Principles and guidelines for surgeons--management of symptomatic breast cancer. On behalf of the European Society of Surgical Oncology.

The European Society of Surgical Oncology is actively involved in the promotion of a high standard of surgical oncology throughout Europe. Such an ambition involves recognition of Centres of Excellence in the management of cancer patients throughout Europe. These centres have a multi-disciplinary system involved in the total care of patients with cancer and are concerned with the delivery of care to the highest available standards. It is accepted that not all patients with cancer can, nor should, necessarily be treated in such highly specialized centres. Yet all cancer patients should be guaranteed a high standard of care. High surgical standards can be ensured if surgeons treating cancer are trained in specialist centres and, when in independent practice, follow established guidelines or protocols of treatment. In common with many national surgical oncology societies, the European Society of Surgical Oncology is in the process of establishing good practice guidelines in the treatment of solid tumours. This document on the management of symptomatic breast cancer is the first of a series of guidelines to be proposed by ESSO. It draws heavily on excellent documents already in existence from the British Association of Surgical Oncology and from the Danish Breast Cancer Co-Operative Group. It is hoped that this document will be sufficiently clear and purposeful to be of help to the individual surgeon and yet sufficiently flexible to allow it to be adopted in the different medical systems throughout Europe.

European guidelines for quality assurance in the surgical management of mammographically detected lesions. European Breast Cancer Working Group.

The European Guidelines developed for mammography screening have contributed to the general discussion on quality assurance and the important tasks of the health professionals dealing with breast cancer screening. The cooperation of each medical discipline is of utmost importance in order to achieve optimal results and eventually a mortality reduction. The following guidelines are based on the British NHS quality assurance guidelines for surgeons in breast cancer screening and modified to meet the different needs in the European Countries. The term "surgeon" denotes a medical doctor trained and involved in the surgical treatment of breast diseases. The members of the working group who participated in order to adapt these guidelines are listed above. We hope that this document will contribute towards a more comprehensive approach of breast cancer screening-detected lesions throughout Europe.

Experience with a high speed biopsy gun in breast cancer diagnosis.

Pre-operative determination of histology and receptor status is important in optimizing the management of breast cancer. The purpose of our study was to evaluate the high speed biopsy gun in 109 patients with palpable breast tumours. High speed biopsies were performed using the system BIP High Speed Multi 22 with 16-gauge-needles at a speed of 30 m/s. All biopsies could be used for frozen sections and for determination of receptor status. In 81 patients (74.3%) malignant breast tumours were diagnosed, and three patients (2.8%) had highly suspicious lesions. The oestrogen receptor status was negative in 32%, progesterone receptor status negative in 41%. In one patient (0.9%) a high grade non-Hodgkin's lymphoma of B-cell-type was diagnosed. In 21.1% benign tumours were found. In one patient a malignant tumour was missed at biopsy (0.9% false-negative). It was concluded that high speed biopsy is a reliable and simple method for preoperative sampling of breast lesions.

Principles and guidelines for surgeons--management of symptomatic breast cancer. European Society of Surgical Oncology.

The European Society of Surgical Oncology is actively involved in the promotion of a high standard of surgical oncology throughout Europe. Such an ambition involves recognition of Centres of Excellence in the management of cancer patients throughout Europe. These centres have a multi-disciplinary system involved in the total care of patients with cancer and are concerned with the delivery of care to the highest available standards. It is accepted that not all patients with cancer can, nor should, necessarily be treated in such highly specialized centres. Yet all cancer patients should be guaranteed a high standard of care. High surgical standards can be ensured if surgeons treating cancer are trained in specialist centres and, when in independent practice, follow established guidelines or protocols of treatment. In common with many national surgical oncology societies, the European Society of Surgical Oncology is in the process of establishing good practice guidelines in the treatment of solid tumours. This document on the management of symptomatic breast cancer is the first of a series of guidelines to be proposed by ESSO. It draws heavily on excellent documents already in existence from the British Association of Surgical Oncology and from the Danish Breast Cancer Co-Operative Group. It is hoped that this document will be sufficiently clear and purposeful to be of help to the individual surgeon and yet sufficiently flexible to allow it to be adopted in the different medical systems throughout Europe.

Malignant schwannoma of the breast.

Malignant schwannoma (MS) is a tumor of the Schwann or nerve sheath cells, most frequently occurring in the lower and upper extremities, trunk and head region. We report the third known case of MS of the breast, which occurred in a 27-year-old woman. The palpable tumor, about 1.2 cm in diameter, was localized in the upper inner quadrant of the right breast. After ultrasonography, mammography and fine needle aspiration cytology, the tumor was removed surgically.

The impact of resection margins in the treatment of primary sarcomas of the breast. A clinicopathological study of 8 cases with review of literature.

