unchanged thereafter, with no difference being observed between the two doses. The values of 17-OHCS remained unchanged during treatment in both groups. Objective responses were 28% (19/69) in the 250 mg and 46% (31/68) in the 500 mg group. In conclusion, the two formestane doses were equally effective in reducing E2 levels without affecting adrenal function, and in inducing a considerable percentage of clinical responses.

Effect of menstrual phase on surgical treatment of breast cancer

1175 premenopausal women whose date of last menstrual period was known were followed up for up to 20 years (average 8 years) after surgery for breast cancer. 525 patients were in the follicular phase and 650 in the luteal phase. We observed 192 unfavourable events among patients operated on during the follicular phase (36.6%) and 192 among patients operated on during the luteal phase (29.6%). The effect of phase was restricted to patients with positive axillary nodes. The 5-year relapse-free survival was 75.5% in 246 node-positive patients operated on during the luteal phase and 63.3% in 190 node-positive patients who had surgery during the follicular phase. The hazard ratio at Cox multivariate analysis was 1.329 for all patients (p = 0.006) and 1.431 for node-positive patients (p = 0.03). In our study, premenopausal patients with breast cancer and positive axillary nodes operated on during the luteal phase had a significantly better prognosis than patients operated on during the follicular phase. It may be that the processes of cell metastases, such as loss of adhesiveness, may be enhanced by high concentrations of unopposed oestrogens or by reduced activity of natural killer cells during the first half of the menstrual cycle.

Soft tissue sarcoma of the breast after conservative surgery and irradiation for early mammary cancer

At Istituto Tumori of Milano in a series of 3295 patients treated with conservative surgery and radiotherapy for breast cancer from 1973 to 1989 three cases of soft tissue sarcoma were observed in irradiated breasts. One patient developed a fibrosarcoma of the breast stroma, 16 months after irradiation. A grade II bulky angiosarcoma was diagnosed in the breast of a patient treated 59 months previously. The third was a grade II angiosarcoma detected 41 months after therapy. At present, the risk of a second primary in the irradiated breast seems too low to justify modification of our present policy of conservative therapy of breast cancer, but a careful and longer follow-up is needed.

Radiotherapy after breast-preserving surgery in women with localized cancer of the breast

BACKGROUND AND METHODS

Conservative surgery and radiotherapy have become well-established treatments for breast cancer, and many trials in progress are attempting to define the most acceptable type of procedure. Between 1987 and 1989 we randomly assigned 567 women with small breast cancers (< 2.5 cm in diameter) to quadrantectomy followed by radiotherapy or to quadrantectomy without radiotherapy. All patients underwent total axillary dissection. The median follow-up period was 39 months (range, 28 to 54).

RESULTS

The incidence of local recurrence was 8.8 percent among the patients treated with quadrantectomy without radiotherapy, as compared with 0.3 percent among those treated with postsurgical radiotherapy (P = 0.001). However, there was a substantial effect of age: patients more than 55 years old who did not receive radiotherapy had a low rate of local recurrence (3.8 percent). The four-year overall survival was similar in the two treatment groups.

CONCLUSIONS

Administering radiotherapy after quadrantectomy reduces the risk of local recurrence in women with small cancers of the breast, but radiotherapy may not be necessary in elderly women.

Breast carcinoma presenting as axillary metastases without evidence of a primary tumor

BACKGROUND

Sixty cases of axillary metastases from clinically occult breast cancer were analyzed. All cases had histologic evidence of metastatic nodes compatible with breast carcinoma.

METHODS

Thirty-three patients underwent breast surgery at the time of histologic diagnosis of the axillary metastases, 6 patients were treated with radiation therapy to the breast, and 17 patients did not receive any immediate treatment of the breast carcinoma (9 of these subsequently had a primary breast carcinoma) during the follow-up. Thirty-seven of 60 patients underwent adjuvant therapy (29 underwent chemotherapy and 8 underwent tamoxifen therapy). From the histologic point of view, the number of metastatic nodes was 1 in 13 patients, 2 to 3 in 10 patients, and 4 or more in 23 patients; the number of metastatic nodes was not evaluable in 14 cases. Invasion was extranodal in 92% of cases. Eighty-six percent of cases were histologically classified as Grade 3 according to Bloom and Richardson.

RESULTS

The 5-year and 10-year survival rates were 77% and 58%, respectively. The comparison between the survival curves of the patients treated with immediate surgery/radiation therapy and of the patients whose cases were followed-up without treatment to the breast showed no difference. Adjuvant treatments did not improve prognoses.

CONCLUSIONS

The coexistence of a minimal (or unidentifiable) primary carcinoma with an extensive involvement of axillary nodes and a predominance of the undifferentiated histologic type, together with an unexpectedly good prognosis, makes this type of presentation an interesting example of a dissociated host resistance.

