Lumpectomy with or without postoperative radiotherapy for breast cancer with favourable prognostic features: results of a randomized study

The aim of this trial was to study the value of adding post-operative radiotherapy to lumpectomy in a subgroup of breast cancer patients with favourable patient-, tumour-, and treatment-related prognostic features. 152 women aged over 40 with unifocal breast cancer seen in preoperative mammography were randomly assigned to lumpectomy alone (no-XRT group) or to lumpectomy followed by radiotherapy to the ipsilateral breast (50 Gy given within 5 weeks, XRT group). All cancers were required to be invasive node-negative, smaller than 2 cm in diameter and well or moderately differentiated, to contain no extensive intraductal component, to be progesterone receptor-positive, DNA diploid, have S-phase fraction </=7 and be excised with at least 1 cm margin. During a mean follow-up time of 6.7 years, 13 (18.1%) cancers recurred locally in the no-XRT and 6 (7.5%) in the XRT group (P = 0.03). There was no difference between the groups in the ultimate breast preservation rate (95.0% vs. 94.4% in XRT and no-XRT, respectively, P = 0.88), distant metastasis-free survival (P = 0.36), or 5-year cancer-specific survival (97.1% in XRT and 98.6 in no-XRT). Radiation therapy given after lumpectomy reduces the frequency of ipsilateral breast recurrences even in women with small breast cancer with several favourable clinical and biological features. However, the breast preservation rate may not increase due to more frequent use of salvage mastectomies in patients treated with postoperative radiotherapy.

Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis--a single-center randomized study

Pancreatic infection is the main indication for surgery and the principal determinant of prognosis in acute necrotizing pancreatitis. Previous studies on the effects of antibiotics have not, however, uniformly demonstrated any reduction in the need for surgery or any decrease in mortality among these patients, although the incidence of pancreatic infections was significantly reduced. This single-center randomized study was designed to compare early vs. delayed imipenem treatment for acute necrotizing pancreatitis. Ninety patients with acute necrotizing pancreatitis (C-reactive protein > 150 mg/L, necrosis on CT) were randomized within 48 hours either to a group receiving imipenem (1.0 g plus cilastatin intravenously 3 times a day) or a control group. Not included were those who had been started on antibiotics at the referring clinic, those who were taken directly to the intensive care unit for multiorgan failure, and those who refused antibiotics or might have had adverse reactions. Thirty-two patients were excluded because they were over 70 years of age (not potentionally operable) or for any study violation. There were 25 patients in the imipenem group and 33 patients in the control group. The main end point was the indication for necrosectomy due to infection (i.e., after the initial increase and decrease, there was a second continuous increase in temperature, white blood cell count [> 30%] and C-reactive protein [> 30%], with other infections ruled out, or bacteria were found on Gram stain of the pancreatic fine-needle aspirate). In the control group, imipenem was started when the operative indication was fulfilled. Conservative treatment was continued for at least 5 days before necrosectomy. The study groups did not differ from each other with regard to sex distribution, patient age, etiology, C-reactive protein concentration, and extent of pancreatic necrosis on CT. Two (8%) of 25 patients in the imipenem group compared to 14 (42%) of 33 in the control group fulfilled the operative indications (P = 0.003). Nine patients in the control group responded to delayed antibiotics but five had to undergo surgery. Of those receiving antibiotics, 2 (8%) of 25 in the early antibiotic (imipenem) group needed surgery compared to 5 (36%) of 14 in the delayed antibiotic (control) group (P = 0.04). Two (8%) of 25 patients in the imipenem group and 5 (15%) of 13 patients in the control group died (P = NS [no significant difference]). Seven (28%) of 25 in the imipenem group and 25 (76%) of 33 in the control group had major organ complications (P = 0.0003). Based on the preceding criteria, early imipenem-cilastatin therapy appears to significantly reduce the need for surgery and the overall number of major organ complications in acute necrotizing pancreatitis, and reduces by half the mortality rate; this is not, however, statistically significant in a series of this size.

