The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients.

BACKGROUND: The treatment of choice for cancer of the breast are mastectomy and axillary clearance or wide excision with axillary clearance. The most common complication following such a procedure is seroma formation. Various methods have been used to prevent it. However, the use of a pressure garment in this context has not been fully evaluated in the current literature. RESULTS: In a randomised trial comparing patients with a pressure garment with those without one, we have found no improvement in post-operative drainage with the use of a pressure garment. There were more complications in the group without the pressure garment (19%) compared with those with the garment (15.7%). The only seroma occurred in those patients not using the garment. The use of the pressure garment appeared to increase the duration of use of the drain (6.8 vs 6.1 days), these differences in the two groups was not significant. One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day. This gave a rejection rate of 5%. CONCLUSION: The use of a pressure garment does not reduce the post-operative drainage, however, the complication rate appears to be higher when the pressure garment is not being used.

Sexuality of women after mastectomy.

Changes in sexual functioning, attitudes and sexual behaviour in local women after mastectomy and conservative breast surgery for breast cancer were assessed in this study. Given the social bearing, only married women agreed to be entered into the study. The complexities of variables other than breast loss, contributing to sexual difficulties were recognized and assessed. Through questionnaires designed for local women, a significant proportion of mastectomy women were found to have disturbances in at least one area in their sexual functioning after surgery. A significant number experienced changes in their sexual habits as well.

Characterization of plasma lipids in patients with malignant disease by 13C nuclear magnetic resonance spectroscopy and gas liquid chromatography.

The purpose of this study was to characterize possible changes in fatty acid composition of plasma lipids associated with malignancy. The very low, low, and high-density lipoproteins were isolated by gradient density ultracentrifugation of plasma from 16 patients with malignant disease and from 15 controls. The triglyceride, esterified cholesterol, and phospholipid constituents of each lipoprotein fraction were isolated, and the fatty acid composition within each lipid component was determined by gas liquid chromatography (GLC). In the 10- to 45-parts-per-million (ppm) region of the carbon-13 (13C) nuclear magnetic resonance (NMR) plasma spectrum, differences were found between patients with malignant disease and controls. The ratio of the 31.6/32.1 ppm resonance intensities was lower in the group of cancer patients. The ratio of the 24.4/24.9 ppm resonance intensities in patients with malignant disease was different from the nonpregnant controls. The NMR changes were interpreted in light of GLC data that indicated derangements in the composition of fatty acids within lipoprotein lipids. In total plasma esterified cholesterol, the relative amount of linoleic acid (18:2, n-6) was lower, whereas oleic acid (18:1, n-9) was higher in the group of patients with malignant disease. In total plasma triglycerides, the amount of oleic acid was higher in the cancer patient group. For total plasma phospholipids, no differences in fatty acid composition between patients and controls were found. Throughout the lipoprotein fractions, the same differences in oleic acid and linoleic acid distribution for triglyceride and esterified cholesterol were found when comparing cancer and control subjects. In conclusion, we found that there are certain differences in the 13C NMR spectra and fatty acid profiles between a small and heterogeneous group of cancer patients after they have received their initial treatment and a group of healthy controls. We suggest that carbon NMR spectroscopy could be useful in characterizing malignancy-associated lipid changes.

Breast size and prognosis in early breast cancer.

The influence of breast size on the prognosis of 196 patients with early breast cancer diagnosed in the period 1984-1985 was studied. Breast size was based on the volume from mammography. This method was validated against the volume of the mastectomy specimen determined by water displacement in 18 patients and found to be accurate (r = 0.93, P < 0.01). The median breast volume was 833.5 cm3 (interquartile range 522.8-1153.3 cm3). Breast size was significantly associated independently with age (Spearman's rank r = 0.24. P = 0.001), menstrual status (z = -4.81, P < 0.001), body weight (Spearman's rank r = 0.61, P < 0.001), T stage (z = -1.91, P = 0.05) but not N stage (z = -1.64, P = 0.10) or hormone receptor status (z = -0.80, P = 0.42). In an analysis of breast size and other known prognostic factors, based upon Cox's proportional hazards regression, N stage was the only significant factor for both breast cancer survival and disease-free survival. Even though women with larger tumours at presentation had larger breasts, breast size was not a significant prognostic factor in early breast cancer.

Proton magnetic resonance spectroscopy of fractionated plasma lipoproteins and reconstituted plasma from healthy subjects and patients with cancer.

Proton nuclear magnetic resonance spectra at 500 MHz of plasma and the very low density lipoprotein (VLDL), low density lipoprotein (LDL), and high density lipoprotein (HDL) fractions isolated by KBr gradient ultracentrifugation were analysed in 16 cancer patients, six pregnant and nine non-pregnant healthy subjects. In spectra with narrow plasma composite aliphatic peaks (methylene at 1.2-1.4 p.p.m. and methyl at 0.8-0.9 p.p.m., respectively), a relative increase in either VLDL, LDL, or both, or a decrease in HDL signals was observed. The mechanism for line-width narrowing seemed different in cancer patients (less signals from HDL relative to VLDL) compared with pregnant women (more signals from LDL). By reconstitution of plasma samples from both healthy subjects and patients with malignant disease, decreased concentration of VLDL or HDL resulted in broadening or narrowing of the composite peaks, respectively. The effects of VLDL and HDL on the plasma line width were moderated by the signals from LDL. Within lipoprotein fractions, the methylene and methyl resonances were shifted to a higher field with increased observation temperature, the change in shift being greatest for HDL. The line width of composite peaks in plasma varied with the observation temperature, depending on the relative concentrations of individual lipoproteins. The correlation coefficient (r) for the relation between total plasma triglyceride level and the average of the line-width of the composite methylene and methyl peaks was -0.78 (p less than 0.001). For spectra of individual lipoproteins, statistical significant relationships were found between line-widths and triglyceride content of the LDL fraction (methyl line-width, r = -0.63) (p less than 0.001) and between methylene line-width and cholesterol of HDL (r = 0.54) (p = 0.003). In summary, the shape and width of the composite aliphatic peaks of plasma were affected by the relative concentration, chemical shift and transition temperature of both VLDL, LDL, and HDL, and by the total triglyceride level. Comparing pregnancy and malignant disease, the lipoprotein resonances contributed differently in giving narrow composite signals.