Breast carcinoma presenting as axillary metastases without evidence of a primary tumor

BACKGROUND

Sixty cases of axillary metastases from clinically occult breast cancer were analyzed. All cases had histologic evidence of metastatic nodes compatible with breast carcinoma.

METHODS

Thirty-three patients underwent breast surgery at the time of histologic diagnosis of the axillary metastases, 6 patients were treated with radiation therapy to the breast, and 17 patients did not receive any immediate treatment of the breast carcinoma (9 of these subsequently had a primary breast carcinoma) during the follow-up. Thirty-seven of 60 patients underwent adjuvant therapy (29 underwent chemotherapy and 8 underwent tamoxifen therapy). From the histologic point of view, the number of metastatic nodes was 1 in 13 patients, 2 to 3 in 10 patients, and 4 or more in 23 patients; the number of metastatic nodes was not evaluable in 14 cases. Invasion was extranodal in 92% of cases. Eighty-six percent of cases were histologically classified as Grade 3 according to Bloom and Richardson.

RESULTS

The 5-year and 10-year survival rates were 77% and 58%, respectively. The comparison between the survival curves of the patients treated with immediate surgery/radiation therapy and of the patients whose cases were followed-up without treatment to the breast showed no difference. Adjuvant treatments did not improve prognoses.

CONCLUSIONS

The coexistence of a minimal (or unidentifiable) primary carcinoma with an extensive involvement of axillary nodes and a predominance of the undifferentiated histologic type, together with an unexpectedly good prognosis, makes this type of presentation an interesting example of a dissociated host resistance.

The preservation of minor pectoralis muscle in axillary dissection for breast cancer: functional and cosmetic evaluation

We have evaluated, in two groups of 50 patients each submitted to axillary dissection for breast cancer (10 mastectomies and 90 conservative procedures), the advantage of the preservation of the minor pectoralis muscle. This muscle was preserved in one group and removed in the other. Whereas in the immediate postoperative period complications (shoulder pain, functional impairment, quantity or duration of serum drainage from the axilla) were the same in the two groups, at longer follow-up (more than 6 months after surgery) the patients whose pectoralis minor muscle was preserved showed a reduction in the incidence of partial atrophy and fibrosis of the pectoralis major muscle. Patients treated with conservation of the pectoralis minor muscle showed this atrophy in 6% of cases vs 54% observed in the other patients. This fact may be related to disruption of the pectoral nerves, which are in close contact with the pectoralis minor during their course from the brachial plexus to the pectoralis major muscle.

Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer

148 consecutive patients treated by two different types of conservative surgery were objectively and subjectively evaluated for cosmetic outcome. In 73 patients, tumorectomy, axillary dissection, external radiotherapy (45 Gy) plus iridium implant (15 Gy) were performed, while in the other group of 73 patients a more extensive surgical approach was carried out: quadrantectomy, axillary dissection plus external radiotherapy (50 + 10 Gy). The appearance of the patients' breasts was analysed for symmetry by computer, and differences in symmetry were correlated with tumour location and breast size. A subjective assessment was given by a 3-member panel and the results were correlated with objective measurements. In addition, patients were asked to fill out a self-assessment questionnaire on the aesthetic result of the operated breast. Better results were generally noted in the group of patients treated by more conservative surgery. Substantial differences in the aesthetic outcome were noted between the patient's own evaluation, the computer's measurement of symmetry and the assessment of the panel of observers.

Distribution of axillary node metastases by level of invasion. An analysis of 539 cases

Five hundred and thirty-nine patients with carcinoma of the breast treated with total axillary dissection and with positive axillary nodes were evaluated. The total number of lymph nodes removed was 11,082, with an average of 20.5 nodes per patient. The average number of lymph nodes at the first level was 13.8, at the second level 4.5, at the third level 2.2. The average number of nodes was 20.7 in cases treated with Halsted mastectomy, 20.9 with total mastectomy and axillary dissection, 20.3 with quadrantectomy and axillary dissection. Of 3259 metastatic nodes, 64 were site of micrometastases; 797 were partially involved, 441 were totally involved and 1957 were site of metastases with extracapsular invasion. In 314 (58.2%) the first level only was involved, in 117 cases (21.7%) metastases were present at the first and second level, whereas in 88 cases (16.3%) all the three levels were sites of metastases. Only 20 cases showed skipping distribution. In 1.5% of the cases the first level was skipped by metastases, in 0.4% the first nodes of the first level are clear the chances that metastatic nodes are present at the second and third levels are negligible. When the nodes at the first level are positive, the chances that metastases are also present at the higher levels are of the order of 40.0%.