Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria

BACKGROUND

Several studies have suggested that breast cancer in black women is associated with aggressive features and poor survival. This study examines molecular markers along with clinical stage and pathological grade in breast cancer material from Jos, Nigeria.

STUDY DESIGN

The histological diagnoses of 178 consecutive Nigerian patients with breast cancer were retrieved from their hospital records. A subset of 36 patients was staged and their tumours typed and graded. Immunohistochemical staining of sections from paraffin wax embedded tissues from these cases for the expression of oestrogen receptor (ER), progesterone receptor (PGR), Human ERBB2 (or HER2/neu), p53 and cyclin D1 (CCND1) was carried out using the avidin biotin complex (ABC) procedure.

RESULTS

A majority of the cases were invasive ductal carcinoma (92.7%), high grade (grade 3, 70.6%) and of late clinical stage (stages III and IV, 58.3%). Only 25% and 27.8% of cases expressed ER and PGR respectively. The ERBB2 and CCND1 antigens were expressed in 25%, and 5.7% of cases respectively. The p53 protein was the most frequently expressed in this study (47.2% of cases). High grade tumours were significantly more likely to be ER and PGR negative (P = 0.006 and P = 0.002 respectively). CONLCLUSION: There is predominance of high grade, invasive ductal carcinomas which are likely to be ER and PGR negative but p53 positive. These features suggest a biologically aggressive form of breast cancer in Nigerian women with the possibility of poor response to both hormonal therapy and chemotherapy.

Taking responsibility for cancer treatment

One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n = 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n = 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n = 41) and a Surgeon Decision Group (n = 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Information and support needs of women with primary relatives with breast cancer: development of the Information and Support Needs Questionnaire

AIMS OF THE STUDY

The aim was to develop and pilot test a newly developed measure, The Information and Support Needs Questionnaire (ISNQ), for use with women with primary relatives with breast cancer.

BACKGROUND/RATIONALE

Breast cancer is a major risk to the health of women in the United Kingdom (UK). Increasingly, research is documenting women's needs for information and support, particularly at the time of diagnosis. However, to date there is little understanding of the information and support needs of women who have a family history of breast cancer. Contributing to the dearth of understanding of female relatives' needs is the lack of valid and reliable instruments for use in descriptive and intervention research with this population.

DESIGN/METHODS

The ISNQ and survey items documenting family history, sources of information and support for breast cancer risk, breast self-care practices, and other variables were pilot tested for the acceptability of the measures, appropriateness of the data collection methods, initial psychometric properties of the ISNQ, and time and financial costs of administration. Data were collected from 39 women living in the North-west of England who had primary relatives with breast cancer using mailed questionnaires and follow-up telephone interviews.

FINDINGS

The items on the ISNQ were reported to be clear, acceptable to women and to yield relevant data. The psychometric properties of the new measure were satisfactory with a high reliability coefficient alpha. Descriptive findings indicate that women had moderate to high needs for information and support, but reported that these needs were not well met.

CONCLUSIONS

The results of this pilot are guiding the development of a larger study in which the information and support needs of women with a family history of breast cancer are explored.

The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature

AIM

Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome.

METHODS

Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status.

RESULTS

Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates.

CONCLUSION

This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres.

Student assessment in undergraduate medical education in the United Kingdom, 1998

This report describes the results of the project 'Assessment of Undergraduate Medical Education: Re-inventing the Wheel?' funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

An evaluation of information cards as a means of improving communication between hospital and primary care for women with breast cancer

This paper describes an intervention study aimed at improving communication between hospital services and the primary health care team. A series of information cards were developed by breast specialist secondary care professionals for members of the primary health care team. Women with breast cancer were involved in the communication pathway and were asked to take the information cards to their own general practitioner (GP) practice. It was envisaged that women would be more likely to utilize the primary health care team for information if they were aware that the primary health care team was in receipt of information specific to the treatment they had received. Women newly diagnosed with breast cancer were allocated to either an intervention (n=38) or non-intervention (n=38) group. Patient interviews were carried out around the time of diagnosis and at 4 months from diagnosis. Interviews were also carried out with 31 GPs to ascertain their views on the provision of information for women with breast cancer, and on the information cards if relevant. The study findings were interesting although not significant in terms of the direction anticipated. The cards did not impact on the utilization of the primary health care team and women in the intervention group were no more likely to utilize primary care sources of information than women in the non-intervention group. Factors such as the long-standing relationship women had with their GP, the perceived lack of specialist knowledge on the part of GPs and district nurses, and the women's perception that information seeking was not a tangible reason for primary care contact had an impact on information-seeking behaviour.