Assessment of morbidity from complete axillary dissection.

The importance of axillary dissection as part of the primary surgical procedure in the treatment of operable cases of carcinoma of the breast is established. The morbidity of this procedure, however, is less well documented. A study of 126 women who had had full axillary dissection as part of their initial surgical treatment was undertaken to assess their degree of morbidity in terms of numbness, pain, weakness, swelling, and stiffness. Seventy per cent of cases complained of numbness, 33% of pain, 25% of weakness, 24% of limb swelling, and 15% of stiffness. Objective measurements confirmed decreased sensation in 81%, weakness in 27%, swelling in 10%, and stiffness in 10%. In no case were these symptoms described as severe, though they did have an effect upon the daily lives of 39%. The side effects of full axillary dissection are common and all women should be warned of them prior to surgery; however they are usually mild and therefore should not preclude this procedure as a part of definitive surgical treatment.

Incidence of arm swelling following axillary clearance for breast cancer.

Arm swelling was measured using volume determination in 118 patients following mastectomy (n = 60) or wide excision (n = 58), both with axillary clearance. The mean age was 60.5 years and the median follow-up was 22.5 months. Axillary clearance removed level III nodes. Axillary irradiation was given to only three patients with extensive (more than 75 per cent) nodal involvement. The incidence of early postoperative complications was 18.6 per cent. The incidence of lymphoedema was 7.6 per cent (nine patients). Three of these patients had early lymphoedema within 6 months of treatment. Arm circumference differences correlated poorly with volume differences. The incidence of lymphoedema following axillary clearance is low and comparable to that for sampling or no axillary surgery.

Oestrogen receptor analysis: correlation between enzyme immunoassay and immunohistochemical methods.

AIMS: To compare oestrogen receptor measurements on fresh tissue done by an enzyme immunoassay (ER-EIA, Abbott) and an immunohistochemical technique (ER-ICA, Abbott) using formalin fixed, paraffin was embedded material. METHODS: The ER-EIA is based on a sandwich immunoassay using fresh frozen tissue, and the absorbance values were read by a Quantum Analyzer. Sections were cut from the corresponding paraffin wax blocks, and after pretreatment with pronase and DNase, the slides were incubated with monoclonal oestrogen antibody. The immunoperoxidase staining was scored semiquantitatively, incorporating both the intensity and percentage of positive staining (HSCORE). RESULTS: HSCORE rating of the ER-ICA slides gave a significant correlation with the quantitative ER-EIA values (r = 0.76; p less than 0.001). The overall sensitivity and specificity of the immunohistochemical method was 88% and 93%, respectively. CONCLUSIONS: ER-ICA on routinely processed material can be a valuable alternative when biochemical analysis of oestrogen receptor content is not available. Furthermore, immunohistochemical staining identifies oestrogen receptor positivity at a cellular level, which ensures that the analysed material is representative. This technique could therefore be particularly valuable in small tumours and in situ lesions.

Breast liver metastases--incidence, diagnosis and outcome.

Breast liver metastases are uncommon and have not been well reported. We studied the clinical outcome of 47 patients who developed liver metastases out of 912 breast cancer patients treated between 1982 and 1987, an incidence of 5.2%. The median disease free interval prior to clinical liver metastases was 20.2 months (range 4-192 months). The most frequent clinical presentations were hepatomegaly (70%) and abdominal pain (34%). The diagnosis was confirmed on ultrasound scan in 72.7% patients. Thirty-one patients (70.5%) received specific treatment with both hormone and chemotherapy but only six showed any evidence of objective response, the majority of whom had metastases only in the liver. The median survival of treated patients was 4 months and absence of jaundice, response to treatment and liver metastases only were associated with significantly better survival. In conclusion breast liver metastases usually present as a manifestation of disseminated disease and have an appalling prognosis. When they occur as an initial site the prognosis is better but very few patients overall respond to conventional treatment.

Gastrointestinal and retroperitoneal sarcoma--local experience and review of the literature.

Gastrointestinal and retroperitoneal sarcoma are uncommon tumours. Out of 26 cases treated over the last 6 years, there were 16 smooth muscle tumours (SMT) and 10 non Hodgkin Lymphomas (ML). 7 cases of SMT were leiomyosarcoma. The majority of the cases were found in the stomach. 8 cases presented as acute emergencies while the non acute cases had non specific complaints. Despite the use of barium studies, gastroscopy and CT scan, only 5 cases were diagnosed preoperatively. The majority underwent curative resection. ML cases had a combination of radiotherapy and chemotherapy. 2 patients with large and high grade leiomyosarcomas have died. 4 patients with ML have also died, 2 with locally advanced disease and 2 with distant metastases. We conclude that most cases are not diagnosed preoperatively due to their rarity and nonspecific clinical presentation. The important prognostic factors are size and mitotic index for SMT and stage of the disease for ML.