Follow-up for screen-detected ductal carcinoma in situ: results of a survey of UK centres participating in the Sloane project.

AIMS: To investigate the variations in follow-up practice for screen-detected ductal carcinoma in situ (DCIS) in the UK. METHODS: A questionnaire enquiring about follow-up practice and the perceived value of clinical follow-up after surgery for screen-detected DCIS was sent to the 74 UK screening centres participating in the Sloane Project. RESULTS: Responses were received from 66 hospitals serving 54 screening centres. These demonstrate wide variations in practice. Clinical follow-up duration ranges from 1 year to indefinite, with the frequency of visits from three-monthly to annually. Formal mammographic follow-up duration ranges from none to indefinite. Mammographic frequency ranges from 1 to 2 years. Follow-up varies according to factors such as size and grade of disease and margin status in 23 units and according to whether adjuvant therapy is given in 23. Seven hospitals perform mammography of reconstructed breasts. Thirty-one centres consider clinical follow-up of DCIS to be of value or limited value whereas 28 consider it to be of little or no value. CONCLUSIONS: There is no consensus with regard to the duration and frequency of follow-up for screen-detected DCIS, the contribution of predictive and treatment factors, the use of mammography of the reconstructed breast or the perceived value of clinical follow-up. Published guidelines show no consensus. Multidisciplinary teams involved in the care of women with screen-detected non-invasive cancer should contribute to audits such as the Sloane Project in order to determine the most effective and efficient ways to treat and follow up these patients.

Protein kinase C alpha expression in normal breast, ductal carcinoma in situ and invasive ductal carcinoma.

The purpose of this study was to determine if Protein Kinase C alpha (PKC alpha) is altered in expression or localisation in normal breast, ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC). We obtained 14 mixed cases of invasive ductal carcinoma (IDC) and DCIS, 36 pure DCIS cases and 25 cases of normal breast. The sections were stained immunohistochemically for PKC alpha expression. Staining was cytoplasmic. The results showed a progressive reduction in staining intensity from normal breast to invasive ductal carcinoma. The staining pattern was heterogeneous in the cytoplasm of DCIS and IDC, but homogeneous in the cytoplasm of normal breast ductal epithelium. Interestingly, mitotic cells and cells with aberrant nuclear morphology showed increased cytoplasmic staining in DCIS and IDC. PKC alpha activity is altered in dividing or abnormal cells, but overall expression is reduced in IDC. This raises the possibility of an alteration in the subcellular localisation of PKC alpha which may relate to changes in desmosomal adhesive state.

Crude open biopsy rates for benign screen detected lesions no longer reflect breast screening quality--time to change the standard.

OBJECTIVES: To investigate the changing nature of the benign screen detected breast abnormalities removed at open biopsy over a seven year period and to compare this with the improving cancer detection rate and non-operative diagnosis rate. SETTING: The Bolton, Bury, and Rochdale Breast Screening Programme. METHODS: The histopathology reports of the benign lesions removed from patients undergoing open biopsy for screen detected abnormalities between 1 April 1994 and 31 March 2001 were reviewed and the lesions classified on the B1 to B5 scale. Cancer detection rates and non-operative cancer diagnosis rates were ascertained from the breast screening computer system. RESULTS: 148 benign surgical biopsies were performed in the seven year period. There was a moderate increase in the overall benign biopsy rate over the period (from 1.26 open biopsies per 1000 women screened for the three years 1994-97 to 1.63 open biopsies per 1000 women screened for the three years 1998-2001). The biopsy rate for B2 (benign) lesions decreased slightly over the study period but the biopsy rate for B3 lesions (that is, of uncertain malignant potential) more than doubled. The majority (84%) of the B3 lesions were radial scars. There was a steady improvement in the cancer detection rate and the non-operative cancer diagnosis rate over the period, similar to that seen nationally. CONCLUSIONS: Improvements in screening technique and detection ability result in an increase in the number of subtle radiologically indeterminate or suspicious lesions detected. Many of these are radial scars, which require excision. Crude benign open biopsy rates for screening programmes are no longer meaningful, and should now be refined with separate rates for B2 lesions and B3 lesions. High quality programmes can expect to have low B2 open biopsy rates and high B3 open biopsy rates. It is inappropriate to have an upper limit for the B3 open biopsy rate.

Complex sclerosing lesions (radial scars) of the breast can be palpable.

Complex sclerosing lesion (CSL)/radial scar and carcinoma of breast can both present mammographically as stellate lesions. The mammographic features used to distinguish these two entities are reported as being unreliable. All reports to date indicate that CSLs are not palpable. Of the 54,407 women screened in the first 2 1/2 years of the Warwickshire, Solihull and Coventry Breast Screening Service, 24 histologically-proven CSLs were identified. This represents an incidence of 0.04%. In six (25%) of these patients a corresponding clinically-palpable abnormality was identified. We found no imaging or histological features that differentiated the palpable lesions from the impalpable lesions. It is important not to assume that a palpable stellate lesion is a carcinoma.

Oncocytoma of the stomach: a case report.

An example of an oncocytoma in the wall of the stomach is reported. The diagnosis was made following ultrastructural studies and must be considered in the differential diagnosis of gastric tumours and especially of atypical leiomyomas and granular cell tumours.

The management of locally advanced carcinoma of the breast by Nolvadex (tamoxifen): a pilot study.

