Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva.

We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.

A prospective randomised study to evaluate the effectiveness of standard 23 gauge fine needle, compared with a thinner 27 gauge needle for breast cytology.

The aim of this study was to determine whether a 27 gauge needle could be used to obtain adequate cytology with less discomfort to the patient. Two types of needles were compared-23 gauge (blue) needle versus 27 gauge very fine needle. The cytology specimen was assessed for quality in terms of adequacy for diagnosis. Ninety samples were randomised into this study. The quality of samples was similar in both groups; there was no statistical difference in the quality of samples obtained. The 27 gauge needle produced two inadequate samples (4.4%), whereas there were no inadequate samples with the 23 gauge needle. There was no statistical difference in the amount of blood on the slide between the two groups. The pain scores were significantly better with the finer needle (P=0.004). This study provides evidence that the 27 gauge FNAC is suitable for obtaining cytology in palpable breast lumps.

Effects of chronic low back pain, age and gender on vertical spinal creep.

This study investigated the effect of chronic low back pain, age, gender, and time of measurement on the magnitude of vertical spinal creep (VSC) and its recovery. A mixed design, involving three independent variables (chronic low back pain, age, and gender) and one repeated variable (time), was used. One hundred and six subjects of both genders, with and without chronic low back pain, aged between 20 and 60 years, participated in the study. The measurement of VSC and its recovery was performed using a seated stadiometer that allowed continuous measurement of VSC without changing the subject's posture over 25 min. Unloaded VSC was measured during the initial 5 min, followed by 10 min with an additional load of 15% of the subject's body weight and then for a further 10 min after the removal of the load. Subjects were grouped into one of eight categories according to the presence of chronic low back pain, age (20-39 years or 40-60 years) and gender. Repeated measures analysis of variance was computed. A significant increase in VSC with time of measurement was observed (p<0.001). No significant main effects for chronic low back pain, age, or gender were found at any time during the 25-min VSC testing protocol. Significant interactions were found between age and gender during the loaded (p=0.02) and unloaded (p=0.02) phases. A significant interaction was found between chronic low back pain and gender at the end of the unloaded phase (p=0.04). These findings suggest a combined influence of chronic low back pain, age, and gender on VSC and its recovery and that the dominance of each variable changed with the time of the measurement. Thus, subjects who differ in the presence of chronic low back pain, age, and gender should not be combined for statistical analysis of VSC and its recovery.

The role of ultrasound-guided cytology of groin lymph nodes in the management of squamous cell carcinoma of the vulva: 5-year experience in 44 patients.

AIM: To assess the accuracy of ultrasound combined with fine-needle aspiration cytology (FNAC) in the detection of lymph node metastasis in patients with squamous cell carcinoma of the vulva. MATERIALS AND METHODS: The groin nodes of 44 consecutive patients with primary squamous cell carcinoma of the vulva undergoing groin node dissection were assessed with ultrasound and FNAC. The results were compared with histology from subsequent inguinofemoral lymph node dissection. Twenty-nine patients underwent bilateral groin node dissections and 15 unilateral providing comparable data for 73 groins. RESULTS: Histology demonstrated metastatic disease in 28 groins and no evidence of metastatic disease in 45. Ultrasound agreed with the histology in 67 of the 73 groins (92%), with two false-positives, four false-negatives and two indeterminate appearances. Cytology agreed with the histology in 65 of 72 FNAC samples obtained (90%), with six false-negatives, and one indeterminate result. No false-positive cytology results were seen. Ultrasound and FNAC together failed to detect metastatic disease in four groins, one with an indeterminate ultrasound appearance, another with indeterminate cytology, the two others each having a single positive inguinal node despite a negative ultrasound and FNAC. CONCLUSION: The combination of ultrasound and FNAC provides a sensitive and specific tool for pre-operative assessment and may prevent unnecessary groin dissection and the attendant morbidity in selected patients with vulval cancer.

Squamous cell carcinoma of the breast: clinico-pathologic implications and outcome.

AIMS: Pure squamous cell carcinoma (SCC) of the breast is a rare tumour and little is known about long-term outcome. We report our experience of a consecutive series of patients. METHODS: All patients with SCC treated at our institution between 1970 and 2001 were included. The pathological features, outcome and prognosis were studied. RESULTS: Eleven patients were identified. The median age was 55 (38-90) years and median follow-up was 62 (3-332) months. Four tumours were T1, three were T2 and three were T3 (one tumour size was unknown). There were seven poorly differentiated and three moderately differentiated SCC. Tumour grade could not be assessed in one patient. Primary treatment was mastectomy in six patients, wide local excision in four patients and radiotherapy in one patient. There was lymph node (LN) involvement in two patients. Oestrogen receptor status was assessed in seven patients and only one tumour was positive. Adjuvant chemotherapy was given to three patients and five patients received adjuvant radiotherapy. Two patients developed local recurrence at 5 and 12 months and three patients developed distant metastasis at 2, 36 and 306 months. Three patients were treated with chemotherapy at recurrence. Three patients have died of the disease, two are alive with disease and six remain well. The 2- and 5-year overall survival was 80% (SE=13%) and 67% (SE=16%) respectively. Large tumour size and positive LN status were prognostic indicators of poor outcome. CONCLUSION: SCC of the breast adopts an aggressive course with outcome comparable to poorly differentiated breast adenocarcinoma.