Impact of molecular biology on the clinical management of breast cancer

The use of molecular markers is being explored in the prediction of risk of developing breast cancer, in the assessment of prognosis and in the identification of appropriate treatment. Rational selection of treatment for a patient requires an accurate assessment of the prognosis and prediction of the response to a given treatment. Neither of these is possible with current clinicopathological markers. As a result, the current management of breast cancer is empirical, based on the outcome of randomized clinical trials that examine average effects within populations. Clinicopathological factors can be used to separate patients into broad prognostic groups, and treatment decisions are made on this basis. With this approach up to 70% of patients receive adjuvant treatment that is either unnecessary or ineffective. Molecular biological markers have the potential to improve this situation. A wide range of markers have been shown to be predictors of prognosis, but added individually to current prognostic indicators they do not improve the functional accuracy of prognosis or response prediction. There is a need for a molecular prognostic index that combines the results of a number of markers and can be used in conjunction with a clinical index to produce a more useful prognosis. There is also a need for an index that will predict responses to specific treatments. The impact of molecular biology on clinical management is a revolution waiting to happen.

The relationship between breast asymmetry, breast size and the occurrence of breast cancer

Breast cancer is the second most common cancer among women in the world and in developed countries it is the most common. The early identification of women at risk is therefore of great importance and any additional measures which may aid diagnosis, particularly in high risk groups, would be of benefit. Breast volume and breast asymmetry were calculated from mammograms of 250 women with breast cancer and compared with those of 250 age-matched controls. There was evidence that breast cancer patients had more breast asymmetry and larger breasts than age-matched healthy women. The former observation is the first evidence that high breast asymmetry may be a risk factor for breast cancer. Breast asymmetry is likely to be a predictor of, rather than the effect of breast cancer.

Examining the technique of angiogenesis assessment in invasive breast cancer

The intensity of angiogenesis as measured by the density of microvessels has been reported to be associated with a poor prognosis in invasive breast cancer in some, but not all, studies. The reasons for these discrepancies may be variations in the methodologies used. The monoclonal antibody used to identify the microvessels, the number of high-density areas or 'hotspots' counted and the type of value taken for statistical analysis (highest count or mean count) have varied between the different studies. We have assessed which of the three commonly used monoclonal antibodies provides the best visualization of microvessels in invasive breast cancer and have used methods that give reproducible data for the optimum number of 'hotspots' to count for each reagent. Thus, microvessels in formalin-fixed paraffin-embedded specimens from 174 primary breast cancers were immunohistochemically stained with monoclonal antibodies to FVIIIRAg, CD31 and CD34 and ten fields counted at 200 x magnification for each antibody. The highest count and the mean value of the highest of three, five and ten counts were used to examine the relationship between the density of microvessels and overall survival of patients with a median follow-up time of 7.1 years. Antibodies to CD31 and CD34 identified more vessels than antibodies to FVIIIRAg (median highest count per mm2: CD31 = 100, CD34 = 100, FVIIIRAg = 81). The monoclonal antibody to CD31, however, was the least reliable antibody, immunohistochemically staining only 87% of sections compared with 98% for the monoclonal to CD34 and 99% for the monoclonal to FVIIIRAg. There was a high degree of correlation between the number of vessels stained by the different antibodies, though there were some considerable differences in actual counts for serial sections of the same specimen stained by the different antibodies. Patients could be divided into two groups corresponding to those with high microvessel densities and those with low microvessel densities. Using Kaplan-Meier survival curves, there was a close association for all three antibodies between vessel density and survival whichever method of recording the highest vessel densities was used. Using log-rank tests and Cox's regression analysis, anti-CD34 gave the most significant results of the three antibodies, whereas a simple cut-off at the 75th percentile for the high and low groups produced the best association with patient survival. For anti-CD34 the highest microvessel density (P = 0.0014) and the mean value of the highest three microvessel densities (P = 0.004) showed a good correlation with patient death, whereas for anti-CD31 (P = 0.008) and anti-FVIIIRAg (P = 0.007) the highest count gave the best correlation using Cox's regression analysis.

Is a histological section representative of whole tumour vascularity in breast cancer?

