Tolerance of adjuvant letrozole outside of clinical trials.

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Granulomatous lobular mastitis: a rare chronic inflammatory disease of the breast which can mimic breast carcinoma.

Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. The differential diagnosis with malign breast disease is often not easy. In most cases a surgical biopsy is needed for correct diagnosis. Idiopathic granulomatous mastitis is an exclusion diagnosis, based on the demonstration of a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous breast lesions. There is still no generally accepted optimal treatment. If surgery forms part of the treatment, a conservative approach seems to be adequate in most cases. Another option is a long-term steroid treatment. It is mandatory to exclude infectious causes of granulomatous mastitis before corticoid therapy is started.

Use of a Port-a-Cath system in the home setting for the treatment of symptomatic recurrent malignant pleural effusion.

Symptomatic malignant pleural effusions represent a common problem in metastatic cancers and are associated with a significant morbidity. Pleurodesis still remains the primary therapy of choice. In a few cases, however, pleurodesis is unsuccessful because of a limited lung expansion and pleuroperitoneal shunts have been used. We describe two cases where an implantable PORT-A-CATH system is used for regular drainage of the pleural effusion. The main advantage of this technique is the fact that the procedure of drainage can be performed by a nurse in the home setting.

Drainage pattern of the upper medial quadrant of the breast in young healthy women after subdermal injection: a lymphscintigraphic study.

This study examines the lymphatic drainage after injection of a radiotracer in the upper medial quadrant of the right breast in young healthy female subjects. Most studies concerning lymphatic drainage pathways have focused on the upper lateral quadrant of the breast because of the high incidence of carcinoma in this quadrant while the drainage pattern of the medial quadrant has been less studied. We injected radiotracer (Human Serum Albumin labeled with 99 technetium) subdermally into the upper medial quadrant of the right breast tissue of 33 young healthy female volunteers and obtained static images with a scintillation camera briefly after injection and approximately one hour after injection. We identified lymphatic pathways in 82.8% of our subjects, lymph nodes in 79.3% and in 3.4%, a sentinel lymph node was found in the internal mammary chain. In early images, lymph nodes were visualized in 65.5% of subjects while in 17.2% of subjects, lymphatic vessels only appeared on later images.

Lymphedema development following breast cancer surgery with full axillary resection.

Several studies have investigated the influence of disease related, treatment related, and patient related risk factors on the development of postmastectomy edema (PME). The aim of the present study was to determine which factors present a higher risk of developing PME after breast surgery with full axillary resection (level I, II and III). To accomplish this aim, we investigated 245 women who underwent unilateral breast cancer surgery in the Academic Hospital of the Vrije Universiteit, Brussels. Information concerning treatment and disease related factors were collected from the patient's medical records and factors related to clinical condition were obtained by a personal interview. Arm circumference was taken at 15 cm proximal and 10 cm distal to the olecranon. PME was defined as 2.5 cm difference between the arms. Height and weight of the patient were also measured. Statistical analysis was performed by calculating the Odds Ratio and the 95% Confidence Interval. We found the following factors posed an increased risk of developing PME: axillary/supraclavicular radiotherapy, pathological status of the lymph nodes, overweight (BMI > 25 kg/m2), trauma to the arm, menopause and surgery on the dominant side.

A key to understanding postoperative lymphoedema: a study on the evolution and consistency of oedema of the arm using ultrasound imaging.

Post-mastectomy oedema is a very serious complication that, in the course of time, will transform into fibrotic tissue. The aim of our study is to evaluate when and in which layer liquid oedema transforms into fibrotic tissue. To do so, ultrasonographic images were taken of 22 patients and 9 control women at the shoulder and 10 cm proximal and distal from the olecranon, with the images then being scanned and imported into a computer program to determine echogenicity of the dermis, subcutis, subcutis on dermal side and subcutis on fascial side. Statistical analyses were performed by means of the Wilcoxon test and a Student's t-test. No significant differences (P< or =0.05) were found for the different parameters in the control group. In the experimental group: significant differences in perimeter, skinfold, thickness of dermis and subcutis were found. Although not significant, subcutaneous tissue was more echogenic on the oedematous side, with significant hyperechogenicity at the fascial subcutaneous layer. This indicates that fibrotic tissue develops distally in the forearm.