Fifty-one postmenopausal women with locally advanced breast cancer were treated initially by Nolvadex (Tamoxifen, ICI) alone and followed prospectively between 1974 and 1982. Twenty-three patients (40%) showed an objective response to therapy of whom 17 (75%) remain in remission at median follow-up of 36 months. Patients who failed to respond to Nolvadex therapy were treated by radiotherapy which achieved local control in 64%, with 10 months median duration. Nolvadex therapy conveys a good quality lengthy remission to a sizeable minority of patients. The majority of those who fail to respond are satisfactorily managed by radiotherapy.

Frostbite in Oxfordshire: the impact of a severe winter on an unprepared civilian population.

The winter of 1981-1982 in Oxfordshire was unusually cold. During this winter, 18 patients with frostbite were referred to the Peripheral Vascular Service of the Nuffield Department of Surgery. The age-range was 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes of both. Patients could be divided into 2 groups based on the severity of their injury. In the first group 10 patients had mild injuries and were managed as outpatients. One patient had terminal phalanges amputated as a day case. Patients in this group had adequate homes and no associated medical disease. Eight patients in the second group had severe frostbite. All were socially disadvantaged and 4 had significant medical disease (mitral valve disease, lymphoma, alcoholism and depression). Because of social circumstances and because it takes time to establish the line of demarcation between healthy and dead tissue, all patients in this group were in hospital for a minimum of 2 months (range 2-10 months). Four patients required skin grafting and 2 needed special shoes to enable them to walk. There needs to be greater public awareness of the dangers and risks of cold injury.

Estrogen receptors and breast cancer.

Estrogen receptors have been assayed in a series of primary breast cancers from postmenopausal women; 59% of which were estrogen-receptor positive. These patients survived for a significantly longer period of time than those whose tumors were estrogen-receptor negative. The effect of estrogen-receptor status was only seen (and then markedly accentuated) in patients who had lymph-node invasion at the time of mastectomy. Such determinations also appear to be of value in preselecting those patients who, on recurrence, will benefit from tamoxifen therapy.

Relationship between primary breast tumor receptor status and patient survival.

For a minimum of 3- months, 250 women who underwent mastectomy for primary breast cancer have been followed up. ER status has had a pronounced effect upon disease-free interval and survival: in patients with node involvement ER-positive (ER+) tumors carry a better prognosis. Of patients with ER-positive primary tumors, 43% underwent objective response to their secondaries for a minimum period of six months. This compares with a response of only 18% for ER-negative (ER-) tumors. In patients who had previously received endocrine therapy and on relapse were treated with cytotoxic chemotherapy, objective response rate to chemotherapy was better in patients in whom the primary tumor had been ER-, but not significantly so.

Bone scanning: its lack of value in the follow-up of patients with breast cancer.

Three hundred and fifty-four women with primary operable breast cancer had a bone scan performed within 6 weeks of a simple mastectomy. Eight (2.3 per cent) were positive, but 7 of these patients had radiological evidence of bony metastases. Follow-up bone scans 1 year postoperatively on 278 patients showed only 12 (4.3 per cent) positive, and of these, 9 had other radiological evidence of metastatic disease. At 2 years postoperatively there were 13 (9.2 per cent) positive bone scans amongst 141 patients. Only 2 of these 13 had no other evidence of metastases. Although a bone scan is a useful investigation in patients with bone pain, there is no place for routine bone scanning in either the staging or follow-up of women with operable breast cancer.

Relationship of oestrogen-receptor status to survival in breast cancer.

The oestrogen-receptor (E.R.) content of the primary tumour was measured in 133 postmenopausal women with operable breast cancer. 79 (59%) were positive for E.R. and 54 (41%) negative. Curves of life survival show that women with E.R.-positive tumours live longer than those with E.R.-negative tumours.

A suggested classification of breast pain.

A system of classification based on the work of Preece et al. (1976) is described. The results of applying this classification over a 4 month period (representing 84 patients) are described.

Identification of the presence and type of biliary microflora by immediate gram stains.

Immediate gram stains were performed on gallbladder bile aspirated at the start of an operation for biliary disease in 191 consecutive patients undergoing elective biliary surgery. The results of the gram stains were telephoned to the operating theater within 20 minutes of collection. The over-all accuracy rate of the telephone gram stain reports compared with the subsequent bile cultures was 77 percent. The incidence of false-positive results was 12 percent, and false-negative results were recorded in 7 percent. The organism was identified wrongly by the gram stain in 4 percent of patients. These results have improved with experience and the over-all accuracy rate of gram stains on bile over the last 6 months have been 87 percent.

Selecting patients requiring antibiotics in biliary surgery by immediate gram stains of bile at operation.

The value of selecting patients for antibiotic cover during biliary surgery by the use of immediate gram stains of bile was determined in a nonrandomized prospective study which compared two groups of patients. Group A consisted of 119 consecutive patients in whom antibiotics were administered during operation according to the results of immediate gram stains on bile. Group B included 101 patients, none of whom received antibiotics. In Group A gentamicin was given for gram-negative bacteria, ampicillin for gram-positive organisms, and no antibiotics were given if no bacteria were seen on the gram stain. In Group A the incidence of wound sepsis was 7 percent, compared with 22 percent in Group B (p less than 0.005). Septicemia occured in 2 percent of Group A, compared with 8 percent in Group B. It is concluded that immediate gram stains of bile will provide a means of selecting patients requiring antibiotic cover during biliary surgery; furthermore, this procedure is a practical way of reducing postoperative sepsis while avoiding unnecessary antibiotic administration.