The assessment of a tumour's angiogenic potential, by measuring the microvessel density in histological sections, assumes that a 4-microm section is representative of whole tumour vascularity. This study has examined this assumption by comparing the vessel density found radiologically, after injecting specimens with contrast, with that found immunohistochemically. Twenty-one breast angiograms were performed following mastectomy for carcinoma and graded 1-3 for vessel density. Sections (4 microm) from these carcinomas were labelled for endothelial cells using anti-CD34, and the vessel counts were compared with the radiological grades. A significant correlation was found between the densities (P < 0.003, Kruskal-Wallis one-way ANOVA). We therefore conclude that the microvessel density measured in histological sections is representative of whole tumour vascularity.

Meaning of illness for women with breast cancer

The meaning that women with breast cancer ascribe to their disease may well have an impact on the effectiveness of coping strategies used to come to terms with breast cancer. Health care professionals need to know what meanings women with breast cancer are ascribing to their disease if they are to identify maladaptive coping strategies and ensure that women receive the support that they need in order to promote physical and psychological recovery. This study involved assessing meaning of illness for a group of women with breast cancer at two points in time, the time of diagnosis and a mean of 21 months from diagnosis. The eight meanings of illness devised by Lipowski were depicted by the following words: challenge, enemy, punishment, loss, strategy, relief, weakness and value. The most popular choice of meaning for the women was challenge, although some women's choices indicated that maladaptive coping strategies were being used. The implications of the study for nurses and other health care professionals are discussed.

Information needs and sources of information for women with breast cancer: a follow-up study

This paper reports a study which examined the specific information needs and sources of information for 105 women with breast cancer at two time points, the time of diagnosis and a mean of 21 months from diagnosis. At diagnosis the priority information needs concerned survival issues. Further from diagnosis survival issues were still a concern, but information about the risk to family members of getting breast cancer showed a significant increase in importance. Information about sexual attractiveness was ranked last at both the newly diagnosed and follow-up stages. Information sources at the time of diagnosis centred around the specialist breast care service, while further from diagnosis few professional or voluntary sector sources were utilized, with women receiving most of their information from media sources such as women's magazines. The relevance of these findings for nurses and other health care professionals is discussed.

Treatment decision making in women newly diagnosed with breast cancer

The purpose of this study was to explore the hypothesis that women with breast cancer had specific preferences about the degree of control they wanted over treatment decision making. One hundred fifty women, newly diagnosed with breast cancer, were interviewed and their preferences for participation in treatment decision making were established using a measurement tool designed to elicit decision-making preferences (Degner LF, Sloan JF. Decision making during serious illness: What role do patients really want to play? J Clin Epidemiol 1992;45:944-50). Two hundred women with benign breast disease served as a descriptive comparison group. Unfolding theory (Coombs CH. A theory of data. New York: John Wiley & Sons, 1964) provided a means of analyzing the data so that the degree of control preferred by each woman could be established. The majority of the newly diagnosed women preferred to play a passive role in treatment decision making, leaving the decision-making responsibility to their physician, whereas the benign control group preferred a collaborative role in which joint decisions could be made between the patient and the physician. The implications of the results for patient participation are discussed.

Impact of fine-needle aspiration cytology, ultrasonography and mammography on open biopsy rate in patients with benign breast disease

The management of breast disease has been influenced by breast imaging and fine-needle aspiration cytology (FNAC) for preoperative diagnosis. To investigate the impact of introducing an in-clinic FNAC service on patient management, the pathology records of patients presenting before and after introduction of the service were studied. Four management changes emerged. The number of patients investigated by histology and/or cytology increased (from 266 to 503), as did specimen numbers (392 to 728). The use of pathological services changed, with more cytology specimens (39 to 554), fewer needle-core biopsies (62 to three) and fewer excision biopsies (245 to 118). The number of patients admitted for surgery fell, especially those with a benign histological diagnosis (174 to 49). These figures demonstrate a change in the management of benign breast disease, from surgery with histopathological diagnosis to cytological diagnosis with surgery only if indicated clinically or from imaging.

