Effectiveness and cost-effectiveness of sentinel lymph node biopsy compared with axillary node dissection in patients with early-stage breast cancer: a decision model analysis.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is less invasive than axillary lymph node dissection (ALND) for staging early breast cancer, and has a lower risk of arm lymphoedema and similar rates of locoregional recurrence up to 8 years. This study estimates the longer-term effectiveness and cost-effectiveness of SLNB. METHODS: A Markov decision model was developed to estimate the incremental quality-adjusted life years (QALYs) and costs of an SLNB-based staging and management strategy compared with ALND over 20 years' follow-up. The probability and quality-of-life weighting (utility) of outcomes were estimated from published data and population statistics. Costs were estimated from the perspective of the Australian health care system. The model was used to identify key factors affecting treatment decisions. RESULTS: The SLNB was more effective and less costly than the ALND over 20 years, with 8 QALYs gained and $883,000 saved per 1000 patients. The SLNB was less effective when: SLNB false negative (FN) rate >13%; 5-year incidence of axillary recurrence after an SLNB FN>19%; risk of an SLNB-positive result >48%; lymphoedema prevalence after ALND <14%; or lymphoedema utility decrement <0.012. CONCLUSION: The long-term advantage of SLNB over ALND was modest and sensitive to variations in key assumptions, indicating a need for reliable information on lymphoedema incidence and disutility following SLNB. In addition to awaiting longer-term trial data, risk models to better identify patients at high risk of axillary metastasis will be valuable to inform decision-making.

Parathyroid hormone venous sampling prior to reoperation for primary hyperparathyroidism.

BACKGROUND: The surgical cure rate for primary hyperparathyroidismis greater than 95%. For those who have recurrent or persistent disease, preoperative localization improves reoperation success rates. Selective parathyroid venous sampling (SPVS) for intact parathyroid hormone is particularly useful when non-invasive localization techniques are negative or inconclusive. METHODS: We present all known cases (n = 13)between 1994 and 2002 who had venous sampling for localization a tour institution prior to reoperation for recurrent or persistent primary hyperparathyroidism. Comparison was made with non-invasive localization procedures. Results of invasive and non-invasive localization were correlated with surgical findings. RESULTS: Of the nine reoperated cases, eight had positive correlations between SPVS and operative findings and histopathology. SPVS did not reveal the parathyroid hormone source in one case with negative non-invasive localization procedures. Comparisons between SPVS,computerized tomography (CT), and parathyroid scintigraphy (MIBI)as expressed in terms of true positive (TP), false positive (FP)and false negative (FN) were: SPVS - TP88.8%, FP 0%, FN 11.1%; CT - TP22.2%, FP 22.2%, FN 55.5%; and MIBI - TP33.3%, FP 0%, FN 66.6%. At least seven of the nine operated cases have been cured; another remained normocalcaemic 2 weeks after subtotal parathyroidectomy. CONCLUSION: In our institution SPVS has proven to be a valuable tool in cases with recurrent or persistent primary hyperparathyroidism and negative non-invasive localization procedures.

Confirmation of susceptibility locus on chromosome 13 in Australian breast cancer families.

Two major genes determining predisposition to breast cancer, termed BRCA1 and BRCA2, have been mapped to the long arms of chromosomes 17 and 13, respectively. Each locus is believed to account for approximately 40% of cases of familial breast cancer. We used linkage and haplotype analysis with simple tandem repeat polymorphisms at chromosomal bands 17q21 and 13q12 to determine the contribution of the BRCA1 and BRCA2 genes to predisposition to breast cancer in four Australian breast cancer kindreds, one of which had two male cousins with breast cancer. Surprisingly all families segregated a haplotype of markers on 13q and showed positive lod scores supporting linkage to BRCA2. In addition, haplotype analysis identified an informative recombination between D13S260 and D13S171 in one affected individual, which refines the localisation of BRCA2 to between D13S260 and D13S267; a distance of 2-3 cM. Tumours of the stomach and cervix, as well as melanoma and leukaemia/lymphoma also occur in these pedigrees but the numbers are too low to determine whether they may be significantly associated with BRCA2 carrier status. Our results confirm the existence of BRCA2 on the long arm of chromosome 13 and support previous findings that this locus is likely to confer risk in families with affected males. Furthermore, our observations suggest that the BRCA2 gene may also contribute to the development of other neoplasma.

