Prognostic factors associated with survival after breast cancer recurrence.

Factors associated with disease-free interval after the primary treatment and survival after a recurrence of breast cancer were studied in 331 female breast cancer patients treated in 1976-1980. Within five years after the primary treatment, recurrence occurred in 131 patients. The observation time of these patients after recurrence was from few weeks to twelve years. Twenty-nine patients were alive at the end of the follow-up. The average disease-free time was 2 years. The clinical stage of the disease in this material was not significantly associated with the disease-free interval. The median survival time after recurrence was 2.7 years when only breast cancer related deaths were included. Survival was significantly better for patients with primarily stage I disease than for patients with primarily stage II-IV disease. The size of the primary tumour was not significantly associated with survival after recurrence. The patients with loco-regional recurrence survived almost significantly better than those with distant recurrence. The disease-free time correlated positively with survival after a recurrence. The present study confirms the view that breast cancer includes several subgroups with a different type of clinical course.

Pancreatic enzyme supplementation in normal and exocrine pancreatic insufficient pigs.

The effect of pancreatic enzyme preparation (Combizyme Forte granulate) on the growth rate of normal, sham-operated and pancreatic duct ligated growing pigs was studied in 2 trials. In the first trial 6 normal Yorkshire pigs were fed a pancreatic enzyme supplement and 6 other pigs from the same litter were fed without supplementation. The growth rate over a period of 4 weeks was not significantly greater in the supplemented group. In a second trial exocrine pancreatic insufficiency, without diabetic symptoms, was produced in 12 pigs (aged 1.5 months and weighing 14 kgs) by ligation of the main pancreatic duct. The growth rates over a period of 20 days after surgery were 240 g, 454 g and 483 g/day in ligated pigs, in ligated pigs supplemented with pancreatic enzyme and in sham-operated control pigs, respectively. The difference between the ligated groups was significant (p less than 0.01) indicating the efficiency of the pancreatic enzyme therapy.

Long-term survival in male breast cancer.

A total of 42 male breast cancer patients (mean and median age 66 years), were followed up for over 25 years or until death. In 24/42 patients (57%) radical surgery and radiotherapy was carried out, surgery alone in 11 patients (26%), and radiotherapy alone in 3 patients (7%). Of the patients 23 died of mammary cancer, 74% of them in five years after primary treatment; 9% of the patients survived 10 years and 7% for 20 years. If only deaths related to breast cancer were included, the 20-year survival was 45%.

A suggested follow-up time for breast cancer patients.

The data for this study, consisting of 300 females treated for breast cancer in 1951-1961, were evaluated in order to ascertain when excess mortality from breast cancer disappears and what would be an appropriate follow-up period for investigational purposes. The clinical stages of the patients were classified as follows: 23.3%, stage I; 49%, stage II; 20.3%, stage III and 7.3%, stage IV. Halsted's radical mastectomy was performed in 79.7% of the cases. Every patient was given radiotherapy. Two hundred and ninety-eight patients could be followed until death or up to the present. Forty-five patients (16%) were still alive. The survival rate over a 20-year period for the various stages was as follows: stage I, 46.1%; stage II, 22.7% and stage III, 10.9%. Only 26% of the patients with stage I died of breast cancer, while the respective figures for stage II were 57% and stage III, 70%. The death rate from the cancer diminished with time in every stage especially 10 years after primary treatment. After this the observed survival rate curves were almost parallel with the expected curves. Our data show that for follow-up studies a 5-year follow-up is good and a 10-year follow-up is very good to show the trend in the treatment of breast cancer.

Ranitidine and prevention of pulmonary aspiration syndrome.

Thirty-seven patients undergoing elective abdominal surgery (excluding gastric operations) received either ranitidine 300 mg or placebo orally at 10 p.m. in the evening preceding surgery in a double-blind randomised study. The mean time interval between this oral premedication and induction of anaesthesia was 12 h. When compared to placebo, ranitidine decreased significantly (P less than 0.05) the amount of gastric juice, and none of the ranitidine-treated patients had an increased risk of acid pulmonary aspiration (pH below 2.5 and volume over 25 ml), while four patients in the control group had an increased risk (21%). The mean ranitidine blood level was 237 ng/ml at the time of induction of anaesthesia. It is concluded that in elective abdominal surgery ranitidine included in the premedication is likely to decrease the risk for acid pulmonary aspiration.