The information needs of women newly diagnosed with breast cancer

Nurses can play a key role in patient education, including providing patients with useful and appropriate information. Rather than focusing on the process of education or information giving by nurses, this study places emphasis on the content of that information by taking the patients' perspective and asking the patients themselves what particular types of information are perceived as important at a specific point in time. The aim of the study was to explore what particular types of information were important to women newly diagnosed with breast cancer; to enable nurses and other health care professionals to utilize their time as effectively as possible and provide a high-quality service to individuals in their care. Women with breast cancer (a mean of 2.5 weeks from diagnosis) were interviewed and asked to compare items of information. The items of information were presented in pairs and the women stated a preference for one item in that pair. Thirty-six pairs were presented in total. The analysis involved the use of a Thurstone scaling model, which allowed rank orderings, or profiles of information needs, to be developed, reflecting the perceived importance of each item. Information about the likelihood of cure, the spread of the disease and treatment options were perceived as the most important items of information at the time of diagnosis. Other information needs, in order of descending priority, included information about the risk to family, side-effects of treatments, impact on family, self-care, effect on social life and sexual attractiveness. Profiles of information needs were produced to take account of differences in age, level of education and social class.(ABSTRACT TRUNCATED AT 250 WORDS)

The value of guidelines in a breast screening service

The use of agreed guidelines in the management of common surgical and medical conditions has received much attention and enjoys varying degrees of support. In May 1992 the UK Breast Screening Programme produced guidelines with the intention of providing criteria for all units to attempt to achieve. We have investigated these guidelines as a means of comparative audit and stimulus for change. Two units were compared, one in a teaching centre and the other in a district general hospital. Although both units performed for the most part within the guidelines, areas where improvement could be made were identified and measures to correct deficiencies taken. This resulted in improved performance in those areas. The study demonstrates that guidelines can have considerable benefit in helping to identify problems in the provision of care and introducing measures to improve the situation.

The relationship between serum p53 autoantibodies and characteristics of human breast cancer

Sera from 182 newly diagnosed breast cancer patients were assayed for antibodies to p53 using an enzyme-linked immunosorbent assay (ELISA) method, and antibodies were detected in 48 (26%) compared with 1 out of 76 (1.3%) normal control volunteers (P = 0.0001). In breast cancer patients, autoantibodies were found in all stages of disease progression: carcinoma in situ, primary invasive breast cancer and in metastatic disease. In the subset of patients in whom sequential sera were assessed over a 6 month period, changes in the p53 antibody titres were observed. The presence of antibodies to p53 correlated positively with high histological grade (P = 0.0012) and a history of second primary cancer (six positive out of eight cases). The incidence of autoantibodies was lower in those patients with a first-degree relative with breast cancer (P = 0.046). Out of 68 patients, there was a significant correlation between positive p53 autoantibody status and the detection of p53 protein in the tissue sections by immunocytochemistry (P = 0.002). In the seronegative patients, positive p53 tumour staining was strongly associated with a family history of breast cancer (P = 0.009). The p53 protein overexpressed in heritable breast cancers may therefore be less immunogenic. The presence of p53 autoantibodies provides important additional information to immunochemistry and may identify patients with aggressive histological types of breast cancer.

Serum p53 auto-antibodies: incidence in familial breast cancer

Inactivation of the p53 gene, which codes for a tumour suppressor protein, is known to occur in the majority of human malignancies. An ELISA technique has been developed which has detected auto-antibodies to p53 in the serum of 25.6% of 176 women with breast cancer, considerably higher than previously reported with an immunoblotting technique. The incidence of auto-antibodies in those cases with a family history of breast cancer was 9.1%, compared to 29.4% in those with no family history (P = 0.029). In women without clinical breast cancer, 4 out of 36 (11.1%) of those with a positive family history were seropositive, compared to 1 out of 73 control women. Auto-antibodies were more frequently seen in the serum of breast cancer patients whose biopsies demonstrated overexpression of p53 protein. We conclude that auto-antibodies to p53 may have a role in the molecular characterisation of familial breast cancer.

Immunocytochemical identification of cell types in benign and malignant breast diseases: variations in cell markers accompany the malignant state

We performed immunocytochemical staining of benign, in situ, and malignant breast disease to identify antigens related to the presence of the major parenchymal cell types of the normal breast. Markers for the epithelial cells, antiserum to epithelial membrane antigen, and three monoclonal antibodies (MAb) to milk-fat globule membranes stained most of the inner cells in benign breast lesions, carcinoma in situ, and invasive carcinomas, but the peripheral cells in benign lesions, as well as in carcinoma in situ, were unstained. MAb to epithelium-specific keratin 18 stained the majority of inner cells in benign breast lesions but comparatively fewer such cells in carcinoma in situ and invasive carcinoma. Markers for the myoepithelial cells, antisera, and MAb to smooth muscle actin and vimentin stained most of the peripheral cells in benign breast lesions and in carcinoma in situ but failed to stain virtually any neoplastic cells in invasive carcinomas. Markers for the basement membrane adjacent to the myoepithelial cells, antiserum, and MAb to laminin and Type IV collagen delineated an intact basement membrane around benign lesions and carcinoma in situ, and fragmented structures in 5-10% of invasive carcinomas; the remaining carcinomas were largely unstained. Markers for both myoepithelial and epithelial cells, keratin MAb PKK2 and LP34, stained most of the inner cells in benign lesions but usually only relatively few malignant cells in carcinoma in situ and invasive carcinomas. Markers for the secretory alveolar cell, MAb to beta- and kappa-casein, stained a few isolated cells in benign lesions, many more inner cells in two such lesions in pregnant females, and none in invasive carcinomas. In conclusion, the myoepithelial cell and, under suitable hormonal conditions, the secretory alveolar cell, are retained in most benign lesions, but they are largely lost in invasive carcinomas.