Radiotherapy after segmental resection of breast cancer with favorable prognostic features: 12-year follow-up results of a randomized trial

PURPOSE

Postoperative breast irradiation is considered standard after breast-preserving surgery for cancer. We evaluated the efficacy of radiation therapy in the prevention of local recurrence in a patient population that had small-size breast cancer with features that suggested low biologic aggressiveness.

PATIENTS AND METHODS

Women (n = 264) older than 40 years who were treated by breast resection with > or = 1 cm of tumor-free margin and axillary nodal dissection were randomly assigned to receive or not to receive breast irradiation (cumulative dose, 50 Gy) after surgery. The tumor was required to be < or = 20 mm, node negative, progesterone receptor positive, well to moderately well differentiated and unifocal, and of low cell proliferation rate (ie, S phase fraction < or = 7% or nuclear Ki-67 expression < 10%) and had to lack an extensive intraductal component. The median follow-up time was 12.1 years after random assignment.

RESULTS

Sixteen (11.6%) and 34 (27.2%) cancers recurred locally in the radiotherapy and the control arms, respectively (P = .0013). Time to local recurrence was longer in the radiotherapy arm (hazard ratio [HR], 0.36; 95% CI, 0.20 to 0.65; P = .00071). Twenty-one patients assigned to radiotherapy and 26 assigned to control died during the follow-up. There were no differences in overall survival time (HR, 0.63; 95% CI, 0.35 to 1.12; P = .11), distant disease-free survival (P = .94), or breast cancer-specific survival (P = .56) between the radiation therapy and control groups.

CONCLUSION

Radiation therapy after breast resection reduces the frequency of ipsilateral breast recurrences, even among women with small-size breast cancers that have favorable histologic features and that are resected with at least a 1-cm margin. Postoperative radiotherapy did not significantly improve survival.

Factors Determining Esthetic Outcome after Breast Cancer Conservative Treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.

Cancer Incidence and Mortality in Patients Treated Either With RAI or Thyroidectomy for Hyperthyroidism

CONTEXT

Some previous studies have suggested increased cancer risk in hyperthyroid patients treated with radioactive iodine (RAI). It is unclear whether the excess cancer risk is attributable to hyperthyroidism, its treatment, or the shared risk factors of the two diseases.

OBJECTIVE

The objective was to assess cancer morbidity and mortality in hyperthyroid patients treated with either RAI or surgery.

PATIENTS

We identified 4334 patients treated surgically for hyperthyroidism in Finland during 1986-2007 from the Hospital Discharge Registry and 1814 patients treated with RAI for hyperthyroidism at Tampere University Hospital. For each patient, three age- and gender-matched controls were chosen. Information on cancer diagnoses was obtained from the Cancer Registry. The follow-up began 3 months after the treatment and ended at cancer diagnosis, death, emigration, or the common closing date (December 31, 2009).

RESULTS

The overall cancer incidence was not increased among the hyperthyroid patients compared to their controls (rate ratio [RR], 1.05; 95% confidence interval [CI], 0.96-1.15). However, the risk of cancers of the respiratory tract (RR, 1.46; 95% CI, 1.05-2.02) and the stomach (RR, 1.64; 95% CI, 1.01-2.68) was increased among the patients. The overall cancer mortality did not differ between the patients and the controls (RR, 1.08; 95% CI, 0.94-1.25). The type of treatment did not affect the overall risk of cancer (hazard ratio for RAI vs thyroidectomy, 1.03; 95% CI, 0.86-1.23) or cancer mortality (hazard ratio, 1.04; 95% CI, 0.91-1.21).

