Detection of loco-regional recurrence after breast-conserving surgery and radiotherapy

This study evaluates the incidence, pattern and mode of detection of loco-regional recurrence (LRR) after conservative surgery for invasive breast cancer. Over an 11-year period, 354 patients were treated with wide local excision, axillary sampling and radiotherapy to the remaining breast. LRR occurred in 33 patients (9.3%). Local recurrence (LR) in the conserved breast occurred in 73% (24/33)of the patients while regional recurrence (RR) accounted for 9% (3/33). There were 6 (18%) patients with both local and regional recurrence. Recurrence was detected clinically in 85% (28/33) and mammographically in 15% (5/33) Of those patients who have had their recurrences detected clinically 61% (17/28) have died. None of the 5 patients with mammographic recurrences have died. Patients who develop LR after conservative surgery do better if the lesion is detected mammographically compared with those detected clinically (P < 0.03, Fisher's exact test). Mammography, in addition to regular clinical review, is an important aspect of the follow-up protocol after breast conserving surgery.

Tamoxifen in breast conservation therapy

Breast conservation surgery for early breast cancer requires post-operative radiotherapy to give local control rates equivalent to mastectomy. Three hundred and thirty-five women presenting with symptomatic breast lumps and receiving radiotherapy and adjuvant systemic therapy at St. Bartholomew's, have actuarial 8-year local relapse-free rates of 90% for T1 and 83% for T2,3 presenting cases. Amongst 49 elderly and/or medically frail patients treated with a similar surgical policy but post-operative tamoxifen only (for standard risk features), the local relapse-free rates were 96% for T1 and 43% for T2,3. Most relapses occurred in the first 2 years in both groups. We conclude that, in the absence of high risk features (defined), breast conservation surgery and tamoxifen only is a safe option for T1 disease in the elderly, but that the risk of local relapse is considerably higher when this policy is employed for patients presenting with larger tumors.

Benign biopsies in the prevalent round of breast screening: a review of 137 cases

In the first round of the National Health Service Breast Screening Programme, 35,533 women attended for screening at the two breast screening units served by St Bartholomew's Hospital. Further assessment was necessary in 2212 women (6.2%), of whom 412 (1%) subsequently underwent surgical biopsy. Of these 137 had benign lesions. The predominant mammographic abnormality leading to biopsy was microcalcification in 55, a mass in 48, parenchymal asymmetry in 18 and architectural distortion in 16. Histology revealed fibrocystic change in 66, fibroadenoma in 27, radial scar/complex sclerosing lesion in 23, atypical ductal hyperplasia only in eight, and a variety of unusual benign lesions in 13. In an attempt to determine criteria which would minimize unnecessary biopsy of benign lesions in future, the mammographic and cytological features of these benign lesions were reviewed and compared with the final histology. The most common diagnostic problems were clustered and variable microcalcification, the radial scar/complex sclerosing lesion, and mammographic features shown to be atypical hyperplasia on histology.

Variations in steroid receptor status with disease stage in breast cancer

Oestrogen and progesterone receptor (ER and PgR) distribution in three clinical subgroups of 421 breast carcinomas was analysed. The groups comprised (1) early breast cancer (T1-2a, N0M0; n = 64); (2) untreated advanced fungating cancer (n = 27) and (3) advanced cancer relapsing after endocrine therapy (n = 29). Receptor distribution in each of the subgroups was compared to that of the total population. The advanced fungating group contained no ER--ve/PgR--ve tumours and the distribution was also significantly different from the total population (P less than 0.001 by Chi-squared test). The proportion of tumours in the total population that contained greater than 40 fmol/mg ER was 187/421 (44.4%). There was no significant difference between the early breast cancer group and the total population (P greater than 0.9). However, the proportion of tumours containing ER greater than 40 fmol/mg in the advanced fungating cancer group (16/27, 59.3%) was significantly higher than in the total population (P less than 0.01). This difference may be partially explained by the older age at presentation in this group. In the relapsed after endocrine therapy group only four of 29 (13.8%) contained ER greater than 40 fmol/mg which was significantly different from the total (P less than 0.001). There was a higher proportion of early breast cancers containing PgR greater than 40 fmol/mg than in the total population (P less than 0.001). There was no significant difference between PgR distribution in the advanced fungating and relapsed groups compared to the total population. The data suggest that patients presenting with advanced fungating cancer are more likely to respond to endocrine therapy than the population as a whole, and that in breast cancer that has relapsed following endocrine therapy receptor levels decrease with progression of the disease.

