Electropotential measurements as a new diagnostic modality for breast cancer.

BACKGROUND: Proliferative changes in breast epithelium are an intrinsic aspect in the development of breast cancer, and result in regions of epithelial electrical depolarisation within the breast parenchyma, which can extend to the skin surface. Diagnostic information might be obtained from a non-imaging and non-invasive test based on skin-surface electropotentials. METHODS: In 661 women, scheduled for open biopsy at eight European centres, we studied whether measurements of breast electrical activity with surface sensors could distinguish benign from malignant breast disease. A depolarisation index was developed. RESULTS: We found a highly significant trend of progressive electrical changes according to the proliferative characteristics of the biopsied tissue. Discriminatory information was obtained in both premenopausal and postmenopausal women, and the index was not related to age. The best test performances were for women with palpable lesions. The median index was 0.398 for non-proliferative benign lesions, 0.531 for proliferative benign lesions, and 0.644 for cancer (ductal carcinoma-in-situ and invasive). A specificity of 55% was obtained at 90% sensitivity for women with palpable lesions when a discriminant based on age and the depolarisation index was used. INTERPRETATION: This new modality may have diagnostic value, especially in reducing the number of unnecessary diagnostic tests among women with inconclusive findings on physical examination. Understanding and control of the biological variability of these electrical phenomena will be important in the improvement of this test. Studies in populations with a lower cancer prevalence are needed to assess further the diagnostic value of this approach.

Results of breast conserving therapy for early breast cancer and the role of mammographic follow-up.

PURPOSE: The following article is a review of 23 years of breast-conserving therapy in our hospital. This study was performed to assess and improve the follow-up care of women with early breast cancer and to evaluate whether or not biannual mammogram is useful. METHODS AND MATERIALS: Between 1972 and December 1995, 3072 women with pathological size pT1 and pT2 breast cancer were treated with conservative surgery and radiation therapy. Eighty-five patients developed a recurrence in the treated breast as the first site of failure, 12 of which had positive axillary nodes. In the following patient study, those with an noninvasive recurrence were excluded. A retrospective assessment of the entire mammographic course was made, starting with the mammogram at the time of original diagnosis to the mammogram of the recurrence. RESULTS: In our study group the probability for local failure ranged from 1 to 2% per year. At 5 and 10 years the actuarial rates were 5 and 10%. The median time to recurrence was 41 months (range 8-161). Twenty-six (31%) recurrences were detected by mammography alone, 10 (12%) by clinical examination only, and 35 (41%) by both methods. For the patients with an ipsilateral recurrence, the overall actuarial 5- and 10-year survival after treatment was 87 and 70%, respectively. The 5-year actuarial rate of survival from salvage mastectomy was 61%. CONCLUSION: Considering the high percentage of recurrences detectable by mammography and the possibility of detection within a short-term interval, we think biannual mammographic follow-up is appropriate for the first years following breast-conserving therapy.

[Quality assurance by improved cooperation structures. The example of decentralized early detection mammography]. / Qualitätssicherung durch bessere Kooperationsstrukturen. Das Beispiel der dezentralen Früherkennungs-Mammographie.

The German Mammography Study investigated into quality assurance measures for screening mammography, proceeding in a decentralised manner and focussing especially on structure, process and outcome of the study. The field phase lasted for three years, and during this period the technology of the equipment used in mammography improved, also to the indicators of process and of early outcome. The annual interval of examinations was well received. To include mammography into the German cancer screening programme is no easy matter: it requires a comprehensive cooperative quality assurance programme incorporating various institutions of medical care. Appropriate recommendations have been made to the Federal Committee of Physicians and Sickness Insurance Bodies.

Nodal involvement in cancer of the uterine cervix: value of lymphography and MRI.

In this study the preoperative staging of lymph node involvement in cervical cancer was analyzed retrospectively in 155 cases. All results were correlated with lymph node histology. One hundred and three patients underwent preoperative lymphography. Twelve of them were investigated by lymphography and MRI (magnetic resonance imaging). One patient was staged Ia, 10 patients were staged Ib and one patient was staged IIb. All patients underwent surgery; 18.5 lymph nodes were removed on average. Histologically lymph node involvement was found in 3 cases. Lymphography was able to detect lymph node involvement correctly in one case (33% sensitivity). We got two false positive results by lymphography (67% specificity). By MRI all cases were classified as nodal negative. MRI did not have advantage over bipedal lymphography in detecting lymph node involvement in our study, even though the results of lymphography were also poor.

[Measurement of the distance of the rectal mucosa from a gynecologic afterloading applicator based on the drop in performance of a cobalt-60-source]. / Messung des Abstandes der Rektumschleimhaut von einem gynäkologischen Afterloadingapplikator über den Dosisleistungsabfall einer Kobalt-60-Quelle.