Incidence of invasive versus non-invasive carcinoma in comparing palpable and non-palpable solid breast lesions.

A retrospective study was done of all patients with a suspicious mammographic breast lesion surgically biopsied in our institution within the last 5 years. Incidence of invasive versus non-invasive carcinoma and stage at presentation (according to TNM classification system) of palpable and non-palpable lesions were compared. We found a significant difference of non-invasive carcinoma in non-palpable and palpable cancers: 42.2% versus 4.3% (p < 0.001). Patients with a non-palpable invasive carcinoma presenting at stage I (i.e. pT1 with no axillary metastasis) rated significantly higher compared to those with palpable lesions 51.8% versus 9.4% (p < 0.001). The true positive biopsy rate is 30%. As low as 10% has been considered reasonable. We have a total of 56% carcinomas detected on all biopsies: 30% for non-palpable lesions and 66.8% for palpable lesions. A more aggressive approach towards screening and biopsy of breast lesions might increase early detection of carcinoma and so improve survival.

What determines primary breast cancer patients' hope to recover.

The main purpose was to offer evidence for the hypothesis that the stronger an acute real life stressor, namely, hearing from the physician that one has breast cancer and that one has to undergo mastectomy, the greater the induced noradrenaline (NA) depletion in the central nervous system (CNS) and the more the patient loses hope to recover. The data were derived from answers to interviews, questionnaires, and analyses of blood samples obtained from the patients on the day of admission to the hospital for a biopsy and 24 hours after the surgeon communicated the results of the biopsy to the patients. Analysis showed that a decline in 3-Methoxy 4-Hydroxy Methoxy 4-Hydroxy Phenylethylene Glycol (MHPG) concentration in blood plasma samples after being informed of the diagnosis is associated with less hope of recovery. MHPG is the main metabolite of CNS noradrenaline.

Can primary breast cancer patients sense the presence of lymph node metastasis? An unexpected research finding.

We found that primary breast cancer patients with lymph node metastasis, compared to patients without apparent metastasis, had a greater expectation that their breast lump biopsy would be malignant. This difference in expectation between the two groups remained after controlling for a range of possible confounding variables.

Emergency treatment of life-threatening spontaneous haematopneumothorax.

We report two cases of spontaneous life-threatening haemopneumothorax, successfully treated by early thoracotomy. In the first patient no source of bleeding could be identified. The second patient presented bleeding from a torn vascular adhesion at the apex of the lung. The first patient benefited from early clot evacuation and in the second patient the bleeding could be controlled by electrocautery and a single suture of the bleeding vessel. These cases stress the need for early recognition and management of a potentially life-threatening event.

Patterns of axillary lymph node metastasis in breast cancer.

The pattern of axillary lymph node involvement was analyzed in a review of 377 cases of T1-4 breast cancers. Clinical judgment of the axillary status proved to be wrong in approximately one-third of the cases. In univariate analysis, a strong correlation (P < .01) between the number of involved nodes, tumor size, and blood vessel invasion was found. Other features of the primary tumor (lymphatic invasion, degree of differentiation, presence of necrotic areas) were related to a lesser degree (P < .05). While others (age, site) were not at all significant. However, the number of nodes resected proved to be the most important determinant of all (P = .003). Also, the simple distinction between node-negative and node-positive cases is strongly dependent on the extent of axillary dissection (P = .009). In multivariate analysis, only the number of resected nodes and T stage showed a good relationship with the number of positive nodes. Skip metastases above levels 1 and 2 were seen in only 2% of the cases. A clear influence of the number of invaded nodes on survival could be demonstrated. These findings are discussed, especially as concerns the technique, prognostic significance, and therapeutic usefulness of axillary dissection.

[Tumors of the submaxillary gland]. / Tumeurs de la glande sous-maxillaire.

