Steroid hormone receptor expression in male breast cancer.

AIMS: To investigate expression of the steroid hormone receptors estrogen receptor (ER)-alpha and -beta, progesterone receptor (PR) and androgen receptor (AR) in male breast cancer. METHODS: Specimens from 16 male breast cancers were immunostained for ERalpha, ERbeta, PR and AR. FINDINGS: Eighty-seven percent of tumours expressed ERalpha, 93% PR, 87% ERbeta and 87% AR. Staining for ERalpha and PR was confined exclusively to the nuclei of epithelial cells with some heterogeneity. Nuclear immunoreactivity was also observed with AR. Again this was restricted to epithelial cells but tended to be more uniform. ERbeta was seen in the nuclei of epithelial cells and also in stromal fibroblasts and lymphocytes. Analysis of serial sections revealed a similar pattern of staining with ERbeta and AR in epithelial cells. CONCLUSIONS: In addition to expression of the better known steroid receptors, ERalpha, PR and AR, we have demonstrated a high rate of expression of ERbeta in male breast cancer. This is in keeping with the generally high steroid receptor expression seen in males. However, the abundance of ERbeta expressed in this small series of male breast cancer is in contrast to female breast cancer where ERbeta expression is often reduced.

Surgical pathological second opinion in thyroid malignancy: impact on patients' management and prognosis.

OBJECTIVES: To evaluate the effect of inter-institutional surgical pathology review of thyroid cancer on patients' treatment and prognosis. METHODS: All cases referred to the Institute of Pathology at Leeds for thyroid pathology review between January 2001 and March 2003 were included. The referring pathologists reports were compared to those produced in the MDT meeting by the expert pathologist. Whenever there was disagreement a third expert opinion was sought who was blinded for both diagnoses. Effects on management and prognosis were evaluated if there was disagreement. RESULTS: Of the 66 patients reviewed, 12 (18%) had a different pathological diagnosis (kappa=0.33). Two had their diagnosis changed from malignant to benign and a further two from benign to malignant. Eight patients had their prognosis downgraded and four upgraded after histopathological review. Five patients had their management affected by the new pathological diagnosis. CONCLUSION: A second opinion of surgical pathology for thyroid tumours can result in major therapeutic and prognostic modifications. All cases of suspected thyroid cancers should be reviewed in a multidisciplinary meeting supported by pathologist with experience in thyroid pathology.

Expression of prostate specific antigen in male breast cancer.

Male breast cancer is uncommon, accounting for less than 1% of all breast cancers. Carcinoma metastatic to the male breast is also unusual, with metastatic prostatic carcinoma being among the most common primary sites from which such tumours derive. Metastatic prostatic cancer and primary breast cancer may be histologically indistinguishable without immunohistochemistry because both often infiltrate with a cribriform architecture. Distinguishing between primary and metastatic disease within the breast is important because the treatment options for each are radically different. Following a case in which metastatic prostatic disease was initially wrongly diagnosed as primary breast cancer, a small series of male breast cancers was examined for expression of prostate specific antigen (PSA) and prostatic acid phosphatase to assess the usefulness of these markers in making this distinction. Focal expression of PSA was found in one of 11 cases of male breast cancer. These results indicate that PSA should be used with caution in this context.

Agreement between preoperative core needle biopsy and postoperative invasive breast cancer histopathology is not dependent on the amount of clinical material obtained.

AIMS: To establish the relation between the amount of breast core needle biopsy (CNB) material examined and agreement between preoperative and postoperative histopathology parameters in invasive breast cancer. METHODS: The CNB and surgical specimen histopathology reports of 113 patients with invasive breast carcinoma were reviewed and the total amount of CNB material examined for each case was determined. Agreement was calculated for tumour type, grade, mitoses, nuclear pleomorphism, and tubule formation. Associations between the amount of CNB material and histopathology agreement before and after surgery were explored using binary logistic regression. RESULTS: Tumour type and grade agreed in 65.4% and 61.6% of cases, respectively. The components used to calculate grade--nuclear pleomorphism (57.4%), mitoses (59.4%), and tubule formation (55.6%)--agreed slightly less frequently. The proportion of cases with preoperative and postoperative assessments that agreed did not depend on the number of cores collected or the total amount of material examined. CONCLUSION: Neither tumour type and grade, nor the individual components used to calculate grade agreed consistently between the CNB and surgical specimen. The number of cores collected and the total amount of material reviewed by the pathologist does not influence the likelihood of agreement between preoperative and postoperative histopathology reports.

Immunohistochemical detection of ERbeta in breast cancer: towards more detailed receptor profiling?

Oestrogen receptor (ER) is used routinely to predict endocrine responsiveness in patients with breast cancer. A second ER, ERbeta has been described but its significance remains undefined; most studies have described mRNA levels rather than protein expression. Here, we demonstrate for the first time, immunohistochemical detection of ERbeta in archival breast tumours.

Teaching laparoscopic surgery: the need for guidelines.

There is a risk that minimally invasive surgery will fall into disrepute unless adequate steps are taken to reassure the public. Some form of accreditation after a recognised training scheme would go a long way towards allaying these fears. The cost of training surgeons must be addressed. Adequate training will probably pay dividends in reduced litigation. The royal colleges should be responsible for maintaining standards of teaching on recognised courses, setting criteria for accreditation, and supervising a national audit of all laparoscopic procedures.

PIP: Laparoscopy was introduced to the UK in 1989. Today, about 33% of surgeons performing laparoscopic cholecystectomy were self-taught. No guidelines for laparoscopic procedures exist. Perforation of the bowel during laparoscopy causing peritonitis and death of a London woman resulted in private London hospitals requiring consultant surgeons to have accreditation before performing laparoscopic procedures. Some trust hospitals bar surgeons who have had problems with these procedures from performing any laparoscopy. The Royal College of Surgeons and surgical societies interested in minimally invasive surgery should be responsible for laparoscopic training and accreditation of surgeons. They would need to establish criteria for accreditation and a mechanism of appeal for surgeons who fail accreditation. Such action would allay public anxieties. 3 consultant surgeons have taught courses for laparoscopic cholecystectomy and laparoscopic hernia repair. They have done demonstrations or proctorships at 29 UK hospitals. These surgeons suggest that the ideal training for a laparoscopic procedure includes, in order, a video, a pelvitrainer, hands-on training, and training under an experienced surgeon at his/her hospital (proctorship). It is best if at least 2 surgeons from the same hospital undergo the training simultaneously. After successful completion of training as deemed by the proctor, the trainee should receive accreditation. The surgeons advise that laparoscopic training first be limited to consultant surgeons until there are enough trained surgeons who can train junior surgeons. The UK government has set up 3 minimally invasive centers in London, Leeds, and Scotland, where commercial companies instead of the Royal College of Surgeons will do the training. A comprehensive evaluation should be conducted to determine true incidence of mortality and complications.

Gastric cancer: a curable disease in Britain.

OBJECTIVE: To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer. DESIGN: Prospective audit of all cases of gastric cancer treated during 1970-89. SETTING: Department of surgery, general hospital. SUBJECTS: 493 consecutive patients with gastric adenocarcinoma. MAIN OUTCOME MEASURES: Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection. RESULTS: 207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%. CONCLUSIONS: These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.