PURPOSE: Assessment of the distance from a gynecological afterloading applicator to the rectum mucosa. METHODS: The appropriate afterloading applicator for HDR-Ir-therapy is used for that purpose. A Co-60-source (370 MBq) with a guiding wire is positioned at the tip of the applicator and then withdrawn in steps of 1 cm. For each of these points the maximum dose at the rectum mucosa is measured with an ionisation chamber. From a reference curve it is then possible to determine the distance from the rectum mucosa to the applicator and to mark it in the calculated isodose plan. The actual daily dose to the rectum mucosa is planned not to exceed 3.0 Gy in the maximum. RESULTS: Up to now the measurements were performed in 91 patients. The minimal distances of the rectum mucosa from the applicator were found to range from 5 to 18 mm with an average value of 14 mm. CONCLUSIONS: The comparison of the measurement with the readings of the rectum probe during each session showed, that the method is suitable to avoid an overdose at the rectum mucosa.

[Controversial attitude to mammography screening in asymptomatic women between 40 and 50 years of age]. / Beitrag zur kontroversen Einschätzung des Mammographie-Screenings bei asymptomatischen Frauen zwischen dem 40. und 50. Lebensjahr.

The results of screening studies conducted in the United States and in Europe in females between the ages of 40 and 50 are analysed. It is shown, that the results of this study on mortality reduction are less favourable, the poorer the technique of mammography (foregoing of general two-view mammography) and the longer the time interval between two mammography screenings. Arguments are presented, that are brought forward when declining to perform general mammography screening in this age group. The author's own results, obtained in the Hamburg mammography screening study, which included from 1971 to 1986 also premenopausal women, show, that the survival rates of patients below 50 years of age with mammographically detected carcinomas of the breast do not differ from those in patients older than 50 years, according to a relevant age group classification. The advances in the technique of mammography in recent years are analysed on the basis of the author's own patient material. It is evident, that the positive predictive value has been doubled, especially in the age group between 40 and 50. An analysis of the distribution of diagnosed noninvasive carcinomas compared with the invasive carcinomas reveals, that particularly this age group has the highest percentage of identification of prognostically favourable carcinoma stages. Further analyses show, why the randomised European mammography studies could not yield a significant mortality rate improvement. A prerequisite for the inclusion of mammography screening in the legally prescribed early detection of carcinoma examinations, however, are the quality controls, whose realisation, in our health system, will have to be confirmed by the German mammography study.

[Determinants of observer variability in early diagnostic mammography--a ROC analysis]. / Determinanten der Beobachter-Variabilität bei der Früherkennungsmammographie--eine ROC-Analyse.

As part of the German mammographic study, the participating doctors were given test films of 30 histologically confirmed cases. Regarding the indications for biopsy there was good sensitivity (the median amongst 25 doctors was 0.87). Specificity (median 0.86) could be improved. Comparison of individual results with the majority showed considerable variability within the group of doctors performing mammography. ROC analysis indicated that there was considerable observer variability which was independent from the specialty or praxis characteristics of the participants. The inclusion of mammography in an early diagnostic programme requires continuing education of the participants in this technique. This should be supported by further methods of quality assurance.

[Results of treatment following breast-saving therapy: analysis of intramammary recurrence]. / Behandlungsergebnisse nach brusterhaltender Therapie: Analyse der intramammären Rezidive.

1,135 patients were subjected to conservation treatment of the breast between 1972 and April 1990. The probability of survival without relapses and metastases is 82.2% (5 years) or 72.1% (10 years), respectively. Local recurrence from relapses is 94.8% (5 years) or 88.9% (10 years), respectively. 31 patients developed an intramammary relapse, whereas 3 presented a renewed ductal in-situ manifestation, that was not considered to be a relapse. An unfavourable prognosis in respect of the rate of local relapses is considered to be dependent upon the size of the tumour. Other unfavourable factors are youthful age, concomitant DCIS formations, lymphangiosis carcinomatosa and "incomplete" resection (i.e. not including healthy tissue surrounding the tumour). These various "risk factors" are discussed on the basis of the literature and the authors' patient material.

Thermography in the follow-up of breast cancer patients after breast-conserving treatment by tumorectomy and radiation therapy.

It is often suggested in the literature that thermography is able to diagnose a recurrence in the breast after breast-conserving therapy by a rise in breast temperature much earlier than other diagnostic tools, but no thermographic values are presented. The thermographic data of a prospective study of 309 women after breast-conserving therapy were evaluated. Seventeen of these women had an intramammary recurrence. A total of 2432 individual measured values were evaluated from 292 patients without evidence of a recurrence and 146 measured values from 17 patients with intramammary recurrence. The thermographic behavior of the breast after breast-conserving therapy is not uniform. However, the breast temperatures of the patients with intramammary recurrences were not significantly different from those without recurrences. This means that thermography is of no value in the care after breast-conserving therapy.