The tumors of the submaxillary gland are rare. The authors are reviewing 23 cases gathered from three Departments over ten years. The tumors of the submaxillary gland are malignant in as many as 50% of all cases! When the lesion is benign, pleiomorphic adenoma is the most frequent possibility. The authors emphasize the necessity of early and complete surgical treatment, requiring at least total submaxillectomy in case of benign tumor. Cervical mode dissection will be considered if the tumor is malignant.

Metastasizing neuroendocrine carcinoma of the larynx with calcitonin and somatostatin secretion and CEA production, resembling medullary thyroid carcinoma.

A 55-year-old man presented with a metastasizing moderately differentiated neuroendocrine carcinoma of the larynx (atypical carcinoid). Immunocytochemical demonstration of neuroendocrine markers (neuron-specific enolase and chromogranin-A) and presence of membrane-bound neurosecretory granules in the cells established the neuroendocrine nature of the tumour. In addition, the tumour was found to produce calcitonin, somatostatin and carcino-embryonic antigen (CEA). Calcitonin and somatostatin were also secreted. On the basis of this particular marker constellation the tumour closely resembles medullary thyroid carcinoma. Review of the recent literature on carcinoids of the larynx reveals immunoreactivity for calcitonin and CEA in a high percentage of cases.

Cervicofacial actinomycosis in a patient treated for tonsillar carcinoma.

A 50-year-old patient who underwent locoregional radiotherapy and surgery for a tonsillar carcinoma, developed osteomyelitis with Actinomyces israelii with fistulization in the treated area, during chemotherapy treatment. This rare complication is discussed.

Modern thoughts on lymph nodes in breast cancer.

Axillary lymph node status remains the single most useful prognostic parameter in breast cancer patients. As clinical examination, imaging techniques, and lymph node sampling methods cannot accurately assess the axillary node involvement, a complete axillary dissection should always be performed. Moreover, this technique provides an excellent treatment modality for regional disease, abolishing the need for radiotherapy to the axilla. The status of the internal mammary lymph nodes is of less importance in the management of the breast cancer patient.

Immunocytochemical and ultrastructural findings in a mature retroperitoneal teratoma.

Report is made of a mature retroperitoneal teratoma in a 32-year-old man. Investigation of the tumor revealed cells immunoreactive for ACTH, Met-enkephalin, beta-LPH, serotonin, FSH, BPP, S100, Neuron-specific-enolase. These cells were mainly present in the glandular epithelium, lining the cysts of the tumor. Ultrastructurally, neuro-secretory granules were demonstrated in the cytoplasm of the tumoral endocrine cells. At no time did the patient display endocrine symptoms.

[Adenocarcinoma of the thyroglossal duct]. / Adenocarcinoom van de ductus thyroglossus.

Carcinoma of the thyroglossal duct is a rare entity. In most cases, papillary carcinomas are reported. Follicular or squamous cell carcinomas are seldom. Insofar no capsular refraction exists, the best treatment seems to be the Sistrunk operation with postoperative thyroid suppression medication.

[Breast-sparing surgery in T1 breast carcinoma]. / Borstsparende heelkunde bij T1 mammacarcinomen.

31 female patients with a T1 No N1a Mo breast tumour (diameter smaller or equal to 2 cm) were treated by segmental resection with complete axillar dissection, followed by radiotherapy. Chemotherapy was given in any case of axillary lymph node involvement. The mean follow-up period was 44 months. Absolute survival is 100%. One patient (3%) developed distant metastasis, 2 patients (6%) had a loco-regional recurrence and 3 presented with a metachronous tumour in the contralateral breast. 97% of the patients are actually alive and free of disease.

Management of large oral tumours by mandibular swing and myocutaneous flap.

Median mandibulotomy with mandibular swing combined with immediate reconstruction by a myocutaneous flap has been carried out in 11 patients with large intraoral tumours. Mandibular swing appeared to achieve better local control and caused less problems in resection of these T3 and T4 tumours compared to lateral mandibulotomy. The use of a myocutaneous pectoral flap instead of a deltopectoral skin flap reduced the need for reintervention and abolished that for delayed reconstruction. The combined approach also reduced the time of hospitalization.