Changes in the treatment and prognosis of breast cancer.

The data of 331 women with breast cancer treated in the Second Department of Surgery, Helsinki University, during the period 1976-1980 (patient material, treatment, prognostic factors) is evaluated and compared with an equally large patient material treated during the period 1951-1961 in the same hospital. A breast lump was the main symptom in 94% and the tumour was found by the patient in most cases. Only two patients were younger than 30 years. The median delays to the first medical contact and to operative treatment were 30 and 20 days respectively. The delay had no influence on the prognosis. Also, the age of the patients and the localization of the tumour had no significant effect on the prognosis. Simple mastectomy with axillary lymph node excision was the main operative treatment in the present material whereas Halsted's radical mastectomy was frequently performed in the previous study. Operative radicality was the same in both studies. The prognosis has improved in all clinical stages. The present relative five year survivals in stages I-IV were 95, 83, 53 and 18%, whereas in the previous study they were 75, 58, 41 and 0%, respectively. The improvement in stage II-IV breast cancers is probably due to advances in radio- and chemotherapy. However, the improvement in the prognosis of stage I and to a lesser extent of stage II breast cancers cannot be explained on this basis alone. Neither do the shorter delays in treatment fully explain the differences in the prognosis. The most frequent sites of metastasis were bone and lung/pleura where almost half of the total metastasis occurring during the follow-up were found.

Fibre-endoscopic insertion of oesophageal tube for palliation in malignant oesophagogastric obstruction.

In 28 patients with malignant obstruction of the oesophagus or cardia, an intraluminal prosthesis was endoscopically inserted as palliation, to permit food intake. Of the 25 who survived the procedure, 23 were able to swallow satisfactorily and required no supporting parenteral nutrition. Complications arose in 13 patients (46%), however. Four of the tubes became obstructed and two were displaced during the follow-up period, and there were two cases of late massive bleeding from mucosal erosions. Perintubation perforation of the oesophagus occurred in two patients. One patient had immediate postintubation myocardial infarction, another had aspiration pneumonia and one had urinary retention. Following intubation, 19 patients could leave the hospital (76%) and 6 were transferred to long-stay units. The authors conclude that endoscopic insertion of an oesophageal prosthesis is a simple and quick procedure, involving less risk than conventional surgical measures for palliation in nonresectable malignant oesophagogastric obstruction. The relatively high incidence of minor complications is emphasized, though many may be prevented by accurate technique.

Contrast-enhanced computed tomography of the gallbladder in acute pancreatitis.

The gallbladder findings encountered in 59 patients examined because of a first attack of acute, alcohol-induced pancreatitis, are reported. Abdominal contrast-enhanced computed tomography was technically acceptable in 54 patients. In 85% of the patients the gallbladder finding was pathological. The density increase in the gallbladder contents was more than twice normal. Possible reasons for this phenomenon are discussed. Intense contrast enhancement of the gallbladder wall was found in 87% of the cases. Increased wall thickness was observed in 64% of the patients.

Duodenogastric reflux in patients with heartburn and oesophagitis.

Forty patients with signs and symptoms of gastro-oesophageal reflux were studied with cholescintigraphy, a noninvasive method, to detect duodenogastric reflux. 150 patients subjected to cholescintigraphy for various medical reasons served as controls. Ten per cent of the patients wit signs and symptoms of gastro-oesophageal reflux and 14% of the control patients had duodenogastric reflux. Of the four patients with gastro-oesophageal and duodenogastric reflux three had ulcers or strictures on oesophagoscopy, whereas one had normal endoscopic appearance. The differences in the frequency of duodenogastric reflux between these groups are not statistically significant.

Disturbances in gastric motility during hypovolaemic shock.

In piglets hypovolaemic shock causes motorical disturbances and gastroduodenal dysrhythmia which both lead to increased duodenogastric reflux and to elevated concentrations of lysolecithine in the stomach. During a long lasting and severe shock gastric movements and electrical control activity waves totally cease. These changes can be observed as well endoscopically as using myoelectrogrammes. Exposition of the gastric mucosa to duodenal juice together with ischemia causes intramucosal haemorrhages and superficial erosions resembling human stress ulcers.

The effect of zinc-protamine-glucagon in acute pancreatitis.