CONCLUSIONS

In this cohort of Finnish patients with hyperthyroidism treated with thyroidectomy or RAI, the overall risk of cancer was not increased, although an increased risk of gastric and respiratory tract cancers was seen in hyperthyroid patients. Based on this large-scale, long-term follow-up study, the increased cancer risk in hyperthyroid patients is attributable to hyperthyroidism and shared risk factors, not the treatment modality.

Is bile flow reduced in patients with hypothyroidism?

BACKGROUND

Disturbances in the sphincter of Oddi (SO) function may prevent normal bile flow and thus enhance the probability of common bile duct stone (CBDS) formation. We have previously shown increased prevalence of diagnosed hypothyroidism in CBDS patients, thyroxine (T(4)) -induced inhibition of the SO contractility both in animal and in human experiments ex vivo, and reduced bile flow to duodenum in hypothyroid rats. The aim of the present study was to investigate human biliary dynamics in relation to altered thyroid gland function.

METHODS

Eight female patients, 1 with diagnosed untreated hypothyroidism and 7 with total thyroidectomy performed due to thyroid cancer, were studied in hypothyroid stage and again after thyroxine replacement therapy in euthyroid stage, with quantitative (99m)Tc HIDA cholescintigraphy (QC), biliary ultrasonography, and serum determinations. Each patient served as her own control in the 2 stages of the study.

RESULTS

In QC, maximal uptake of (99m)Tc HIDA was not changed in hypothyroidism compared to euthyroidism. The first appearance of radioactivity to large bile ducts at the hepatic hilum remained unchanged in the 2 stages of the study. Hepatic clearance of (99m)Tc HIDA was decreased at 45 minutes (28% [11-38] vs 50% [33-54]; P =.028; median and range) and at 60 minutes (55% [28-80] vs 69% [61-79]; P =.028; median and range) and hilum-duodenal transit time increased by 31% compared to euthyroid stage. In US no changes were seen in gall bladder or bile ducts in the 2 stages of the study. Serum hypercholesterolemia was observed in the hypothyroid stage.

CONCLUSIONS

We conclude that hypothyroidism may result in delayed emptying of the biliary tract, as studied with QC. In addition to the changes in bile composition and excretion rate suggested before to take place in hypothyroidism, according to the present study changes in biliary emptying also may be included in the probable causes for the increased prevalence of CBDS in hypothyroidism. This may be due to the absence of the prorelaxing effect of thyroxine on SO, which we have shown before to exist ex vivo.

A core needle biopsy provides more malignancy-specific results than fine-needle aspiration biopsy in thyroid nodules suspicious for malignancy

BACKGROUND AND AIMS

The most commonly used diagnostic method for the preoperative diagnosis of thyroid nodules is ultrasound-guided fine-needle aspiration biopsy (FNA), which often yields non-diagnostic or non-definitive results and seldom produces definite malignant diagnoses. To improve upon the malignancy-specific sensitivity, we tested core needle biopsies (CNBs) of thyroid lesions taken from surgical specimens.

MATERIAL AND METHODS

52 consecutive patients with malignant or malignant-suspicious thyroid nodules were referred to Tampere University Hospital between May 2010 and December 2011. Preoperative FNAs were categorised as follicular neoplasm (48%), suspicion for malignancy (46%) or malignancy (6%). Intraoperative FNA and CNB samples were acquired from surgical specimens removed during surgery. The results of the needle biopsies were compared with the final pathological diagnosis.

RESULTS

CNBs had a high definitive sensitivity for malignancy (61%, CI 41% to 78%) whereas the definitive sensitivity for malignancy of FNAs was significantly lower (22%, CI 10% to 42%). CNB was not beneficial in the diagnosis of follicular thyroid lesions. When all suspected follicular tumours were excluded, the definitive sensitivity of CNB rose to 70% (CI 48% to 86%).

CONCLUSIONS

CNB may be beneficial for the diagnosis of papillary thyroid carcinoma and other non-follicular thyroid lesions. CNB may be considered as an additional diagnostic procedure in cases with FNA suspicious for malignancy.