Prognostic significance of cathepsin-D in patients with breast cancer

The expression of the protease cathepsin-D has been evaluated using an immunohistochemical technique with a polyclonal antibody in paraffin-embedded tissue from 359 patients treated between the years 1975-1981 for Stage I and II breast cancer. One hundred and twenty seven patients (35%) have strongly positive, granular staining, 138 (38%) are intermediately stained in the cytoplasm, and in 94 (26%) no staining is observed. There is a strong positive association between expression of cathepsin-D and the presence of tumour in axillary lymph nodes (P < 0.006). Expression of the protease is associated with significantly poorer survival of patients in univariate analysis (P = 0.025); however, this is not independent of other tumour variables.

The role of magnetic resonance imaging in the assessment of local recurrent breast carcinoma

Experience with magnetic resonance imaging (MRI) of the breast remains limited. MRI studies to date have shown that differentiation of carcinoma from certain benign breast changes can be difficult. The problem of suspected tumour recurrence in patients with known but treated breast carcinoma is considered. Forty-five patients were studied, all having been treated by lumpectomy combined with radiotherapy and/or chemotherapy. Suspicion of recurrence was suggested by X-ray mammography or clinically by the presence of a current breast mass, breast pain, or nipple discharge. The principle differential diagnosis rested between post-treatment fibrosis and recurrent tumour. Axial and sagittal images were obtained using T1-and T2-weighted pulse sequence. Images were enhanced with intravenous gadolinium DTPA in cases where there was a mass. The tomographic format and inherent high soft tissue contrast provided by MRI are of particular value in this situation. The morphological appearances of recurrent tumour, fibrosis, and other post-radiation affects are described and compared. MRI allowed accurate differentiation in the majority of case. In equivocal cases enhancement of mass lesions with gadolinium DTPA provided excellent confirmatory evidence of recurrent tumour.

Threat and loss in breast cancer

The psychological well-being of forty-four breast cancer patients was assessed shortly before and after surgery, and at three and twelve months post-operatively. Regression analysis revealed type of treatment, control over treatment and concern for appearance as significant predictors of nature of subsequent mood state. Results are discussed with reference to the theoretical position that type of severe life event can predict the nature of ensuing psychological disorder.

Viral involvement in breast cancer

Particles containing reverse transcriptase activity have been detected in metastatic cells. This suggests that there may be viral particles within the primary tumour. The concept that this virus is oncogenic, and is an aetiological agent in breast cancer is attractive, although presently, there is no evidence of this nor of the mode of viral transmission.

A randomised controlled trial of adjuvant hormono-chemotherapy in Stage II breast cancer

From 1979 to 1984 women with histologically proven Stage II breast cancer were entered into a randomised controlled trial of adjuvant hormono-chemotherapy following mastectomy. Adjuvant therapy was started within 2 weeks of surgery and was given for 6 months as continuous 'Tamoxifen' and 6-monthly cycles of vincristine, adriamycin and cyclophosphamide (VAC). Of the 157 women randomised 82 were assigned to the control group and 75 to the adjuvant group. Comparing the two groups by life table analysis the rate of recurrence was found to be significantly greater in the control group (n = 46) than in the adjuvant group (n = 25) (Peto log rank test chi 2 = 7.46 P less than 0.01). Although there were more deaths amongst the control patients (n = 31) than in those randomised to receive adjuvant therapy (n = 18), this difference did not achieve statistical significance (chi 2 = 2.80 P less than 0.1). This analysis has shown that although adjuvant hormono-chemotherapy may significantly delay recurrence the trial has failed to demonstrate any significant improvement in the survival of women with Stage II breast cancer following mastectomy.

