Understanding a ductal carcinoma in situ diagnosis: patient views and surgeon descriptions.

Following the release of the national clinical treatment recommendations for ductal carcinoma in situ (DCIS), consumers' and surgeons' characterisation of this disease was assessed. Telephone interviews were conducted with 231 women diagnosed with DCIS, in Victoria, Australia in 2006/2007 and 63 treating surgeons completed a mailed survey. The main outcome measures were: women's diagnostic experience, women's and surgeons' description of DCIS, women's understanding of DCIS, confusion and worry about the disease and risk perceptions. While the majority of women had not heard of DCIS prior to diagnosis, most reported a positive diagnostic experience. Surgeons' and women's description of DCIS were consistent. Women understood that DCIS is a contained disease (86%), can progress (88%) and treatment aims to prevent invasive cancer (97%). However, only 13% understood that DCIS alone cannot spread to other parts of the body. A quarter of the women were confused about the risk of DCIS spreading. Younger women had more concerns about developing breast cancer (P= 0.008) and the disease spreading (P= 0.002) and rated their risk of invasive disease higher (P= 0.007). Most women diagnosed with DCIS in 2006/2007 understand the 'early, contained nature' of the disease, but understanding of the 'non-invasive' nature of DCIS could be improved.

Simple day-case surgery for pilonidal sinus disease.

BACKGROUND: Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. METHODS: A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. RESULTS: Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. CONCLUSION: Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.

The impact of publication of Australian treatment recommendations for DCIS on clinical practice: A population-based, "before-after" study.

BACKGROUND: Clinical practice guidelines/recommendations have been promoted as a mechanism for ensuring evidence-based medicine. We examine the impact of the publication of Australian treatment recommendations (ATR) for ductal carcinoma in situ (DCIS) on clinical practice and surgeons' attitudes to the ATR. METHODS: All new cases of DCIS diagnosed in the 12-months immediately before the ATR release (pre-ATR: September 2002 to August 2003) and three years later (post-ATR: September 2006 to August 2007) were identified from the state of Victoria's population cancer registry. Treatment information, extracted for each case by treating surgeon or study manager, was available for 342 of 353 (97%) tumours pre-ATR and 371 of 378 (98%) tumours post-ATR. Sixty-three surgeons (58% response) completed a survey on awareness and attitudes to the ATR. RESULTS: The proportion of cases undergoing image-guided biopsy, or breast conservation surgery (BCS) did not change between surveys nor did extent of surgical margins. Compared to the pre-ATR period, more BCS cases were referred to a radiation oncologist (67% versus 58%) and more received radiotherapy (53% versus 44%) post-ATR. Tumours greater than 20 mm, of intermediate grade and moderate necrosis were more likely to receive radiotherapy post-ATR. While surgeons agreed with most recommendations, items reflecting radiotherapy recommendations generated most disagreement. CONCLUSION: With the possible exception of adjuvant radiotherapy, most DCIS cases were treated according to treatment recommendations before the ATR's release. The lack of change in radiotherapy for low grade, smaller tumours may reflect surgeon's uncertainty regarding this therapy for all BCS treated cases.

Tubular carcinoma of the breast: prognosis and response to adjuvant systemic therapy.

BACKGROUND: Tubular carcinoma of the breast is an uncommon and usually small tumour, and is thought to have a favourable prognosis. The present study examined the long-term prognosis of patients with tubular breast carcinoma and the roles of axillary dissection and adjuvant therapy. METHODS: Eighty-six tubular cases were identified from a large worldwide database of 9520 breast carcinoma patients entered into randomized adjuvant therapy trials run by the International Breast Cancer Study Group from 1978 to 1999. These patients were followed for a median of 12 years. RESULTS: Forty-two (49%) cases were node-positive, of which 33 (79%) had 1-3 nodes involved. Ten (32%) of the 31 smaller tumours (< or = 1 cm in size) were node-positive. Patients with node-positive tubular carcinoma had a significantly better 10-year relapse-free survival (P = 0.006) and survival (P < 0.0001) compared with non-tubular node-positive cases. Overall survival was similar for node-positive and node-negative tubular carcinoma. Overall, 71 patients (83%) received some form of adjuvant systemic therapy. Of the 86 cases, 43 (50%) received more than one course of chemotherapy. There was an 85% decrease in the risk of death for patients who received more than one course of chemotherapy compared to those who did not (hazard ratio 0.15, 95% confidence interval (CI): 0.03-0.82; P = 0.03). CONCLUSIONS: Compared to other histological types of breast cancer, tubular carcinoma has a better long-term prognosis. Adjuvant chemotherapy may further improve prognosis and involvement of axillary nodes may not be an indicator for early death due to breast carcinoma.