We reviewed the clinical and pathological features of eight patients (seven females, one male), who underwent surgery for sarcomas of the breast, to evaluate the effect of the margins of resection and histological tumor type on survival. Patients with carcinosarcoma, cystosarcoma phyllodes or dermatofibrosarcoma protuberans were excluded. Tumor size ranged between 4.5 and 26 cm (median 12.8 cm); there were three grade 3, four grade 2 and one grade 1 lesions. Of the five patients treated by radical resection margins, two with large grade 3 sarcomas died of distant metastasis 3 and 10 months later. One patient out of the five radical resected patients developed a local recurrence 96 months later. The recurrence was resected radically, radiotherapy was administered, and the patient is still alive at 168 months. The remaining four radical resected patients are free of disease until now. One of three patients, treated by wide or marginal resection, received adjuvant radiotherapy. This patient developed local recurrence and solitary distant metastasis at 26 and 49 months, respectively, and died of multiple distant metastasis at 54 months. Regional axillary lymph node metastasis was not observed in five patients in whom lymph node dissection was performed, with a median of 14.2 dissected lymph nodes. Two of eight patients received preoperative chemo- or radiotherapy because of large tumor size; five of eight received postoperative radiotherapy. Local tumor control was achieved in six of eight patients. The median follow-up time was 53.9 months (3-168 months), of all survivors median 72.2 months. Recurrence and disease-free survival rates were analysed according to histologic grade, tumor size, stage, surgical and adjuvant treatment.

[A rare tumor of the sciatic nerve--myxoid neurofibroma. A case report]. / Seltener Tumor des N. ischiadicus--myxoides Neurofibrom. Ein Fallbericht.

The surgical resection of soft tissue tumors in peripheral nerves often poses problems, since the extent of resection depends on tumor dignity, determined by incisional biopsy. This case report is about a myxoid neurofibroma of the sciatic nerve. In the literature, this rare entity is a precursor of malignant neurilemoma. The choice is difficult between radical resection in view of possible locoregional recurrence or possible malignant transformation and preservation of the nerve. In this case, the sciatic nerve was encased in the pseudocapsule of the tumor and was nearly totally spared during surgical resection. Following surgery, there were no neurological defects.

[Breast cancer in the catchment area of the Graz Institute of Pathology. Evaluation of morphologic parameters based on 1,510 cases]. / Das Mammakarzinom im Einzugsgebiet des Grazer Instituts für Pathologie. Evaluierung morphologischer Parameter an Hand von 1510 Fällen.

The patient's age, tumour size, histological type and degree of differentiation as well as involvement of axillary lymph nodes are decisive for prognosis and therapy of breast cancer. Moreover these parameters reflect the achievement of early diagnosis and the surgical standard of treatment of breast carcinomas. Therefore we retrospectively reviewed 1510 cases diagnosed from 1984-1987. Non-invasive carcinomas were diagnosed in 4%. 75% of them were classified as intraductal carcinoma and 25% as lobular carcinoma in situ. 96% of the tumours were invasive at time of diagnosis. Invasive ductal carcinoma (NOS-type) was found in 70.2%, invasive lobular carcinoma in 12.3%. 3.2% of the tumours showed both ductal and lobular differentiation and 2.3% corresponded to invasive ductal carcinoma with a predominantly intraductal component. Medullary and mucinous carcinomas were detected in 2.1% and 2% of cases, respectively. Papillary carcinomas were observed in 0.9%, the frequency of other histological types was less than 1%. 44% of the tumours corresponded to UICC-category pT1, 38% to pT2, 6% to pT3 and 8% to pT4. A meaningful correlation of tumour size and axillary lymph node involvement was possible in only 906 cases, in which 10 or more lymph nodes were verified histologically. Lymph node metastases were detected in 23% of tumour category pT1 and in 47% of category pT2. PT3- and pT4-tumours metastasized to axillary lymph nodes in 77 and 86% of cases, respectively.

Surgical treatment of dermatofibrosarcoma protuberans. A retrospective study of 20 cases with review of literature.

The clinicopathological features and results of surgical treatment of 20 patients with dermatofibrosarcoma protuberans (DFSP) were reviewed. All patients have been observed until the present time or death. The primary treatment usually consisted of marginal, wide or radical excision. Re-excision because of recurrence was performed in six of the 20 patients who were treated primarily only by marginal excision. Following re-excision two patients have remained disease-free until the present, the other four of these six patients had a second recurrence. Three of these four patients with a second relapse were successfully treated by excision. Although six patients out of 20 had 13 recurrences at the site of primary therapy, no patient developed lymph node or distant metastases. To date, none of the remaining 14 patients has had recurrence, all having been treated by excision of from 1 to 5 cm, the mean follow-up time was 8.75 years. Based on our data, the high recurrence rate after marginal surgical treatment implies an initial radical resection.

Sigma S, a measure of reactive sulfur groups of immunoglobulin G, is a sensitive tumor marker discriminating different stages of breast cancer.