Postoperative glucose metabolism in patients with gastrointestinal malignancy

Patients with gastrointestinal malignancy demonstrate impaired postoperative glucose disposal (17.5 +/- 1.4 mumol/kg min vs 28.9 +/- 2.5 mumol/kg min; P less than 0.001) and a reduced insulin response, during steady state hyperglycaemia, when compared with control. Analysis of glucose disposal when compared with insulin concentration suggested insulin resistance as a factor in the causation of impaired glucose disposal. In the control group both glucose disposal and insulin response demonstrated a negative correlation with malnutrition score (as assessed by a 13 factor, three grade scoring system), whereas in the cancer group only the insulin response was related to malnutrition score. However, the insulin response in the cancer group was quantitatively different from control subjects. The possible clinical implications of these findings are discussed.

A prospective 10-year study of the post-thrombotic syndrome in a surgical population

A total of 564 patients undergoing laparotomy entered a prospective 10-year study to determine the influence of postoperative DVT relative to other thrombotic episodes on the subsequent development of post-thrombotic syndrome (PTS). Pre-existing venous thrombotic disease and postoperative thromboses were assessed at the initial hospitalisation. Subsequent thrombotic episodes and signs of PTS have been monitored at biennial review. Thirty-five patients had PTS by the tenth year but it was already present in 16 before the index operation. Twenty-six patients without previous thrombotic episodes developed spontaneous DVT or phlebitis during the 10-year follow-up. New leg ulcers developed in six patients. Although all thrombotic episodes, irrespective of the relation to the index operation, increased the risk of PTS, most PTS occurred in patients without recognised DVT, although most had lesser venous problems prior to operation. PTS should be seen as resulting from the summation of a number of incidents of damage to the leg veins rather than one postoperative incident. Direction of prophylactic effort to patients with pre-existing venous problems may best reduce PTS among patients undergoing abdominal surgery, but will not make a major impact on the total population incidence of PTS.

Sequential chemotherapy, surgery and radiotherapy in locally advanced breast cancer

Thirty-seven patients with locally advanced breast cancer, 86% of whom had skin involvement, were treated with three to six cycles of vincristine 1.4 mg m-2, doxorubicin 40 mg m-2 and cyclophosphamide 600 mg m-2. A complete response rate of 19%, and overall response rate of 61% were achieved. Fourteen patients had received a trial of hormone therapy, but no patient had been given prior cytotoxic chemotherapy or radiation therapy. In no case was chemotherapy discontinued on account of toxicity. In patients with partial remission where gross disease more than 3 cm remained, mastectomy (10 patients) or local excision (five patients), was carried out increasing the complete remission rate to 49%. Thirty-two patients then received 45 Gy in 24 days to the breast and regional lymphatics with a further 12 Gy boost to the tumour site. The overall response rate achieved was 86% of the 37 patients, with a total, complete response rate of 76%. The median time to relapse in the 28 complete responders was 17 months. Local palliation, defined as absence of pain, ulceration or an enlarging mass was achieved in 92% of the total number of patients, and the projected local palliation rate at 2 years by life table analysis was 60%. Only 50% of the 10 N3 patients were alive at 1 year, compared to 93% of the 27 N0-N2 patients (P less than 0.05). The overall survival in the entire group at 2 years was 50%. This is an effective and tolerable combined modality approach for the control of local disease in a subgroup of breast cancer patients with complex management problems.

Factors associated with mammographic parenchymal patterns

The relationship between mammographic parenchymal patterns and known risk factors for breast cancer was studied in 5319 consecutive women presenting for breast screening. Using a multivariate analysis, correlations were found in pre-menopausal women between breast size, weight, age at first pregnancy, history of biopsy and history of cyclical breast pain and parenchymal pattern. In post-menopausal women the parenchymal pattern correlates with breast size, weight, weight change, age at first pregnancy, a history of biopsy and a history of breast feeding. The DY pattern correlated with age, breast size, weight, history of biopsy and menopausal status. When pre-menopausal women were considered separately the DY pattern correlated only with weight and breast size.

The spontaneous disappearance of breast calcification

The spontaneous disappearance of both coarse and fine calcification in the breast was noted in 11 cases who presented either with breast symptoms or to a screening unit. While fine and coarse calcification occur in benign disease, the spontaneous regression of this finding appears not to have been reported previously.