Cardiovascular morbidity and mortality in surgically treated hyperthyroidism - a nation-wide cohort study with a long-term follow-up

OBJECTIVE

Previous studies suggest that patients with hyperthyroidism remain at an increased risk of cardiovascular morbidity even after restoring euthyroidism. The mechanisms of the increased risk and its dependency on the different treatment modalities of hyperthyroidism remain unclear. The aim of this long-term follow-up study was to compare the rate of hospitalizations for cardiovascular causes and the mortality in hyperthyroid patients treated surgically with an age- and gender-matched reference population.

PATIENTS AND MEASUREMENTS

A population-based cohort study was conducted among 4334 hyperthyroid patients (median age 46 years) treated with thyroidectomy in 1986-2007 in Finland and among 12,991 reference subjects. Firstly, the hospitalizations due to cardiovascular diseases (CVD) were analysed until thyroidectomy. Secondly, the hazard ratios for any new hospitalization due to CVDs after the thyroidectomy were calculated in Cox regression analysis adjusted with the prevalent CVDs at the time of thyroidectomy.

RESULTS

The risk of hospitalization due to all CVDs started to increase already 5 years before the thyroidectomy, and by the time of the operation, it was 50% higher in the hyperthyroid patients compared to the controls (P < 0·001). After the thyroidectomy, the hospitalizations due to all CVDs (HR 1·15), hypertension (HR 1·23), heart failure (HR 1·17) and valvular diseases or cardiomyopathies (HR 1·55) remained more frequent among the patients than among the controls for 20 years after thyroidectomy. The increased morbidity was not clearly related to the aetiology of hyperthyroidism. Despite the increased CVD morbidity among the patients, there was no difference in cardiovascular mortality.

CONCLUSIONS

The present study shows that hyperthyroidism increases the risk of hospitalization due to CVDs and the risk is sustained up to two decades after effective surgical treatment. However, there was no excess CVD mortality in the middle-aged patient cohort studied.

An in vitro long-term culture model for normal human mammary gland: expression and regulation of steroid receptors

Steroids and their nuclear receptors play crucial roles in the development and maintenance of normal functions of the human mammary gland (HMG). They have also been implicated in breast carcinogenesis. However, the study of steroid action in normal HMG has been hampered by experimental difficulties. By using a newly established in vitro long-term culture method, we successfully cultured normal HMG tissue for more than 2 months without detriment to its morphology or steroid receptor expression. Expression of the cellular structural and extracellular matrix proteins was similar to that prior to culture, and HMG tissue retained its properties of steroid receptor expression and regulation. Addition of 17-beta estrogen to mammary tissues markedly increased the expression of progesterone receptor (PR) but only slightly affected that of the estrogen receptor (ER). Medroxyprogesterone acetate down-regulated the expression of PR within 24-48 h and also increased the expression of androgen receptor. When HMG tissue was cultured in medium containing normal or dextran-coated charcoal-stripped fetal calf serum or normal human serum, the expression and regulation of steroid hormone receptors were similar, although different in extent. When serum was omitted, the morphology of HMG was normal after 1 week, but the expression and regulation of ER and PR were altered. Thus, as HMGs retain the capacity to express steroid receptors in culture, this long-term culture system is probably a good model for studying the regulation of the mammary gland by steroids.

Chest computed tomography in the staging of pancreatic and periampullary carcinoma

BACKGROUND

Staging of the tumours in the pancreas and periampullary region usually consists of abdominal computed tomography (CT). Laparoscopy is also advocated. Little attention has been paid to extra-abdominal staging. In addition to peritoneal, lymphatic and hepatic metastases, lung metastases are frequently found. The chest CT scan has been demonstrated as better than the plain chest roentgenogram or conventional tomography in demonstrating lung tumours. This study was done to evaluate whether the chest CT scan gives information additional to the plain chest roentgenogram in the staging of pancreatic and periampullary tumours.