A double blind study testing the effect of long-acting zinc-protamine-glucagon (7.5 mg every 12 hours for 4--5 days) was carried out in acute pancreatitis. There were 32 patients in ZP-glucagon- and 39 patients in the placebo group. The results show that glucagon had a slightly favourable effect on the general clinical course of the disease but they do not give enough evidence for routine use of glucagon in pancreatitis.

Premedication for out-patient endoscopy of the upper gastro-intestinal tract.

Upper gastrointestinal endoscopy was performed on 342 out-patients. The patients were allocated to four groups according to premedication given. The premedication used was atropine 0.1 mg/10 kg (A), atropine 0.1 mg/10 kg and diazepam 5 mg (AD), atropine 0.1 mg/10 kg and fentanyl 0.2 mg (AF), atropine 0.1 mg/10 kg diazepam 5 mg and fentanyl 0.2 mg (ADF). Premedication was given about 30 minutes before the procedure intramuscularly; the mouth and pharynx were sprayed with 10% lidoc,ine. The patients as well as the endoscopist considered the premedication in groups A and AD to be satisfactory. From the patient's point of view there were hardly any differences between the var;ous groups, except in drowsiness, which occurred more often in groups where fentanyl had been used. From the endoscopist's point of view groups A and AD were preferred because they offered better working conditions for the procedure. The longest period of observation was required in group ADF. On the basis of these results premedication with only atropine or if desired a combination of atropine and diazepam in addition to local sprayed anaesthesia of the mouth and pharynx is sufficient, and is recommended for endoscopy of the upper gastrointestinal tract.

Esophageal signs after resection of the gastroesophageal junction: endoscopic follow-up study.

A follow-up examination was performed on 15 patients who had undergone esophagogastric resection or total gastrectomy for cancer an average of ten years earlier. Endoscopy was done in each case. None of the patients who had the esophagogastrostomy high in the esophagus had esophagitis. The diameter of the esophagogastrostomy appeared to have no direct effect on the patient's dysphagia if he adhered to his customary eating habits. Patients with postgastrectomy Roux-en-Y esophagojejunostomy had no dysphagia or esophagitis and mastication was no problem during eating.

Relative risk of stump cancer following partial gastrectomy.

The relative risk of stump cancer following partial gastrectomy for a benign gastroduodenal condition was estimated using an individually matched retrospective study design based on autopsy material. Data on all patients dying with gastric cancer and autopsied at the Central Laboratory of Pathology, University Central Hospital, Helsinki, during 1961-75 were collected. Matched pairs of the same sex and age were used as controls. Of the 464 patients dying with gastric cancer, 9 had undergone previous partial gastrectomy, while the respective number among the controls was 5. This result suggests that the risk of cancer in the gastric stump was not significantly increased as compared to the normal unoperated population.

Ultrastructural changes in the gastric mucosa following hemorrhagic shock in pigs.

Ultrastructural changes in the gastric mucosa of 14 piglets subjected to transient hemorrhagic shock (3 hr duration; mean arterial pressure 40 mmHg) are described. After 30 min there was mucosal edema and extravasation of red blood cells. Microthrombi with degranulating thrombocytes and fibrin strands were seen in the capillaries. These changes were also seen in the antral mucosa where no subsequent ulceration usually occurs. At this stage the cells of the neck region of the gastric glands showed mitochondrial dilatation and their apical parts were seen to bulge into the lumen of the gastric glands. Other cell types were affected later and necrosis progressed from the surface into deeper parts of the mucosa. Mast cells and mucosal endocrine cells were relatively resistant, being mostly undamaged at the end of the shock period and later. The findings suggest that, during the shock, local formation of thrombi contributes to mucosal ischemia and ulcer formation, and that the cells at the neck region of the gastric glands form the locus of limited resistance to ulcerogenic effects.

Selective loss of parietal cells in the gastric remnant following antral resection.

The mucosa of the gastric remnant of 41 subjects who had been operated upon 17-18 years earlier for peptic ulcer was studied histologically. The histological changes were classified as follows: 1) normal mucosa, 1; 2) simple gastritis, superficial or atrophic, 27; and 3) "selective loss of parietal cells", 13 subjects. The latter type was characterized by marked loss of parietal cells without corresponding loss of other epithelial elements and without an inflammatory reaction. These changes were thought to reflect a lack of a trophic action on parietal cells exerted by gastrointestinal hormones, as e.g. gastrins.