Particles with properties of retroviruses in monocytes from patients with breast cancer

An agent with the properties of a retrovirus has been detected regularly in monocytes from patients with breast cancer. In 97% of breast cancer patients the cell-free culture medium (CFCM) in which the monocytes had been cultured possessed reverse transcriptase (RT) activity. In contrast, RT activity was detected in the CFCM from only 11% of age and sex matched controls (p less than 0.0001; Wilcoxon rank sum test). The RT activity was associated with particles having a buoyant density of between 1.165 and 1.18 g/ml, similar to that of retroviruses. Treatment of the samples with non-ionic detergent abolished the peaking of the activity in this fraction. Enveloped particles (100-120 nm in diameter) with a fringed surface resembling murine mammary tumour virus were found on negative-stain electron microscopy in CFCM obtained from patients with breast cancer. Retrovirus-like particles were also observed in the cytoplasm of giant cells formed by monocytes from these patients, and also in macrophages in breast cancer tissue; however, no such particles were detected in the tumour cells. These findings strongly suggest the presence of a retrovirus in the monocytes from patients with breast cancer. The importance of these observations in the pathophysiology of carcinoma of the breast remains to be established.

Insulin resistance in patients with colorectal cancer

The euglycaemic glucose clamp technique has been used to assess insulin resistance in patients with colorectal adenocarcinoma. Ten cancer patients were studied and compared with control subjects matched for age, sex and nutritional status. Forty-one euglycaemic clamps were performed at one of five different insulin infusion rates (20, 30, 40, 100 or 200 milliunits min-1 m-2). Glucose disposal was significantly decreased in the cancer group at all insulin infusion rates, whilst attained insulin levels and metabolic clearance rates of insulin were comparable in the control and cancer groups. Analysis of dose-response data allowed assessment of sensitivity (insulin concentration of half maximal glucose disposal) and responsiveness (maximal glucose disposal). Responsiveness was significantly reduced in the cancer group (40.3 versus 71.5 mumol kg-1 min-1; P less than 0.001), whilst sensitivity was similar (93.7 milliunits l-1 in controls versus 90.8 milliunits l-1 in cancer patients), suggesting a postreceptor defect in insulin action in the cancer group.

Alteration in monocyte function in patients with breast cancer

Migration, phagocytosis and lysozyme production of peripheral monocytes from 36 patients with breast carcinoma was compared with a group of 36 healthy controls. A significant reduction in monocyte random migration and migration towards a chemotactic agent (P less than 0.001) was observed in patients with breast cancer. Furthermore monocyte phagocytic activity was also significantly decreased (P less than 0.001) in breast cancer patients compared to the controls. In contrast lysozyme production by peripheral monocytes was significantly increased in patients with breast cancer compared to controls (P less than 0.001). The changes in monocyte function in patients with breast carcinoma were not due to abnormal blood biochemistry or to direct continuous serum inhibitors, suggesting that the defect may be intrinsic. This defect in monocyte function may play an important role in the control of malignancies by cellular immune processes.

Factors which influence the occurrence of vascular calcification in the breast

Breast arterial calcification, as seen on mammography, increases in frequency with advancing age, especially after menopause. No association was found with systemic hypertension. The number of diabetics in the series was too small for comparative purposes. An early menopause and a history of pregnancy were factors which influenced incidence. Oral contraception was associated with a lower incidence of calcification before, but not after menopause. On the other hand, hormonal preparations taken for menopausal symptoms were associated with a lower incidence of calcification in postmenopausal women.

The biopsy of impalpable lesions of the breast

It is not necessary to undertake special techniques for localization if impalpable lesions of the breast are noted on mammography before biopsy. A simple technique using measurements from the nipple to locate the lesion is described. This method reduces patient discomfort by eliminating preoperative manipulation without increasing the size of the specimen needed for biopsy of the breast. Any impalpable lesion excised must be submitted to serial section after paraffin embedding and must not be submitted to frozen section.

Cyclical mastalgia: clinical and mammographic observations in a screened population

The incidence of cyclical mastalgia in well women presenting for breast screening was 69 per cent. The incidence of cyclical mastalgia increases with age up to the menopause. There was a higher incidence of 'high risk' mammographic patterns and a lower incidence of 'low risk' patterns, according to the Wolfe classification, in women with cyclical mastalgia compared with the rest of the screened population. This finding correlated with the severity, duration and need for treatment. The differences in breast pattern did not persist after the menopause. The question of whether or not cyclical mastalgia can be regarded as a risk factor for breast cancer is uncertain and needs further evaluation.

