Extranodal extension of axillary metastasis of invasive breast carcinoma as a possible predictor for the total number of positive lymph nodes.

INTRODUCTION: By the implementation of the sentinel node procedure in the treatment of breast carcinoma routine axillary lymph node, dissection can be abandoned in patients with a tumour-negative sentinel node. When the sentinel node is positive there are two options; an axillary dissection or radiotherapy of the axilla. In the latter case one is not informed about the total number of positive lymph nodes which can be of importance for the choice of adjuvant chemotherapy. In this paper we analyse whether it is possible to use histological parameters of a lymph-node metastasis to predict the number of tumour-cell-containing nodes. METHODS: Four hundred and ninety-eight patients treated for invasive breast cancer at our department from 1991 to 1996 were investigated to see whether extranodal extension of axillary metastases had a significant predictive value for the number of positive lymph nodes. Extranodal extension was scored as: no extranodal extension (NEE) and extranodal extension (EE); the latter was subdivided in minimal extranodal extension (MEE) or extensive extranodal extension (EEE). RESULTS: Of 498 patients, 230 patients had axillary involvement. NEE was seen in 83 (36.1%) patients and 147 (63.9%) had EE. Subdivision of this latter group revealed 77 patients with MEE (52%), 65 patients with EEE (45%) and five patients not further specified (3%). The number of positive nodes for the EE-group (6.9+/-0.5) was significant higher compared with the NEE-group (2.1+/-0.2) (P<0.001). The number of positive nodes was also significantly higher for the EEE-group compared to the MEE-group, 10.6+/-0.8 vs 4.0+/-0.4 (P<0.001). The predictive value for > or =4 positive axillary lymph nodes was 84.6% for EEE, 58.5% for EE and only 14.5% for NEE. These differences were significant (P<0.001). CONCLUSIONS: The presence of extranodal extension in axillary lymph-node metastases can be a good predictor for the expected number of positive nodes. This histological parameter could be of value to determine the kind of adjuvant chemotherapy after a positive sentinel-node biopsy with only radiotherapy of the axilla and no further axillary lymph-node dissection.

Isosorbide dinitrate in the treatment of anal fissure: a randomised, prospective, double blind, placebo-controlled trial.

OBJECTIVE: To assess the efficacy of isosorbide dinitrate in healing anal fissures. DESIGN: Randomised, prospective, double blind, placebo controlled trial. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 37 consecutive subjects with anal fissure diagnosed in the surgical outpatient department. INTERVENTIONS: After randomisation, 20 patients were given isosorbide dinitrate, and 17 patients placebo. MAIN OUTCOME MEASURES: Healing of anal fissure, recurrence, and tolerance. RESULTS: Both groups were treated for a median (range) of 5 weeks (range 1-10). After this period, 17 in the isosorbide group had healed compared with 6 controls (p < 0.003). The fissure recurred in 2 patients who had had an initial good response to isosorbide, and in 2 in the control group. Side effects (particularly headache) were more common after isosorbide dinitrate, but not significantly so (9/20 compared with 3/17). CONCLUSIONS: Isosorbide dinitrate is an effective treatment for anal fissure, and is significantly better than placebo.

Arterial reconstruction for subclavian obstructive disease: a comparison of extrathoracic procedures.

OBJECTIVES: Comparison of the immediate and long-term results of three different extrathoracic arterial reconstruction procedures for subclavian obstructive disease. DESIGN: Retrospective analysis of 51 extrathoracic subclavian artery reconstructions in 49 patients performed in a single centre over an 18-year period (mean follow-up 64 months, range 3-192). METHODS: Carotid-subclavian bypass (CSB, n = 21), subclavian-carotid transposition (SCT, n = 21) and subclavian-subclavian or axillo-axillary cross-over bypass (COB, n = 9) was performed. Upper extremity ischaemic complaints were present in 45/49 patients (92%) and vertebrobasilar insufficiency in 25/49 patients (51%). Symptom relief, improvement of haemodynamic parameters and graft patency were compared. RESULTS: Operation time was significantly shorter (p < 0.001, t-test) in SCT (80 +/- 5 min) compared to CSB (112 +/- 7 min) and COB (116 +/- 6 min). Symptom relief and improvement of haemodynamic parameters were similar for all groups. There were no differences in morbidity rate and there was no mortality. The cumulative patency of SCT was significantly better with 100% at 2, 5 and 10 years postoperatively compared to CSB (75.6%, 62.6% and 52.2%, respectively) (p < 0.005, log-rank test) and COB (76.5%, 63.7% and 63.7%, respectively) (p < 0.02, log-rank test). There was a tendency for a better patency in prosthetic grafts as compared to autologous vein grafts in CSB (NS, log-rank test). CONCLUSIONS: Satisfactory immediate and long-term results were obtained with all of the above techniques. When technically feasible, SCT is the procedure of choice for extrathoracic arterial reconstruction in subclavian obstructive disease.