Symptomatic benign breast disease and hormone replacement therapy.

The effect of hormone replacement therapy (HRT) on presentation and diagnoses of post-menopausal women has been examined by a retrospective review of patients presenting to a symptomatic Breast Clinic over a 5-year period. Sixty-seven post-menopausal women aged less than 65 years taking hormone replacement therapy for more than 6 months were compared with 144 post-menopausal women aged less than 65 years not taking hormone replacement therapy. There was no difference in the pattern of presentation, rate of intervention or final diagnoses between these two groups. HRT does not appear to effect the pattern of presentation of benign breast disease in post-menopausal women.

Axillary dissection and ductal carcinoma in situ of the breast: a change in practice.

BACKGROUND: Axillary dissection may be associated with significant morbidity and, while it is necessary in the treatment of invasive breast cancer, is not indicated for the treatment of pure ductal carcinoma in situ (DCIS), although it is being performed in a significant number of cases. The present study examined the incidence of elective axillary dissection in the treatment of DCIS cases detected in a mammographic screening programme over a 4-year period, and whether surgeons have changed their practice in this respect. METHODS: BreastScreen Victoria records were examined retrospectively for the period from January 1995 to December 1998 to identify patients treated for DCIS. The incidence and indications for axillary surgery were investigated. RESULTS: There were 579 cases of DCIS and 93 (16%) had some form of axillary surgery, which was thought to be inappropriate in 57 (10%), the latter being performed by 21 city surgeons and 20 rural surgeons. Before surgery, 36 (63%) cases were diagnosed by core biopsy or excision, and 21 (37%) had imaging and cytology alone for diagnosis. The rate of unnecessary axillary dissections dropped steadily from 14% in 1995 to 4% in 1998, a significant reduction (P = 0.01). CONCLUSION: The incidence of axillary dissection for DCIS has dropped significantly over the last 4 years in Victoria, possibly due to increased awareness through education and guidelines. Surgeons are now more aware that in situ lesions do not need axillary dissection, and that axillary dissection should not be performed for breast cancer unless invasion has been proved histologically.

Glucagon-like peptide-2 increases sucrase-isomaltase but not caudal-related homeobox protein-2 gene expression.

To determine the effect of glucagon-like peptide-2 (GLP-2) on sucrase-isomaltase and caudal-related homeobox protein-2 (Cdx-2) gene expression, male Wistar rats were divided into total parenteral nutrition (TPN)-fed and GLP-2-treated, TPN-fed groups. TPN was given via a jugular line, inserted under anesthesia, for 7 days. The treatment group received 40 microg/day of GLP-2 intravenously with the TPN diet. The small intestine and colon were weighed and measured. Tissue was obtained from the jejunum, terminal ileum, and midcolon. RNA analysis, morphometry, and microdissection were performed. The weight of the small intestine of GLP-2-treated rats was greater than that of TPN-fed rats (P < 0.001). GLP-2 increased the mean metaphase arrests/crypt in both the jejunum and ileum (P < 0.001). Ileal expression of sucrase-isomaltase was increased by 1. 6-fold (P < 0.05). Jejunal expression was increased by a similar amount, although not significantly (P = 0.08). There was no change in Cdx-2 gene expression. Thus GLP-2 can maintain small intestinal morphology and function, but effects on gene expression are not mediated by gross changes in the level of the mRNA for the homeobox protein Cdx-2.

Intravenous nutrition: focus on delivery (3-in-1 bags or not?).

The practicalities of providing intravenous nutrition support the use of 3-in-1 bags. However, problems with stability are an important consideration, especially because the clinical consequences can be devastating. Infusion sets designed with different colored tubing to decrease peroxide formation have been investigated. Also, even though high-dose heparin should not be combined with lipid emulsions, evidence for prescribing low dose in neonatal practice has been published. Furthermore, the largest study testing lipid stability with different drugs highlights 23 that should not be combined. Generation of oxalate as a marker of vitamin C loss and degradation of cocarboxylase have been investigated. Practical guidance has been published on the prevention of copper sulfide and iron phosphate precipitates. A study demonstrating that parenteral nutrition admixture is a poor growth medium has been reported. Finally, cyclical intravenous feeding may have a beneficial effect on the liver through protecting mitochondrial function from hypoxic damage.