Rapid access multidisciplinary lymph node diagnostic clinic: analysis of 550 patients.

Lymphadenopathy is common, affecting patients of all ages. The current referral pattern for investigating patients with lymphadenopathy varies widely with no universally practised pathway. Our institution set up a lymph node diagnostic clinic (LNDC) accepting direct referrals from primary care physicians. Details of clinical presentation and investigations were recorded prospectively. Between December 1996 and July 2001, 550 patients were referred (M: 203; F:347). The median age was 40 years (range 14-90). The median time between initial referral and the first clinic visit was 6 days. Of 95 patients diagnosed to have malignant diseases, the median time from the first clinic visit to reaching malignant diagnosis was 15 days. Multivariate logistic regression analysis identified five significant predictors for malignant nodes: male gender (risk ratio (RR)=2.72; 95% confidence interval (CI): 1.63-4.56), increasing age (RR=1.05; 95% CI: 1.04-1.07), white ethnicity (RR=3.01; 95% CI: 1.19-7.6) and sites of lymph nodes: supraclavicular region (RR=3.72; 95% CI: 1.52-9.12) and > or = 2 regions of lymph nodes (RR=6.41; 95% CI: 2.82-14.58). Ultrasound and fine-needle aspiration cytology of palpable lymph nodes were performed in 154 and 289 patients, respectively. An accuracy of 97 and 84% was found, respectively. In conclusion, a multidisciplinary lymph node diagnostic clinic enables a rapid, concerted approach to a common medical problem and patients with malignant diseases were diagnosed in a timely fashion.

Reliability of the vertical spinal creep response measured in sitting (asymptomatic and low-back pain subjects).

Vertical spinal creep (or change in stature) has been used as an index of spinal loading, yet reliability of the testing protocol has not been fully examined. This study investigated the reliability of a vertical spinal creep response in 10 asymptomatic and five low-back pain subjects. Each subject performed the 25-min testing protocol, which consisted of three phases (5-min preload, 10-min loaded and 10-min unloaded), at the same time on two separate days. Good reliabilities in vertical spinal creep response between two days of testing were demonstrated for both asymptomatic and low-back pain subjects.

A retrospective study comparing the individual modalities of triple assessment in the pre-operative diagnosis of invasive lobular breast carcinoma.

AIMS: Early invasive lobular breast carcinoma (ILC) is associated with few symptoms and signs. The individual sensitivity of clinical examination, mammography, ultrasonography, cytology and core biopsy have each been reported to be of limited value. The aim of this study was to evaluate the accuracy of triple assessment in the pre-operative detection of patients identified to have ILC from their surgical pathology. METHODS: Pure ILC was defined as tumours containing at least 90% lobular features. The triple assessment of 273 patients diagnosed primarily at our institution were reviewed. RESULTS: 87.5% of women were symptomatic and 12.5% were screen detected. The mean patient age was 59 (range 30-81) years and the median tumour size was 26 (range 5-110) mm. The main mammographic abnormalities were a spiculated lesion (33.3%), an ill-defined mass (33.3%) or architectural distortion (23.5%). The sensitivities for detecting ILC of each modality were: clinical examination (76.6%), mammography (79.8%), ultrasound examination (93.9%), fine-needle aspiration cytology (FNAC) (60.5%) and core biopsy (90.8%). Combining the three modalities of clinical examination, imaging and cyto/pathology increased the pre-operative detection rate of ILC. CONCLUSION: Triple assessment is useful in the diagnosis of ILC. As the features of ILC may be subtle, a high index of suspicion is required to facilitate early diagnosis.

Contribution of soft tissue deformation below the sacrum to the measurement of total height loss in sitting.

This study investigated the contribution of soft tissue deformation below the sacrum (S) and vertical spinal creep to total height loss (THL) measured in sitting. Eight asymptomatic subjects (four males, four females) aged between 21 and 51 years were measured. Simultaneous measurement of THL and S were commenced after the subjects had been sitting for 5 min. THL was recorded while subjects were positioned in a seated stadiometer, which controlled their spinal posture. S was measured by placing an ultrasound transducer at the level of the top of the subject's sacrum. Over 25 min of sitting with loaded and unloaded interventions applied to their spine, different response characteristics between S and THL were noted. This study demonstrated that soft tissues below the sacrum could contribute up to 30% on average of total height loss. This suggests that researchers should take into account the soft tissue deformation outside the spine when studying vertical creep in sitting.

