Magnetic flux transport on the sun.

Although most of the magnetic flux observed on the sun originates in the low-latitude sunspot belts, this flux is gradually dispersed over a much wider range of latitudes by supergranular convective motions and meridional circulation. Numerical simulations show how these transport processes interact over the 11-year sunspot cycle to produce a strong "topknot" polar field, whose existence near sunspot minimum is suggested by the observed strength of the interplanetary magnetic field and by the observed areal extent of polar coronal holes. The required rates of diffusion and flow are consistent with the decay rates of active regions and with the rotational properties of the large-scale solar magnetic field.

Randomized trial of chemoendocrine therapy started before or after surgery for treatment of primary breast cancer.

PURPOSE: To evaluate in a randomized clinical trial systemic chemoendocrine therapy used as primary (neo-adjuvant) treatment before surgery in women with primary operable breast cancer. PATIENTS AND METHODS: Patients aged less than 70 years with clinically palpable, primary operable breast cancer diagnostically confirmed by fine-needle aspiration cytology (FNAC) and suitable for treatment with surgery, radiotherapy, cytotoxic chemotherapy, and tamoxifen were considered eligible. Patients randomized to neoadjuvant treatment received four cycles of chemo-therapy for 3 months before surgery followed by another four cycles after surgery, and were compared with patients randomized to adjuvant therapy who received eight cycles of chemotherapy over 6 months after surgery. RESULTS: Of 212 patients who were randomized to receive either adjuvant (n = 107) or neoadjuvant (n = 105) chemoendocrine therapy, 200 are now assessable for response. The two groups are comparable for age, menopausal status, disease stage, and surgical requirements. The overall clinical response rate was 85%, with a complete histologic response rate of 10%. There was a significant reduction in the requirement for mastectomy in patients who received neoadjuvant treatment (13%) as compared with those who received adjuvant therapy (28%) (P < .005). Symptomatic and hematologic acute toxicity was low and similar for adjuvant and neoadjuvant therapy. The median follow-up period for patients in this trial is 28 months, during which time four patients have relapsed locally and 20, including one of the local relapses, have developed metastatic disease, 19 of whom have died. The follow-up period is too brief to evaluate relapse rate or survival duration. CONCLUSION: This trial confirms previous reports of a high rate of response to neoadjuvant therapy, but is the first to include small primary cancers and to show, in the context of a randomized trial, a reduction in the requirement for mastectomy. Until disease-free and overall survival data are available from the larger National Surgical Adjuvant Breast and Bowel Project (NSABP)-18 trial, such neoadjuvant treatment cannot be recommended outside of a clinical trial.

Nocardia asteroides: an unusual cause of breast abscess.

A case of nocardial breast infection is presented and infection by nocardia organisms must be considered as a rare differential diagnosis of chronic inflammation of the breast.

Pre-vascular hernia: a rare cause of chronic obscure groin pain after inguinal hernia repair.

A rare case of pre-vascular hernia is reported in a woman complaining of chronic obscure groin pain following an inguinal hernia repair. The condition was only diagnosed by means of a herniogram, emphasising the value of this investigation in unexplained groin pain. The hernia was successfully repaired using a polypropylene mesh plug, a simple technique widely employed in both femoral and recurrent inguinal hernia, but never before described in pre-vascular hernia.

Avoidable delay in the management of carcinoma of the right colon.

A retrospective study of 89 consecutive patients with carcinoma of the right colon presenting in a district general hospital over a 5-year period is reported. Of the patients, 74% were anaemic at the time of diagnosis and 27% of these had anaemia or a low mean corpuscular volume (MCV) for a significant time (mean 177 days, range 76-496 days) before developing symptoms. All doctors should be more vigilant towards anaemia or low MCV as presymptomatic indicators of possible colonic disease. Appropriate investigation is required in order to detect disease at an earlier stage and therefore influence survival. Significant delay in the diagnosis of symptomatic disease occurs before referral to hospital (mean 61 days vs 36 days, P < 0.05). Treatment delay is similar whether patients are referred to surgeons or physicians. The preoperative duration of symptoms for emergency admissions was significantly shorter than for elective admissions (mean 50 days vs 119 days, P < 0.05). The 30-day mortality was significantly higher for emergency admissions (20.7% vs 3.3%, P < 0.05). Earlier diagnosis of symptomatic disease may not reduce the proportion of emergency admissions (33%) or improve survival. Many tumours are at an advanced pathological stage (39% node positive) by the time symptoms develop.

Diagnosis and management of phyllodes tumour of the breast: experience of 33 cases at a specialist centre.

This study reviews the diagnosis and management of a consecutive series of 33 phyllodes tumours of the breast treated at The Royal Marsden Hospital, Sutton, between 1981 and 1992. The mean age of patients at presentation was 41 years (range 15-67 years). Tumours occurred equally in each breast and were significantly more common in the upper outer quadrant (chi 2 = 12.7, df = 3, P < 0.01). Clinical features (age, tumour size, palpation) and diagnostic investigations (mammography, ultrasound and fine needle aspiration cytology) were not sufficiently accurate to reliably make a preoperative diagnosis or predict histological type (benign, borderline or malignant). The diagnosis of phyllodes should be considered in patients aged 30-50 years with an apparent fibroadenoma. Of the patients, 66% underwent wide excision or mastectomy resulting in a favourable local recurrence rate of 14%. Our experience and review of the literature suggests that adequate local surgery is the treatment of choice and adjuvant treatments have no place in the routine management of phyllodes tumours. Regional lymph nodes were not involved in any of our patients and axillary dissection is not indicated.