Accurate PEG tube placement with magnetic positional imaging.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a common procedure and accounts for an increasing proportion of an endoscopist's workload. Serious complications can occur from inaccurate abdominal wall puncture. Electronic three-dimensional imaging has been used to aid colonoscopy. We adapted the principles of this technique to PEG insertion in a procedure called magnetic positional imaging. METHODS: Magnetic positional imaging was used to determine the abdominal wall puncture site and angle of insertion that would provide the shortest distance from abdominal wall to the stomach. The pull-through technique was used to perform PEG. RESULTS: PEG insertion with magnetic positional imaging was performed on four patients without complications. The average distance between the internal and external sensors was 5 mm. CONCLUSION: A new technique, magnetic positional imaging, facilitates the pull-through technique for PEG. Additional studies are needed to clarify the potential benefit in endoscopic practice.

Parenteral nutrition.

The indications for parenteral nutrition have been examined over the past year. These studies have mostly supported the enteral compared to the intravenous route. Because a formal diagnosis of intestinal failure has not always been the key to initiating intravenous nutrition, however, the clinical applications of their conclusions are uncertain. Studies have also focused on supplementing intravenous nutrition with glutamine; the lack of ideal control groups makes interpretation difficult. Finally, based on present evidence, a pragmatic approach to the provision of intravenous nutrition can be supported.

Internal mammary node relapse following breast conservation: a case for reirradiation.

Internal mammary node involvement in early breast cancer is a prognostic factor of uncertain significance. This paper addresses isolated regional recurrence at this site following breast conservation radiotherapy. A case is presented of a woman who developed an internal mammary recurrence after lumpectomy and breast irradiation. This recurrence was diagnosed as a bone metastasis, a common mistake which may lead to suboptimal management. The true incidence of regional recurrences in the internal mammary nodes has been underestimated and their clinical significance has not been appreciated. Salvage procedures for local control and long-term cure are likely to be successful if the diagnosis is made before distant metastases have occurred and a lengthy period has elapsed since initial treatment was given. The role of reirradiation should be considered as the tissues at this site will generally tolerate a second course of radical radiotherapy given more than 10 years after the first.

Characteristics and treatment of breast cancers 10 mm or less detected by a mammographic screening programme.

BACKGROUND: Small invasive breast cancers up to 10 mm in size have an excellent prognosis and are being detected in increasing numbers by mammographic screening, yet optimal treatment remains controversial. METHODS: A review was made of pathology and treatment data relating to 100 consecutive invasive breast cancers up to 10 mm in size detected among 52,126 women who were screened over a 32-month period. RESULTS: The most common radiological finding was a stellate lesion (44%). Thirty-three cases had an extensive in situ component in addition to the invasive tumour, and included among these were seven ductal carcinoma in situ (DCIS) cases with microinvasion. Of 79 patients who had axillary dissections, seven (9%) were node-positive. Tumours < or = 5 mm were as likely to be node-positive (11%) as those 6-10 mm in size (8%). Positive nodes were found only in patients with more than five nodes excised. Breast conservation surgery was performed in 84% of patients treated by surgeons associated with the programme, and 63% of patients were treated by other surgeons (P = 0.054, exact test). Breast radiation after breast conservation surgery was used in 44% of the cases, but was almost twice as likely to be used if the tumours were > 5 mm (51%) than if the tumours were < or = 5 mm (29%). Adjuvant tamoxifen was given to 61% of the cases. CONCLUSIONS: We found that small invasive breast cancers are commonly treated by breast conservation, which usually includes axillary dissection. Even the smallest may be node-positive, and there is uncertainty about the place of adjuvant radiation therapy and tamoxifen.

Pilonidal sinus: experience with the Karydakis flap.

A personal series of 141 patients with postanal pilonidal sinus was treated by the Karydakis operation. Each sinus was totally excised with a vertical eccentric elliptical excision. A thick flap was created by undercutting the medial edge and advancing it across the midline so that the whole suture line was lateralized to reduce the risk of recurrence. Follow-up was achieved in 114 patients for 1-108 months; 79 (69 per cent) were followed for more than 18 months. Overall there were five recurrences (4 per cent) which required further surgery. Thirty-three patients (23 per cent) were referred following recurrence or failure of healing after previous surgery elsewhere; all were cured by this method. The Karydakis operation has a low recurrence rate because it produces a shallow midline furrow free from scar or suture holes which is less vulnerable to hair penetration than a midline wound.

Changes in the investigation and management of primary operable breast cancer in Victoria.