Mastalgia: a 3 year Australian study.

Mastalgia is a common but often poorly understood condition with little Australian data available on the subject. Details are presented of 170 patients who have attended a specific mastalgia clinic at the Princess Alexandra Hospital, Brisbane, Queensland, over a 3 year period. The aims and management protocol of the clinic are outlined. The mastalgia sufferer in this study had an average age of 42 years and 87% were multiparous. Cyclical pain occurred in 59% as determined by a daily pain record chart. Unilateral pain occurred in 38%. Lack of previous breast feeding and low levels of regular physical exercise were identified as two significant factors in the history of those attending the clinic. The responses to treatments are outlined. Response rates of 18 and 26% to two commonly used 'natural products', Vitamin B6 and Evening Primrose Oil, respectively, are considered little better than placebo effect. A complete response was achieved in 67% of women who took low dose danazol with minimal side effects. The overall response rate to all treatments was 65% with a mean follow up of 15.5 months for those women who continued to attend the clinic. For women with mastalgia, a systematic approach can achieve relief of pain.

Survival from pentamidine induced pancreatitis and diabetes mellitus.

Serious and occasionally fatal reactions to pentamidine have been reported and with the increased use of the drug in immunocompromised patients they are likely to become more frequent. We report the development of acute pancreatitis and permanent diabetes mellitus in an AIDS patient treated with intravenous pentamidine for Pneumocystis pneumonia. The literature on pentamidine induced pancreatic damage is reviewed.

Incarcerated sigmoid bottle.

A 67-year-old man presented to Casualty approximately 12 hours after the insertion of a bottle into his rectum. An attempt was made to deliver the bottle through the rectum but because of perirectal oedema and a coat-hanger wire around the internal end of the bottle, this proved impossible. Laparotomy was performed and the bottle was removed through a longitudinal colotomy.

Remote arterial injury. Another cause of spurious arterial spasm.

The need for urgent diagnosis and treatment of arterial injury is fully accepted but surgical exposure of the injured vessel is often preferred to pre-operative diagnosis by arteriography. Exposure of the artery at the site of limb injury may reveal spasm or thrombosis without evidence of direct trauma to the vessel. In that case, traction injury of the artery remote from the surgical field is likely. Commonly this affects a proximal segment of the artery but it can occur at a distal fixed point also. Attempts at thrombectomy risk further disruption of the vessel and diagnostic arteriography is required for satisfactory management. An illustrative case is presented.

Solitary thyroid nodule: audit shows improved care requires cytological diagnosis.

An audit was conducted of all patients undergoing thyroid surgery in a district general hospital over the 8-year period during which fine needle aspiration cytology (FNAC) was introduced. Of the 252 patients, 32 (14%) were toxic and 92 (36%) had large multinodular goitres, but 118 (46%) had a solitary thyroid nodule removed to exclude neoplasm. However, only 12.7% of such resected nodules were found to be carcinomas. Where FNAC was used, the accuracy for preoperative diagnosis was 82.6% and the sensitivity for prediction of carcinoma was 87.5%. Cytology correctly predicted 81% of the colloid nodules and these may have been managed without surgery if the patient was agreeable. It is suggested that one-half of the patients with solitary thyroid nodules could have been spared operation. Analysis of the operative procedure shows that one-fifth of the neoplasms may have been more accurately dealt with had FNAC been used, and four patients could have avoided the trauma and risks of a second operation. The study suggests that FNAC and increased specialisation will improve the quality of thyroid surgery in a district general hospital.

Diverticulosis of the vermiform appendix.

A case of appendicitis that was associated with a rare congenital diverticulum of the appendix is presented, along with the results of a retrospective study of diverticulosis of the appendix over a 10-year period. The incidence of the condition in this series (0.65%) is similar to other published series; however, two cases involved rare congenital diverticula--only 43 of such cases have been previously recorded in the medical literature world-wide. The average age of patients who present with acute appendicitis with acquired diverticula (37.8 years) is greater than that of patients without the condition. The perforation rate of an inflamed appendix when diverticula were present (27%) was higher than when no diverticula existed (6.6%). Because of the earlier and higher perforation rate, it is proposed that appendicectomy be performed if an appendix with diverticula is found during the course of a laparotomy for some other condition.

Splenorrhaphy in the management of splenic injury.

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.