[Radiotherapy in primary radically operated ovarian cancer]. / Die Strahlentherapie beim primär radikal operierten Ovarialkarzinom.

The basis of primary treatment is consequent surgery. Radiation therapy is not necessary for borderline tumors. An effect has been seen in stages Ib to III with a small amount of post-operative residual tumor. A comparison with the value of alternative chemotherapy has not yet been made. Instillation of the radioisotopes is effective. The value of radiation therapy after successful chemotherapy of stages III/IV has not yet been investigated enough. The results of radiation therapy after surgical and chemotherapeutical failure are poor.

[Secondary vulvectomy treatment results in local recurrence of a vulvar carcinoma following electron irradiation]. / Behandlungsergebnisse durch sekundäre Vulvektomie bei Lokalrezidiven nach Elektronenbestrahlung eines Vulvakarzinoms.

Between 1965 and 1979 vulvectomy was performed in 41 patients because of histologically demonstrated local recurrence of a vulval carcinoma after electron beam therapy. Of the patients thus treated, 36.6% survived more than 3 years and 19.5% more than 5 years. An analysis of this group of patients shows that only recurrences less than 3 cm in size have a good prognosis with secondary vulvectomy. However, even with a more severe local condition, a secondary vulvectomy is justified as a palliative. Previous electron beam therapy does not represent an absolute contraindication to surgery, even though there may only be secondary healing in almost all cases.

[Intraductal breast carcinoma. Clinical, x-ray and histological findings and their therapeutic consequences]. / Das intraduktale Mammakarzinom. Klinische, röntgenologische und histologische Befunde und ihre therapeutischen Konsequenzen.

116 cases of early ductal breast cancer diagnosed during 1971 to 1981 were analysed. In 65 cases no invasion was detectable. 37 cases showed an early stromal invasion and in 14 cases the invasion was questionable. A palpable mass was seen in 32% of the noninvasive and in 46% of the early invasive cases. The most important mammographic signs were grouped, suspicious microcalcifications (87%). Multicentricity occurred in 26% of the noninvasive and 43% of the early invasive cases. Two cases of the noninvasive and two of the early invasive group had axillary metastasis. Positive nodes were seldom in early ductal carcinoma (3%) compared to 42 invasive comedo-carcinomas (36% positive axillary nodes). In the follow-up five local recurrences were detected in the noninvasive group and one each in the other groups. In the noninvasive group 17% local recurrences occurred after breast conserving modalities compared to 4% in mastectomy patients. As no reliable data for the selection and the results of breast preserving modalities are available now, mastectomy and axillary dissection may be the safest therapy. Only in small intraductal breast cancer (under 25 mm) the breast may be conserved (wide excision, segmental resection, quadrantectomy), if complete excision is carefully controlled by mammography and histology and follow-up is guaranteed.

[Radiotherapy of vulvar cancer. Treatment results of electron therapy in 446 patients 1956 to 1978]. / Die Strahlenbehandlung des Vulvakarzinoms. Behandlungsergebnisse einer Elektronentherapie bei 446 Patientinnen im Zeitraum von 1956 bis 1978.

446 patients with malignant tumour of the vulva were treated from 1956 to 1978. In 432 patients with invasive squamous cell carcinoma, a five-year survival rate of 43.1% was obtained after exclusive exposure to electron radiation. Severe complications were seen in 10.9% of the treated patients. On comparing the results with those obtained after electrocoagulation or vulvectomy, it was seen that a therapy based on electron radiation only yielded more favourable results, especially in cases with advanced stage carcinomas. In younger women with early tumour stages, surgery should be given preference.

[Axillary lymph node metastases as first manifestation of occult breast cancers]. / Die axilläre Lymphknoten-metastasierung als erste Manifestation eines klinisch noch okkulten Mamma-karzinoms.

Within a period of 8 years 12 women patients were referred to the authors with histologically established lymph node metastases in the axilla without a primary tumour being identified despite careful examination. Subsequent follow-up showed that the only possible cause in these patients was a primarily occult carcinoma of the breast. This rare manifestation of a carcinoma of the breast is discussed on the basis of the case reports and the literature with particular regard to the diagnostic and therapeutic problem involved.

Treatment of advanced cancers of the cervix uteri with external irradiation alone.

The five year survival rates of 150 patients who were treated by external irradiation alone for cancers of the cervix uteri are presented. Intracavitary radium therapy had been rejected as inappropriate in all of them on account of the size and type of spread of the tumor. The average age of the selected patients was considerably higher than that of control groups. Results and incidence of side-effects are comparable with those obtained by radium-telecobalt therapy; however, rectovaginal/vesicovaginal fistulas as a reaction to radiation treatment did not occur.