Sigma S is a measure of the disulfide bonds and free thiol groups of serum immunoglobulin (Ig) G, as determined by the reaction with dithionitrobenzoate. Significant decreases of sigma S previously were detected in malignant compared with benign diseases of various organs. This study shows the application of sigma S for the diagnosis of breast cancer. The following results were obtained. First, 132 patients with benign breast diseases showed a sigma S of 1.48 +/- 0.29 (standard deviation) per mole IgG; this was not different from 1.51 +/- 0.36 found in 182 controls. In contrast, IgG from 198 patients with primary breast carcinoma of all four stages (tumor-node-metastasis system) gave a sigma S of 1.22 +/- 0.29, a significant (P less than 0.0001) decrease of sigma S from benign to malignant breast disease. Second, sigma S values of single Stages I, II, III, and IV, were 1.27 (n = 59), 1.23 (n = 83), 1.19 (n = 35), and 1.10 (n = 21), respectively, each significantly different from sigma S in benign disease and showing a decreasing trend with increasing tumor progress. Differences were significant between Stages I and IV (P less than 0.025) and II and IV (P less than 0.05). Third, 63% of Stage I breast carcinoma patients had sigma S values below a critical threshold of 1.38. This serum positivity rose to 90% in Stage IV. These values exceeded those reported with other tumor markers. The overall power of sigma S to distinguish between benign and malignant breast disease had a specificity of 61% and a sensitivity of 78%. Early stages (I and II) of breast cancer could be distinguished from benign diseases with 64% specificity and 69% sensitivity. Advanced Stage IV could be discriminated from early Stages I and II with 55% specificity and 71% sensitivity. Thus, the analysis of sigma S may significantly contribute to the surveillance of patients with breast cancer.

The immunoscintigraphic use of Tc-99m-labelled monoclonal anti-CEA antibodies (BW 431/26) in patients with suspected primary, recurrent and metastatic breast cancer.

The discrepancy between serum CEA levels and CEA tissue expression in patients with breast cancer is well known. Whereas immunohistochemistry shows positive CEA expression in 70-90%, the serum CEA levels are often within the normal range. We performed immunoscintigraphy and SPECT with a Tc-99m labelled anti-CEA monoclonal antibody (MAb BW 431/26) in 46 women with suspected breast cancer or recurrence. The results of anti-CEA immunoscintigraphy, mammography, serum CEA levels and immunohistochemistry were evaluated according to the histology of the tumor. Histology verified breast cancer or recurrence (pT1 [n = 7], pT2 [n = 17], pT3 [n = 3], pT4 [n = 3]) in 30 out of 46 patients; benign breast disease such as fibrocystic disease, fibroadenoma, fatty necrosis or chronic mastitis was responsible for suspicious mammographic findings in 16 patients. Immuno-SPECT showed 25 true-positive, 5 false-negative, 11 true-negative and 5 false-positive findings (sensitivity 83%, specificity 69%). Anti-CEA immuno-SPECT of 2 patients with bone metastasis showed all lesions previously detected by bone scintigraphy to be CEA-expressing metastases. In contrast, serum CEA levels were slightly elevated in only 5 out of 30 patients with histologically verified breast cancer (sensitivity 17%). The results of immuno-histochemistry were surprising; tissue CEA expression could be demonstrated in only 5 patients with breast cancer. According to our experiences with this Tc-99m labelled anti-CEA MAb, immuno-SPECT is a suitable additional method for the diagnosis of breast cancer and especially of recurrence. Pre-operative serum CEA levels give no support for the differentiation between benign and malignant breast tumors.

[Scar tissue cancer: observations and results of 23 cases]. / Narbenkarzinom: Beobachtungen und Ergebnisse in 23 Fällen.

The scar tissue carcinoma is a rare disease which arises from the floor of unstable scars, chronic fistulae, ulcera and radiation injuries. The clinical pictures of 23 cases between 1976 and September 1990 have been elucidated. Compared to earlier findings it must now be stated that the development of cancer in stasis ulcera is more frequent than in burn scars or X-ray cancer. Generally, the number of scar tissue carcinomas seems to decrease. Since surgical and adjuvant therapies are--like in any other cancers--limited, prevention and early diagnosis have become of major importance. Though the cancer grows mainly on the body surface and could, therefore, be easily recognised, we still found tumours of remarkable dimension and disturbance, which were either shown to the physician too late or remained unrecognised by the diagnostician.

[Multiple symmetrical lipomatosis. A retrospective study of 14 cases and review of the literature]. / Multiple symmetrische Lipomatose. Eine retrospektive Studie über 14 Fälle mit Literaturübersicht.

"Multiple symmetric lipomatosis" is an accumulation of fatty tissue in upper areas of the body mainly effecting middle aged men. It is a rare benign disease connected with differing disorders. We report 14 male patients suffering from "multiple symmetric lipomatosis" and focus on the etiology and on associated disorders. Differential diagnosis, pathohistological considerations, clinical behaviour, and operative treatment are discussed. A review of the literature is presented.

[Stewart-Treves syndrome and lymphangiosarcoma]. / Stewart-Treves-Syndrom und Lymphangiosarkom.

Lymphangiosarcomas represent the most dangerous complication of chronic lymphedema usually following mastectomy and irradiation therapy on account of breast carcinoma, well-known as Stewart-Treves syndrome. Still more rarely documented are lymphangiosarcomas arising in chronic lymphedema due to other causes. Two cases of Stewart-Treves syndrome on the forearm and one case of lymphangiosarcoma of the hand following a fifty-year existing chronic lymphedema after burn injury in childhood are reported. Clinical description and illustrations of all three cases are given, including list of references. Therapeutic procedures are described.