METHODS

Fifty-three patients with a pancreatic or periampullary tumour underwent helical CT scan of the chest in addition to the abdominal CT scan. The CT scans and the chest roentgenograms were read separately without the result of the other being known; the results were compared with each other and with the clinical and operative findings.

RESULTS

In the chest CT scan, 7 out of 53 (13%) patients had nodules in the lungs. The chest pathologies were not seen in the chest roentgenogram except for pneumonia in one patient and lung tumours in another (sensitivity of the chest roentgenogram 2/7 = 29%). Liver metastasis, local invasion of the tumour or poor general condition of the patient made lung biopsy or bronchoscopy unnecessary or impossible.

CONCLUSION

Lung metastases seldom appear in patients with pancreatic or periampullary carcinoma without other contraindications for resection, which is why the chest CT scan cannot be recommended in the staging of these tumours for operation.

Effect of radiotherapy on the interpretation of routine follow-up mammography after conservative breast surgery: a randomized study

Radiotherapy after conservative surgery causes fat necrosis, fibrosis, skin thickening and other parenchymal distortion of the breast. The interpretation of a mammogram of the irradiated breast may therefore be difficult. We studied the effect of radiotherapy on the interpretation of the routine mammography used in the follow-up of breast cancer patients. A total of 144 low-risk breast cancer patients were randomized to radiotherapy or to no further treatment after conservative surgery. The first routine follow-up mammography was performed 18 months after surgery and every 18 months after that. The number of mammography examinations was estimated per patient and per follow-up year. The number of extra diagnostic tests and the occurrence of positive findings were assessed per mammography session and per follow-up year. Further diagnostic tests prompted by difficulties in interpreting the mammogram were performed to an extent of 0.19 per mammography examination in the radiotherapy group and of 0.15 in the non-radiotherapy group, i.e. 1.3 times more often. Findings that turned out to be negative at confirmation were 2.0 times (P< 0.05) more common in the radiotherapy group. These false-positive findings were more common in the radiotherapy group than in the surgery group and only shortly after treatment. Mammography is more difficult to interpret after radiotherapy than after conservative surgery alone, especially shortly after treatment, and more often involves extra diagnostic tests and findings that will be negative at confirmation.

Dynamic infrared imaging in identification of breast cancer tissue with combined image processing and frequency analysis

Five combinations of image-processing algorithms were applied to dynamic infrared (IR) images of six breast cancer patients preoperatively to establish optimal enhancement of cancer tissue before frequency analysis. mid-wave photovoltaic (PV) IR cameras with 320x254 and 640x512 pixels were used. The signal-to-noise ratio and the specificity for breast cancer were evaluated with the image-processing combinations from the image series of each patient. Before image processing and frequency analysis the effect of patient movement was minimized with a stabilization program developed and tested in the study by stabilizing image slices using surface markers set as measurement points on the skin of the imaged breast. A mathematical equation for superiority value was developed for comparison of the key ratios of the image-processing combinations. The ability of each combination to locate the mammography finding of breast cancer in each patient was compared. Our results show that data collected with a 640x512-pixel mid-wave PV camera applying image-processing methods optimizing signal-to-noise ratio, morphological image processing and linear image restoration before frequency analysis possess the greatest superiority value, showing the cancer area most clearly also in the match centre of the mammography estimation.

Imaging of breast cancer with mid- and long-wave infrared camera

In this novel study the breasts of 15 women with palpable breast cancer were preoperatively imaged with three technically different infrared (IR) cameras - micro bolometer (MB), quantum well (QWIP) and photo voltaic (PV) - to compare their ability to differentiate breast cancer from normal tissue. The IR images were processed, the data for frequency analysis were collected from dynamic IR images by pixel-based analysis and from each image selectively windowed regional analysis was carried out, based on angiogenesis and nitric oxide production of cancer tissue causing vasomotor and cardiogenic frequency differences compared to normal tissue. Our results show that the GaAs QWIP camera and the InSb PV camera demonstrate the frequency difference between normal and cancerous breast tissue; the PV camera more clearly. With selected image processing operations more detailed frequency analyses could be applied to the suspicious area. The MB camera was not suitable for tissue differentiation, as the difference between noise and effective signal was unsatisfactory.