Enterolith ileus

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Histopathology of benign non-palpable breast lesions identified by mammography

Over four years the histological features of benign breast diseases, diagnosed after biopsy of non-palpable mammographic abnormalities, were reviewed and correlated with the mammographic appearances. The histological features were compared with those from all other benign biopsy specimens taken during the same period. The incidence of sclerosing adenosis and microcalcifications was considerably higher in the group of non-palpable mammographic lesions; fibrous disease of the breast and radial scar (infiltrating epitheliosis) were also more common. There was no difference in the incidence of epithelial hyperplasia between the two groups. Correlation with the mammographic appearances showed that microcalcification was most often associated with blunt duct adenosis and that stromal distortion or masses were most often caused by fibrous disease.

Malignant cysts of the male breast

Two cases of male breast carcinoma presenting as cystic swellings are reported. Cysts of the male breast are rare, but unlike cysts in female breasts are more likely to represent significant pathology. We recommend consideration of excision biopsy of isolated cysts in male breasts.

Aminoglutethimide as second-line hormonal therapy in advanced breast cancer: response and toxicity

Seventy-nine postmenopausal patients received aminoglutethimide (AG; 750 mg daily) and hydrocortisone therapy for metastatic or locally recurrent breast cancer following the failure of other hormonal therapy. Fourteen of 64 patients, tolerating the drug and assessable for response, achieved a complete or partial response. Disease stabilisation occurred in a further 2 patients giving a response rate of 25% in these patients. Median duration of response was 10 months. Response rates to AG were not significantly different whether or not there had been a response to previous hormonal therapy but a trend to higher response rates in ER rich tumours was observed. Those with a longer interval from first relapse to the start of AG appeared more likely to respond. Side-effects were noted in 35 patients overall (44%) and in 70% of those over the age of 65 years. Treatment was discontinued because of toxicity in 10 patients and there was one death due to agranulocytosis. AG is active in postmenopausal breast cancer following failure of first-line hormonal therapy, toxicity limiting its use earlier in the disease.

Stab injury--the experience of an East London Hospital 1978-1983

A retrospective review of 201 patients with stab wounds admitted to an East London Hospital over a period of six years was performed. There was no striking increase in the annual incidence of these injuries over the period reviewed. The majority of patients were young males who arrived at the Accident and Emergency Department after 1800 h on a Friday, Saturday, or Sunday and had consumed alcohol prior to admission. There were 47 abdominal injuries (23%), 69 thoracic (34%), 51 limb injuries (25%) and 34 injuries involving the head and neck (17%). Forty patients (20%) had injuries involving more than one site. Abdominal stabbings were managed by a selective approach resulting in 28 laparotomies of which only 2 (7%) were negative. Evisceration of small bowel or omentum was always associated with significant intraperitoneal injury.

Steroid sequestration and tightly bound oestrogen-protein complexes in human breast tumours and a breast cancer cell line

Homogenates of breast tumours taken at surgery were prepared in phosphate-buffered medium in the presence or absence of the protease inhibitors N-alpha-p-tosyl-L-arginine methyl ester (TAME, 10 mM) or soy bean trypsin inhibitor (STI, 1 mg/ml). Aliquots (0.25 ml) were incubated in 5 ml medium, with the addition of excess trypsin (2 mg/ml) to experimental flasks. Oestrogen was measured by means of a radioreceptor assay (RRA) based on rat or human uterine cytosolic oestradiol receptor. In oestrogen receptor positive (ER +ve) tumour homogenates, TAME decreased while STI increased ethyl acetate extractable oestrogen in these preparations. The addition of trypsin enhanced yields of oestrogen in the TAME, but not in the STI or control (no inhibitor) preparations. None of these treatments affected RRA detectable oestrogen in homogenates of ER -ve tumours. Suspensions of ZR-75-1 cells, prepared in Krebs Ringer bicarbonate (KRBG) incubated with trypsin also gave greatly enhanced yields of extractable oestrogen. Fractionation of oestrogens from both tumour homogenates and from the cell line showed coincidence of RRA detectable steroid with oestradiol and oestrone, and, particularly in trypsin flasks, very non-polar components were also found. In the cell-line extracts, HPLC fractionation combined with specific radioimmunoassays confirmed the presence of both oestradiol and oestrone. The major extracted component was oestrone. The data suggest the existence within breast tumour tissue of sequestered pools of steroid requiring proteolytic action for their release. One possibility, consistent with reports in the literature, is that the steroids may themselves be directly conjugated to protein. Their presence in ER +ve but not ER -ve tumours strongly suggests some relationship to the development of hormone-sensitive disease. Alternatively, the phenomenon may be associated with the rigid compartmentalization of the paracrine function of the tissue.