'Occult' breast cancer.

The aim of this paper is to explore current trends in the diagnosis, investigation and treatment of patients presenting with axillary lymph node metastases without a primary in the breast being found and, more rarely, those cases with metastatic breast cancer where the primary remains unknown--the so-called, 'occult' breast cancer. A retrospective study of 25 reported cases were selected from our database at the Royal Marsden and 6 patients were found to have true 'occult' breast cancer. These 6 patients are all still alive with no primary ever having been found in the breast. A literature review was then undertaken exploring the changing trends in this diagnostic enigma. MRI scanning, it is reported, may reveal the primary. Occult cancers in which imaging totally fails to show the primary will become increasingly rare. The prognosis of these, however, may be surprisingly better than one would expect from the nature of their presentation.

Breast reconstruction after failed conservation.

We report our experience of using latissimus dorsi myocutaneous flaps after failed conservation for breast carcinoma. Twenty-nine patients were treated by two methods of reconstruction. Seventeen patients with central recurrent tumours and three patients with radiation necrosis of the breast were treated by total mastectomy and latissimus dorsi reconstitution with silicone implant. Nine patients underwent latissimus dorsi reconstruction with preservation of the nipple for recurrent peripheral tumours. After a mean follow up period of 20.2 months no local recurrences have been observed but a longer period of follow-up is necessary to evaluate the likely long term recurrence rate.

A single axillary crease incision for wide local excision and axillary clearance in breast cancer.

Wide local excision and axillary clearance or sampling has become the standard surgical treatment for many breast cancers. We describe a single incision that allows good access to the primary tumour and the axilla, lies parallel to Kraissl's lines of the skin and gives good cosmetic results.

Mastectomy and breast reconstruction preserving the nipple.

Total mastectomy and immediate reconstruction using the latissimus dorsi myocutaneous flap with nipple preservation has been performed in 87 women. The palpable tumours were all more than 3 cm from the nipple. No recurrence in the preserved nipple was seen in 63 women who underwent the procedure for tumour recurrence after previous radiotherapy. Nipple recurrence occurred in 3 out of 24 women (12%) where the indication was multifocal disease and no radiotherapy was given. This non-irradiated group should either not have the nipple preserved or should undergo postoperative electron field therapy to the nipple-areolar complex.

The place of subcutaneous mastectomy with immediate silicone prosthetic implantation in diseases of the breast.

Subcutaneous mastectomy with immediate silicone prosthetic implantation has been performed on 32 patients. The main indications for this were severe fibrocystic disease and non-invasive carcinoma. Five patients with advanced invasive carcinoma were also included. An improved operative technique is described. The indications and results are discussed.

Chest wall reconstruction after resection of recurrent breast tumours.

A series of 13 chest wall resections for recurrent breast tumours are reported, the defects being closed by synthetic prostheses. In nine patients the prostheses were covered by a latissimus dorsi flap, while in the last eight patients a rigid 'shield' prosthesis of methyl methacrylate was used, and a stable chest obtained. Mechanical ventilation for more than 24 h was not required in those patients in whom a shield was used.

Central breast carcinoma treated by simultaneous mastectomy and latissimus dorsi flap reconstruction.

Simultaneous mastectomy with latissimus dorsi flap reconstructions have been performed on 15 women with primary central breast cancer and on 5 women with local recurrence after local excision and deep X-ray treatment. The indications and technique are discussed. There was no mortality and no initial morbidity. No prosthesis has become infected. One prosthesis has slipped laterally, requiring removal and re-insertion at the time of nipple reconstruction. In all patients an acceptable cosmetic result, as assessed by the patient and the surgeon, has been achieved. Follow-up is very brief, 1-18 months, but there is as yet no sign of local recurrence.

The uptake of gallium 67 in colonic macrophages.

A case is presented in which a patient with a well-differentiated adenocarcinoma showed high gallium concentration in the segment with melanosis coli proximal to the obstruction. Although in this case the Gallium was associated with an increased number of faecal pigment containing macrophages it is unlikely that macrophages are the main factor in tumour uptake of Gallium compounds.

Oral cholecystographic findings and the incidence of wound infection after cholecystectomy.

Six hundred and sixty-one patients undergoing cholecystectomy were reviewed, and the over-all incidence of postoperative wound infection was found to be 18.6 per cent. Of the 274 patients who underwent cholecystography preoperatively, 150 were found to have functioning nonobstructed stone filled gallbladders. There were 12 postoperative wound infections in this group, 8 per cent. One hundred and twenty-four patients had nonfunctioning and obstructed gallbladders, 31 of whom, 25 per cent, had wound infections develop. The finding of an obstructed gallbladder upon oral cholecystography was associated with a high incidence of wound infection. This group should be considered for prophylactic antibiotics.