Glucose metabolism in patients with gastrointestinal malignancy but without excessive weight loss

Patients with gastrointestinal malignancy demonstrate impaired glucose disposal during steady state hyperglycaemia, 20.5 +/- 1.4 mumol/kg min when compared with controls 28.2 +/- 2.2 mumol/kg min. This appears to be unrelated to antecedent weight loss, but is related to the presence of metastatic spread (P less than 0.05). Insulin response to hyperglycaemia is normal, but analysis of glucose disposal with time suggests insulin resistance as a factor in the causation of impaired glucose disposal. Free fatty acid levels fail to suppress in cancer patients but their role in the causation of insulin resistance remains unclear.

Altered monocyte function in patients with benign breast disease

Monocyte migration, lysozyme production and phagocytosis was studied in 34 patients with fibroadenosis, 28 patients with fibroadenoma and 48 healthy female controls. In patients with fibroadenosis and fibroadenoma, monocyte migration and phagocytic activity were significantly reduced when compared to controls (P less than 0.001). Conversely, lysozyme production by monocytes from patients with benign breast disease was significantly higher than in controls (P less than 0.001). In 20 patients with benign breast disease, there was no significant difference in monocyte function before and 3 months after operation. The observed impairment of monocyte function in fibroadenosis and fibroadenoma would not appear to be the result of abnormal blood biochemistry or due to a direct serum inhibitor, but is probably related to an intrinsic cellular defect. Further studies are required to evaluate the significance of impaired monocyte function in the pathophysiology of benign breast disease.

Elevated fibrinopeptide A levels in patients with clinically localised breast carcinoma

58 patients with clinically localised breast carcinoma, treated by either mastectomy alone or lumpectomy plus local radiotherapy, have now been followed for up to 51 months (median 12 months). 21 of the 58 patients (36.2%) had a persistently elevated or rising fibrinopeptide A level after surgery and 11 of these patients (52%) to date have subsequently developed recurrent breast carcinoma up to 27 months after the fibrinopeptide A level became elevated (median 6 months). Conversely, only 2 (5.4%) of the 37 patients with persistently normal post-operative fibrinopeptide A levels have developed recurrent disease. Elevated fibrinopeptide A levels appear to be a marker of persistent tumour activity and precede clinical recurrence in certain patients with breast carcinoma, but normal values do not exclude recurrent or residual disease.

The effect of colorectal malignancies on monocyte migration, lysozyme production, and phagocytosis

Peripheral monocyte migration, phagocytosis and lysozyme production has been investigated in 46 patients with colorectal malignancies. The diagnosis of colorectal carcinoma was based on clinical, radiological, and endoscopic examinations and confirmed histopathologically after removal of the tumour. The results were compared with a group of 36 normal healthy controls. Monocytes from patients with colorectal malignancies displayed reduced migration towards the chemotactic agent (P less than 0.001), random migration (P less than 0.001), and phagocytic activity (P less than 0.01) compared to normal controls. Lysozyme production by monocytes from patients with colorectal malignancies was significantly increased (P less than 0.01) compared to control subjects. The impairment in monocyte function in patients with colorectal carcinoma was not due to direct serum factors or to abnormal blood biochemistry, suggesting that the defect is intrinsic to the monocytes. These results suggest that an impairment in monocyte function may play an important role in the control of malignancies by cellular immune processes.

An analysis of referral patterns from a breast screening unit

The reasons for referral from a breast screening unit are reviewed, together with the subsequent outcome and biopsy findings. 4.94% of persons attending were referred for assessment in a breast clinic, biopsy being performed on 2.09% with a detection rate of 4.1 cancers per 1000. 24.4% of the cancers were palpable and 36.6% were non-invasive. A rounded ill-defined mass was the commonest mammographic reason for biopsy. Cancer was found in 15.2% of cases with microcalcification. In no case did clinical examination in the screening unit reveal cancer which was not detected on mammography.

Transformation of blood monocytes to giant cells in vitro from patients with breast cancer

Monocytes from patients with breast cancer and from control subjects were cultured under agarose for 6 days. Giant cell formation occurred in 32 out of the 36 patients with breast cancer (89 per cent). In contrast giant cell formation was only observed in two of the control subjects (6 per cent). Menstruation and menopause had no effect on giant cell formation. Furthermore, under the experimental conditions of this study, it seems unlikely that serum factors, lymphokines or phagocytic stimulators induced giant cell formation. The results therefore, suggest that giant cell formation may be initiated by viruses already present in the monocytes from patients with breast cancer. Further studies are required to confirm this hypothesis and to elucidate the significance of giant cell formation in the pathogenesis of breast cancer.