Evaluation of ER, PgR, HER-2 and Ki-67 as predictors of response to neoadjuvant anthracycline chemotherapy for operable breast cancer.

Primary systemic therapy (PST) for operable breast cancer enables the identification of in vivo biological markers that predict response to treatment. A total of 118 patients with T2-4 N0-1 M0 primary breast cancer received six cycles of anthracycline-based PST. Clinical and radiological response was assessed before and after treatment using UICC criteria. A grading system to score pathological response was devised. Diagnostic biopsies and postchemotherapy surgical specimens were stained for oestrogen (ER) and progesterone (PgR) receptor, HER-2 and cell proliferation (Ki-67). Clinical, radiological and pathological response rates were 78, 72 and 38%, respectively. There was a strong correlation between ER and PgR staining (P < 0.0001). Higher Ki-67 proliferation indices were associated with PgR- tumours (median 28.3%, PgR+ 22.9%; P = 0.042). There was no relationship between HER-2 and other biological markers. No single pretreatment or postchemotherapy biological parameter predicted response by any modality of assessment. In all, 10 tumours changed hormone receptor classification after chemotherapy (three ER, seven PgR); HER-2 staining changed in nine cases. Median Ki-67 index was 24.9% before and 18.1% after treatment (P = 0.02); the median reduction in Ki-67 index after treatment was 21.2%. Tumours displaying >75% reduction in Ki-67 after chemotherapy were more likely to achieve a pathological response (77.8 vs 26.7%, P = 0.004).

Tuberculosis of the breast: experience of a UK breast clinic serving an ethnically diverse population.

Tuberculosis (TB) of the breast is an uncommon disease in the West but its incidence is likely to increase. Five cases of breast tuberculosis are presented. The diagnosis and management of this condition are discussed.

Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual.

We describe a female-to-male trans-sexual, aged 33, who developed breast cancer 10 years after cosmetic bilateral subcutaneous mastectomy and nipple reimplantation. The complex hormonal pathways involved and the implications for women undergoing prophylactic mastectomy because of a high risk of familial breast cancer are discussed.

The use of carbon suspension as an adjunct to wire localisation of impalpable breast lesions.

AIM: To determine the accuracy and therapeutic success of localisation of impalpable breast lesions by hookwire with additional lesion marking with carbon suspension to mark screen detected abnormalities requiring surgical excision. MATERIALS AND METHODS: Retrospective review of all breast localisation procedures performed in our unit on women with a screen detected abnormality requiring excision over a 7 year period. RESULTS: One hundred and thirty eight women underwent breast localisation procedures. All of the mammographic abnormalities were excised at the initial surgical procedure. The benign to malignant ratio was 1:2. Pre-operative cytology was used to guide the extent of surgical excision, with clear margins in 70 of the 92 patients (75 percent) with malignancy. Twenty patients had further surgery: mastectomy in 7 and further local excision in 14. The localisation procedure was a therapeutic success in the local excision of malignancy in 73 of the 92 patients (79 percent) with malignancy. CONCLUSION: This method of localisation biopsy is an accurate technique for surgical excision of mammographically detected impalpable abnormalities. The surgeon is able to choose the site of surgical incision to give the best cosmetic result, the lesion is easier to identify at operation and the confidence that the abnormality has been excised is improved.

Evaluation of good clinical response to neoadjuvant chemotherapy in primary breast cancer using [18F]-fluorodeoxyglucose positron emission tomography.

To determine whether [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) can predict complete pathological response (pCR) in patients achieving a good clinical response to neoadjuvant chemotherapy for primary breast cancer, 10 patients underwent FDG PET scanning prior to definitive breast surgery. Scan reports were compared with histopathological findings. No abnormal uptake at the primary tumour site was visualised in any patient. 9 of the 10 patients had residual invasive carcinoma at operation, ranging from 2 to 20 mm in maximum dimension. One patient achieved a complete pathological response. Of the 5 patients who underwent axillary surgery, no axillary FDG uptake was seen preoperatively although 3 of the 5 were histologically node-positive. FDG PET did not reliably identify residual disease in this series of good clinical responders to neoadjuvant chemotherapy, and its discriminatory power as a tool to predict complete pathological response therefore appears to be inadequate for clinical use in this setting.

Recurrent pulmonary embolism in pregnancy managed with the Greenfield vena caval filter.

Recurrent embolisation from venous thrombosis despite anticoagulation, in pregnancy, constitutes a major diagnostic and management problem. We present just such a patient who was managed with a Greenfield vena caval filter, which enabled her pregnancy to continue, resulting in a vaginal delivery of a healthy female infant at 38 weeks gestation.

Diagnosis of soft tissue tumours by Tru-Cut biopsy.