OBJECTIVES: To investigate the surgical practice and adjuvant therapies used in the treatment of primary operable breast cancer in Victoria in 1990 and compare them with results of a similar study in 1986. DESIGN: All 856 cases of primary operable breast cancer registered by the Victorian Cancer Registry between 1 April and 30 September 1990 were identified. Each patient's surgeon was sent a standard questionnaire covering diagnosis, investigations, operative procedures, adjuvant therapies and reasons for certain management choices. Data were collected on 89% of the patients from 176 participating surgeons. RESULTS: Most patients (82%) were referred to surgeons by general practitioners. Mammographic screening detected 14% of the cancers. The proportion of women receiving breast-conserving operations rose from 22% in 1986 to 42% in 1990. Surgeons operating on more than 20 breast cancers per annum were most likely to perform breast-conserving operations. The most common reasons given for non-conservative operations were the size of the tumour (37%), its central location (25%) and/or patient concern about the risk of recurrence if the breast was to be conserved (22%). Among these patients, reconstruction was done at the time of primary treatment in 13%, subsequently in 2%, and was planned by another 5%. Of all patients, 33% were referred to a radiation oncologist and 24% actually received radiotherapy (similar to 1986). Medical oncologists saw 33% of the patients and 20% of all patients received chemotherapy (similar to 1986), which was given by a medical oncologist in 83% of the cases. Use of endocrine therapy increased from 20% in 1986 to 40% in 1990. CONCLUSIONS: There has been a strong trend towards more conservative breast surgery in Victoria, with surgeons who are most active in breast cancer surgery most likely to perform breast-conserving operations. Apart from a significant increase in the use of endocrine therapy, use of adjuvant therapies was unchanged from 1986.

Clinical significance of HER-2/neu oncogene amplification in primary breast cancer. The South Australian Breast Cancer Study Group.

PURPOSE: To determine prospectively the prognostic significance of HER-2/neu oncogene amplification in the primary tumors of breast cancer patients. METHODS: HER-2/neu amplification in tumor DNA was determined by the slot-blot technique in 1,056 patients with breast cancer (stage I to III) diagnosed between 1987 and 1990. Parameters such as estrogen receptor (ER) and progesterone receptor (PgR) levels, tumor size, axillary nodal involvement, tumor grade, and time to relapse were prospectively obtained. RESULTS: HER-2/neu oncogene amplification, > or = 2, > or = 3, and > or = 5 copy number, was detected in 21%, 11%, and 7% of patients, respectively. In a test set of 529 patients, Cox multivariate analysis showed HER-2/neu copy number > or = 3 or > or = 5 was associated with shorter disease-free survival (DFS) duration. HER-2/neu copy number > or = 3 correlated significantly with pathologic stage of disease, number of axillary nodes with tumor, histologic type, and absence of ER and PgR. For all patients, after a median follow-up duration of 39 months, Kaplan-Meier univariate analysis indicated that tumor oncogene copy number > or = 3 correlated with shorter DFS in both node-negative and node-positive patients. In Cox multivariate analysis, HER-2/neu copy number > or = 3 was associated with shorter DFS, independent of nodal status, ER level, and tumor size. CONCLUSION: Although the follow-up duration of this study is relatively short, we conclude that HER-2/neu amplification is an independent predictor of shorter DFS in both node-negative and node-positive patients.

A comparison between radioligand and immunohistochemical assay of hormone receptors in primary breast cancer.

The detection of oestrogen and progesterone receptor (ER and PgR) levels in human breast carcinoma has traditionally been performed using a biochemical radioligand binding method. This method has several disadvantages including the requirement for generous tissue samples, the production of radioactive waste products and the inability to exclude non-malignant cellular material from the assay process. An alternative method for detecting hormone receptors is available with the use of a monoclonal antibody specific for the ER or PgR receptor using immunocytochemical assay (ER-ICA or PgR-ICA). Although designed for use on frozen section material, with modifications this method can be used on paraffin sections of routinely fixed and processed tissue, on archival material and on very small specimens. Further, an objective assessment or scoring of staining intensity is possible using computerized video-image analysis. Forty-three cases of primary breast carcinoma, treated from 1989 to 1991 at Goulburn Valley Base Hospital, Shepparton were assessed for ER and PgR content using both the radioligand method and immunohistochemistry with video-image analysis, and the results were compared. Of the 43 cases, ER-ICA and ER had a concordance of 81% (P < 0.001, r = 0.58) and in 39 cases, PgR and PgR-ICA had a concordance of 87% (P < 0.001, r = 0.54). Because the sample for radioligand assay is of uncertain composition and the immunohistochemical stain can be scored specifically for malignant epithelium, a degree of discordance is thought to be mostly attributable to the limitations of the radioligand assay.