Surgical drainage

The principle factor governing the efficacy of a drain is the tissue reaction to the constituent material. This was appreciated during the early development of drainage. Modern materials have been available for more than 20 years but have escaped sound clinical evaluation. In abdominal surgery there is virtually no evidence to support routine intraperitoneal drainage especially with latex rubber unless it is intended to create a fibrous tract as with T-tube drainage of the biliary tree. When drainage is used either static symphonage (Fig. 7), low pressure suction or sump suction with a bacterial air inlet filter should be employed. Silicone rubber (Silastic) tubes are the preferred material. In the parietes closed suction drainage is safe and has achieved a sound reputation for improving healing where serosanguinous oozing is expected. High pressure suction is probably the most effective system. Because of the risk of infection, open drainage systems should, in general, be avoided, especially where a prosthesis is present. Finally, if in doubt, all surgeons should recall the words of Halsteads in 1898 "No drainage at all is better than the ignorant employment of it" rather than the advice of Lawson Tait.

Local management of surgical sepsis

The most important aspect of the prevention of infection in traumatic wounds is early and thorough débridement. In elective surgery there is no substitute for meticulous technique. The successful treatment of established infection depends on early diagnosis and accurate localization of the sepsis, followed by incision and adequate drainage or, in the case of an infected viscus, excision.

The effect of faecal loading on colonic anastomotic healing

The effect of faecal loading of the colon on the healing of rat colonic anastomoses has been investigated in a prospective randomized and controlled study. Anastomotic dehiscence occurred significantly more often when the bowel was loaded with faeces at the time of operation than when it was empty. Suture line cultures bore no relationship to the outcome of the anastomosis. This result emphasizes the importance of an empty colon as a contributory factor in successful colonic healing in the rat.

The effect of surgical drainage materials on colonic healing

The effect of surgical drainage materials on rat colonic healing has been investigated in a prospective randomized and controlled study. Latex, silicone rubber (Silastic), polyvinylchloride (PVC) and polytetrafluoroethylene (Teflon) tubes were implanted alongside a colonic anastomosis and compared with a 'no drain' group using mechanical and histological assessments. There was a significant increase in anastomotic leakage in the latex group in which there appears to be a local inhibition of healing. Silastic, PVC and Teflon were not found to interfere with healing. The continued use of latex drains in colonic surgery is therefore questioned.

Surgical audit: Comparison of the work load and results of two hospitals in the same district

Surgical audit is being undertaken to monitor and compare (by computer) the type of patient, work load, and results of two similar surgical units. Both units are in the City and Hackney District of London, one at St Bartholomew's Hospital and the other at Hackney Hospital. During 1978, 736 patients were admitted by the unit at St Bartholomew's Hospital and 902 by the unit at Hackney. At St Bartholomew's 70% of admissions were elective compared with 49% at Hackney, where 86% of patients lived within the district compared with only 36% at St Bartholomew's. The wound was the commonest site for complications, infection affecting 9% of those at Hackney and 6% at St Bartholomew's, despite identical antibiotic policies. There were six post-operative deaths at St Bartholomew's and 32 at Hackney. In both hospitals the length of stay was similar, 50% of patients being discharged within one week and 80% within two weeks. As a result of the audit a vigorous venous thrombosis prophylactic regimen has been instituted, and at Hackney the anaesthetic department has been strengthened and a new intensive care unit opened.

A study of the effect of povidone-iodine on polymorphonuclear leucocyte chemotaxis

Studies were made of the effect of povidone-iodine on polymorphonuclear leucocyte chemotaxis. Polymorphonuclear leucocytes were incubated with various concentrations of povidone-iodine and allowed to migrate across a membrane towards a chemotactic agent. Chemotactic movement was found to decrease as the concentration of povidone-iodine rose, 75 micrograms/ml completely inhibiting all movement. A concentration of 10 micrograms/ml of povidone-iodine was found actively to repel the white cells. In vivo studies in mice showed a reduction in polymorphonuclear leucocytes at wound surfaces in the presence of povidone-iodine dry powder spray.

A comparison between disposable and non-disposable suction drainage units: a report of a controlled trial

A randomized trial of high vacuum Redivac drains and low vacuum Portovac drains has been conducted in 46 female patients undergoing simple mastectomy through a transverse skin incision. The Redivac units drained less fluid, stayed in place for a day less than the Portovac units and were emptied once less often.