Tru-Cut biopsies were obtained from 52 consecutive patients referred with soft tissue tumours. Forty-five patients had soft tissue sarcomas; seven had benign soft tissue tumours. Of the biopsies 96 per cent provided adequate material for diagnosis. The histological diagnosis made from the Tru-Cut biopsy was compared with that made from the resected specimen. There were no false positive diagnoses of malignancy. The accuracy of Tru-Cut biopsy was 98 per cent for the diagnosis of malignancy and 94 per cent for the diagnosis of sarcoma. Tumour subtype was correctly specified in 85 per cent of sarcomas and tumour grade in 88 per cent. Tru-Cut biopsy should replace open biopsy as the primary means of diagnosis of soft tissue tumours unless a satisfactory tissue sample cannot be obtained.

Pyomyositis mimicking soft-tissue sarcoma.

A case of pyomyositis mimicking a soft-tissue sarcoma of the adductor muscle group is described. The aetiology and several presentations of pyomyositis and their differential diagnosis from sarcoma are discussed.

The place of first rib resection in the management of axillary-subclavian vein thrombosis.

Eight patients with axillary-subclavian vein thrombosis were studied. Three presented acutely and five with chronic symptoms of pain and swelling exacerbated by and limiting normal use. Initial venography showed complete occlusion of the axillary vein in 7 cases and marked narrowing in the remaining patient. Venographic evidence of narrowing or occlusion was also seen in 6/8 clinically normal contralateral arms. One of these arms became symptomatic 2 years later, and required surgery. The patients presenting acutely were anticoagulated. Symptoms resolved slowly in 2 cases, but persisted in one. This patient and the five presenting chronic symptoms underwent decompression of the thoracic outlet by transaxillary resection of the first rib. Satisfactory decompression was confirmed at operation by eliciting and then abolishing "nipping" of the surgeon's finger between the first rib and the clavicle on abducting and then relaxing the arm. Symptomatic relief was achieved in 5/7 limbs thus treated (one patient had bilateral first rib resection). Although postoperative venographic improvement was seen in some cases, clinical success did not depend on recanalisation of the main axillary-subclavian vein. The two patients with persistent symptoms after first rib resection subsequently had venous bypass procedures. Despite initial patency, both had occluded with return of symptoms within 4 months.

Transurethral resection of the prostate and bladder neck incision: a review of 700 cases.

Transurethral resection (TUR) is regarded as the treatment of choice for relief of outflow tract obstruction in the male, but bladder neck incision (BNI) is an acceptable alternative when the gland is small. Seven hundred cases of TUR/BNI have been reviewed (TUR = 388; BNI = 312). BNI was performed when the gland was less than 35 g and where there was no clinical suspicion of malignancy. The operative details of our single incision technique are given. While the patients in the BNI group were younger, catheter stay was shorter, there was less infection, a significantly reduced need for blood transfusion and a satisfactory outcome in terms of control and need for further surgery. BNI is a technically simpler procedure than TUR and is easy to teach and learn. Results show it is safe and effective for patients in acute retention as well as those treated electively and it is the operation of choice for small benign prostates.

Survival after extended resection for locally advanced carcinomas of the colon and rectum.

Two hundred and fifty five patients were treated surgically for adenocarcinoma of the colon or rectum on the Surgical Unit at Westminster Hospital in the years 1962-78. After 13 patients had been excluded on the grounds of inadequate data, 57 of the remaining 242 had tumours which, at laparotomy, were firmly adherent to neighbouring organs or the abdominal wall. These 'locally advanced' tumours were treated by an extended en-bloc resection of the tumour and neighbouring organs. The operative mortality after extended resections was higher than after standard resections, but subsequent survival did not differ significantly from survival after standard excisions for tumours of the same Dukes' stage. Histological examination of the neighbouring organs included in the extended resections confirmed direct tumour spread in only 33%.

Further observations on mechanisms of bone destruction by squamous carcinomas of the head and neck: the role of host stroma.

Mechanisms of bone invasion by squamous carcinomas of the head and neck have been investigated using fresh tumours and established tumour cell lines in an in vitro bone resorption assay with 45Ca-labelled mouse calvaria. Fresh tumours regularly resorb bone in vitro. Activity is consistently reduced by indomethacin. The tumours release E2 prostaglandins (PGE2) in amounts sufficient to account for approximately 50% of the bone resorption observed. Small amounts of non-prostaglandin (indomethacin-resistant) osteolytic factors are also produced. Control non-neoplastic tissues show a variable capacity to resorb bone in vitro; PGE2 levels in these tissues may be related to their content of inflammatory cells. Tumour cell lines also resorb bone in vitro but, for most lines, activity is not significantly blocked by indomethacin and PGE2 levels are generally insufficient to account for the osteolysis observed. Non-prostaglandin bone resorbing factors thus predominate. It is concluded that most squamous cancers of the head and neck are osteolytic in vitro and release a mixture of prostaglandin and non-prostaglandin factors which stimulate osteoclastic bone resorption. These factors are derived from both neoplastic and stromal elements, and are "tumour-associated" rather than "tumour-specific". In vitro bone resorption and prostaglandin release does not correlate with pathological features of the tumour or with post-operative survival.