Symptoms, clinical disability scores and reflux in complicated and uncomplicated primary varicose veins

Objective: To evaluate the role of subjective symptoms, grade of disability and axial reflux in superficial veins in different clinical stages of varicose veins (VVs).

Methods: A total of 172 legs with primary venous insufficiency from 126 patients were studied. The examination involved evaluation of the CEAP clinical class and clinical disability score (CDS), recording of any symptoms of varicose disease, and a hand-held Doppler (HHD) examination of the superficial veins. Colour-flow duplex imaging (CFDI) was also performed in 22% of the legs.

Results: The rate of insufficiency of the great saphenous vein (GSV) was 83% in complicated legs (C4-6), and 68% in uncomplicated legs (C2-3), ( P > 0.05). There was a difference between complicated and uncomplicated legs in the insufficiency of the whole GSV [C4-6: n = 18 (39%) versus C2-3: n = 12 (12%), P < 0.005]. Sensation of pain was noted in 68% of the legs in class C1, 60% of those in class C2-3 and 81% of those in class C4-6. Sensation of oedema was recorded in 70% of the legs in class C1, 65% of those in class C2-3 and 86% of those in class C4-6, respectively. CDS classes 2-3 were significantly more frequent among complicated legs (C4-6: 54% versus C2-3 12%, P < 0.005).

Conclusions: Leg symptoms are frequent throughout classes C1-6. Their clinical usefulness is therefore limited. CDS parallels well with the clinical classification. In complicated disease the whole saphenous vein is more frequently insufficient.

A dynamic infrared imaging-based diagnostic process for breast cancer

BACKGROUND

Dynamic infrared (IR) imaging is an emerging functional imaging modality for the detection of breast cancer without evidence of optimal imaging and diagnostic application.

PURPOSE

To evaluate dynamic IR imaging in breast cancer diagnostics by comparing a stepwise diagnostic scheme to digital mammography and postoperative histopathology.

MATERIAL AND METHODS

Dynamic IR imaging of breasts was undertaken preoperatively with a long-wave quantum well (QWIP) and two mid-wave photovoltaic (PV) IR cameras in 10 cases (age 34-80 years) with breast cancer size 6-45 mm on mammography. Image stabilization, two-phase frequency analysis, and two image-processing algorithms were applied.

RESULTS

Combining image processing with frequency analysis proved advantageous in detecting breast cancer. The IR imaging process recognized the cancer area independently of tissue density, cancer size, and cancer appearance on mammography. Compared to histopathology, all cancers yielded abnormal analysis results, including one case of ductal carcinoma in situ. Evidence of lymphatic invasion in postoperative histopathology, imaging with PV camera, and image processing with the Wiener filtering combination correlated with highest confidence between normal and cancer tissue measured by the calculated superiority value.

CONCLUSION

Dynamic IR imaging with image-processing-guided frequency analysis is a promising modality for breast cancer detection and may not have the tissue-dependent limitations of mammography. Our results encourage further work on medical IR imaging and comparison to established breast-imaging modalities.

The profile of leg symptoms, clinical disability and reflux in legs with previously operated varicose disease

PURPOSE

It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.

METHODS

A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.

RESULTS

The site of superficial reflux was at the groin in 58% (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11% (unoperated short saphenous vein). In 58% of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74% of the legs, sensation of oedema in 64%, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2-3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2-3) were significantly more frequent among complicated legs (CEAP clinical class C2-3: 22% versus CEAP clinical class C4-6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7% versus severe reflux: 48%; p < 0.005).

CONCLUSIONS

Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.