Prevention of intraperitoneal adhesions: a comparison of noxythiolin and a new povidone-iodine/PVP solution

Peritoneal adhesions were induced in 250 female Wistar rats by the excision and closure of a right lower quadrant parietal peritoneal defect. After closure of the defect each rat was randomly allocated to one of five treatment groups: A, control with no instillate; B, control with Ringer solution; C, noxythiolin 0.5 per cent solution; D, noxythiolin 1 per cent solution; E povidone-iodine/PVP solution. Two millilitres of the appropriate solution were injected into the peritoneal cavity just before closure of a standard 4-cm midline incision. Assessment of adhesion formation was made at 1 week in ignorance of the treatment group. Noxythiolin 1 per cent was more effective than Ringer solution and noxythiolin 0.5 per cent in reducing the mean number of adhesions (P less than 0.05) but was inferior to povidone-iodine/PVP (P less than 0.05). Povidone-iodine/PVP solution significantly reduced the number of adhesions compared with the four other groups. In addition, it significantly reduced the mean length of attachment of each adhesion compared with the two control groups (P less than 0.001).

Topical noxythiolin in colonic healing

Rats were subjected to division and anastomosis of the colon just proximal to the rectum to study the healing of colonic anastomoses. The effect of noxythiolin irrigation of the divided colon before and after anastomosis was investigated and compared with controls. Healing was assessed using five variables--macroscopic and microscopic inspection, bursting pressure and tensile strength estimations and angiography for new vessel formation. The study shows that noxythiolin irrigation of the colon in the rat significantly increases the chance of a sound anastomosis without interfering with healing. Furthermore, it inhibits the formation of adhesions.

Prophylactic intraperitoneal povidone-iodine in alimentary tract surgery

In controlled experiments intraperitoneal povidone-iodine significantly reduced the mortality of mice (p less than 0.01) and rats (p less than 0.01) with induced peritonitis. Povidone-iodine irrigation of the rat colon before and after anastomosis did not interfere with healing or inhibit peritoneal adhesion formation. However, a newly formulated povidone-iodine solution containing increased PVP significantly reduced adhesion formation in a controlled study in rats.

Colonic anastomosis healing. The effect of topical povidone-iodine

The effect of povidone-iodine (0.1% available iodine) irrigation on colonic anastomosis healing was investigated in 196 Sprague-Dawley rats. Each end of the divided colon was irrigated with 5 ml of povidone-iodine solution or with an equal volume of normal saline before anastomosis and again after the anastomosis had been completed. Healing was assessed at 2, 4, 6, 8, 10, and 14 days after operation: macroscopically, mechanically, histologically and angiigraphically. Povidone-iodine irrigation did not impair healing in any way.

Effect of noxythiolin on experimental peritonitis

The intraperitoneal instillation of noxythiolin in the treatment of peritonitis is widespread in clinical practice despite contradictory evidence as to its efficacy. In this light the value of noxythiolin was reappraised by studying its effect in guinea-pigs and mice with induced bacterial peritonitis. Treatment with a 1% solution of noxythiolin reduced the mortality rate of mice by 14% (P less than 0.1). The guinea-pig model proved unreliable giving inconsistent mortality rates throughout. Further studies are required to determine the optimum dose and concentration of noxythiolin while the search for more effective intraperitoneal antiseptics should continue.

150 years after. A tribute to Joseph Lister

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A study of the effect of povidone-iodine on wound healing

The effect of dry powder povidone-iodine (Disadine D.P.) on wound healing was assessed experimentally and clinically. It did not interfere with wound healing macroscopically, histologically or mechanically in Wistar rats. One hundred and one patients undergoing 'clean' elective surgery were included in the controlled clinical study and povidone-iodine did not affect wound healing in any way. In the control group 4% of patients developed infection compared with none of those sprayed with povidone-iodine. No adverse reaction to povidone-iodine was seen in either study. This antiseptic offers a safe alternative to antibiotics for use at operation whenever there is risk of wound infection from operative bacterial contamination.

A reappraisal of the use of antiseptics in surgical practice

The use of antiseptics was reappraised because of the increasing problem of antibiotic-resistant bacteria. A formaldehyde (noxythiolin) and a halogen (povidone-iodine) were investigated, these being the most appropriate antiseptic groups. Povidone-iodine solution significantly reduced the mortality of mice (P less than 0.01) and rats (P less than 0.01) with peritonitis. Noxythiolin (1% and 0.5%) did not. Antiseptic irrigation of the rat colon before and after anastomosis resulted in significantly fewer 'poor' anastomoses (P less than 0.05) without inhibiting healing. Noxythiolin 2.5% and 1% significantly reduced peritoneal adhesion formation in rats, but a newly formulated povidone-iodine solution with increased polyvinylpyrrolidone content was superior to noxythiolin 1% and 0.5%. Povidone-iodine neither inhibited rat abdominal wound healing nor induced bacterial resistance. In 3 subsequent controlled clinical trials a dry-powder povidone-iodine formulation halved wound infection after grid-iron appendicectomy (P less than 0.025), reduced infection in elective 'clean' surgery, and significantly reduced infection after a wide variety of 'potentially contaminated' abdominal procedures (P less than 0.01). A return to the principles of Lister is advocated.

Noxytiolin and peritoneal adhesion formation

Clinical and experimental studies have suggested that intraperitoneal noxytiolin prevents adhesion formation. A reliable experimental animal model was therefore established and the effect of noxytiolin on adhesion formation was evaluated in a controlled trial using 80 rats. All 40 rats given Ringer solution developed adhesions, whereas in 7 out of 40 given noxytiolin no adhesions were found (P less than 0-02). Noxytiolin reduced both the total and the mean number of adhesions formed (P less than 0-2) and their mean length of attachment (P less than 0-05). The anti-adhesive effect of noxytiolin may be due to its anticoagulant, cytotoxic or antibacterial properties.

Absence of bacterial resistance to povidone iodine

Povidone iodine is now being increasingly used in hospitals as an antiseptic. The possible habituation of bacteria to iodine was studied by serial passage of two strains of Pseudomonas aeruginosa, two strains of Escherichia coli, two strains of Klebsiella aerogenes, and one strain of Serratia marcescens in subinhibitory concentrations. After 20 passages, no significant change was observed in the minimal inhibitory concentration, minimal bactericidal concentration, and killing times between parent strains and 20th subcultures under standardized conditions.

Prophylactic interparietal povidone-iodine in abdominal surgery

This study sought to determine in a district general hospital (a) the frequency and nature of bacterial contamination at operation, (b) the incidence of consequent infection and (c) the prophylactic effect, if any, of interparietal povidone-iodine against postoperative wound infection. Bacterial contamination was shown in 49 per cent of all the abdominal surgical wounds at the end of operation. From 61 per cent of the subsequently infected wounds, organisms identified as contaminants at operation were again found. Interparietal instillation of povidone-iodine resulted in a statistically significant reduction in wound infection (P less than 0.01) in treated patients compared with untreated, randomized, matched controls. It was of significant value in cases of intestinal resection and peritonitis, in obese patients and in those with paramedian incisions. Laboratory studies indicate that povidone-iodine does not induce bacterial resistance. This chemical antibacterial agent may thus provide a preferable alternative to antibiotics in preventing such infections.

An antibiotic policy for surgical patients

This paper offers guidance on antibiotic usage in surgical patients. A policy is outlined rather than the comprehensive coverage of every surgical situation. The principles of antibiotic prescribing are given. The antibiotics available and their routes of administration are reviewed. Indications for the prophylactic and therapeutic use of antibiotics are discussed. Factors causing the failure of antibiotic therapy are considered in brief.

Appendicitis and mimicking conditions. A prospective study

A prospective study of 444 consecutive patients diagnosed as having acute appendicitis was carried out in a district general hospital. The appendix was acutely inflamed, gangrenous, or perforated in 346 patients. Diagnostic error, 22% overall, was twice as common in females as in males. Organisms were isolated from the outer appendix wall in 117 patients, isolation increasing with the severity of inflammation. 12% of children under 11 had mesentric adenitis, 10% of all females had gynaecological lesions, and 14% of patients over 50 had acute diverticulitis. In only 6% of patients was no abnormality found at operation, and in every case the disorder was dealt with through the gridiron incision.

Aetiology and prevention of wound infection in appendicetomy

A study at the Reading District Hospitals on 451 consecutive patients undergoing appendicectomy through grid-iron incisions sought to determine factors influencing wound infection and the effects of a prophylactic wound-spraying procedure. Wound infection increased with the severity of appendicular inflammation and was well correlated with the degree and nature of bacterial contamination at the time of wound closure.

The infection rate was reduced by about one-half when either an aerosol dry-powder formulation of povidone iodine (Disadine D. P.) or an aerosol antibiotic powder spray containing neomycin, bacitracin and polymixin (Dispray) was sprayed on the wound before and after closure. The reduction of infection achieved by spraying with pouidine iodine was statistically significant (P &lt; 0.025). The results of the polyantibiotic spraying did not quite reach significance (P &lt; 0.06).

The povidone iodine dry powder was better overall since it reduced infection in all degrees of appendicular inflammation, in all age groups and in enlarged, drained, contaminated and non-contaminated wounds without the attendant disadvantages of antibiotics.