Cellular characteristics of nipple aspiration fluid during the menstrual cycle in healthy premenopausal women.

Cellular characteristics of nipple aspiration fluid during the menstrual cycle in healthy premenopausal women Fifteen healthy premenopausal female volunteers underwent weekly nipple aspiration of ductal fluid from both breasts during two menstrual cycles to investigate the variability of the cellular profile of the ductal fluid. Ductal fluid was successfully obtained using breast massage and nipple-areolar suction from 247/280 (89%) breasts. 83% of samples available for cytological analysis were cellular and 30% of cellular aspirates contained ductal epithelial cells identified using standard morphological criteria. No significant variation in cell number or cell type was identified during the menstrual cycle. All samples tested had an 'H' score of zero for oestrogen receptor. Seven out of 14 women expressed the proliferation marker Mcm-2 in the cells of at least one of the specimens, with no evidence of a menstrual cycle influence on expression. In conclusion, the cellular profile of breast ductal fluid did not vary consistently during the menstrual cycle, permitting future breast cancer screening studies incorporating serial nipple aspirations to be performed independent of the phase of the cycle.

Adolescent versus adult responses to vertical spinal loading.

This study compared the vertical spinal creep response between adolescent and adult males. Thirty healthy male subjects, 15 adolescents (aged 12 to 16 years) and 15 adults (aged 30 to 57 years) were measured. Spinal creep was measured continuously over 25 min under loaded and unloaded conditions using a seated stadiometer that controlled spinal posture. Both adolescent and adult subjects showed significant increase in vertical spinal creep with time but the magnitude of vertical spinal creep was significantly greater in adolescent than in the adult subjects.

Investigating lymphadenopathy--report on the first 12 months of the lymph node diagnostic clinic at the Royal Marsden Hospital.

The lymph node diagnostic clinic was set up at the Royal Marsden Hospital to provide a direct access service for general practitioners. In the first year 82 patients were seen. The malignancy pick-up rate was 19.5% which compares very favourably to rates in breast and colorectal clinics. Patient and general practitioner satisfaction with the service was high.

Differences in stakeholder expectations in the outcome of physiotherapy management of acute low back pain.

OBJECTIVE: To compare stakeholder expectations of outcome of physiotherapy management of acute low back pain. DESIGN: Observational design using interviews and questionnaires. SETTING: Practice/workplace. STUDY PARTICIPANTS: The study sample was from South Australia. It comprised 74 physiotherapists randomly selected from professional association listings (49.3% response rate), 121 physiotherapy patients (recruited by participating physiotherapists when attending their first physiotherapy treatment for acute low back pain), 21 general practitioners randomly selected from medical practitioner listings in the metropolitan telephone book (36.2% response rate) and 13 third party payers of a total of 16 available insurers in the metropolitan area (82% response rate). MAIN OUTCOME MEASUREMENTS: Stakeholders reported expectations of outcome at the end of the first treatment session and at the completion of the episode of care. RESULTS: There were differences in expectations between stakeholders, as well as between naive and experienced patients. Overall, patients expected symptom relief at the end of the first treatment. Naive patients decided to return for further treatment based on the relationship established with the therapist, whereas experienced patients also expected some advice on their condition during the first contact. Physiotherapists and referrers expected symptom relief and then long-term management strategies to be provided, and third party payers expected cost-efficient management of the condition and patient satisfaction. CONCLUSION: Physiotherapists need to address potential imbalance of consumer knowledge and foster a quality partnership with their patients on the first visit to physiotherapy. Patients who are in pain may not derive full value from information provided in an untimely manner.

The role of high resolution ultrasound with guided cytology of groin lymph nodes in the management of squamous cell carcinoma of the vulva: a pilot study.

The accuracy of high resolution ultrasound with guided fine needle aspiration cytology in detecting inguinal lymph node involvement was assessed in 24 women undergoing radical vulvectomy and groin node dissection for squamous cell vulval cancer. Of the 43 groins dissected, ultrasound correctly diagnosed the lymph node status in 36, with five false positive and two false negative results. Cytology in 40 groins showed no false positive and five false negative results. The sensitivity and specificity for the combined techniques were 83% and 82% respectively. Assessed together, the combined technique failed to detect metastatic disease in two groins; in both cases the extent of nodal metastatic involvement was a solitary focus < 3 mm in diameter. The ultrasound and fine needle aspiration procedure is safe and well tolerated and can be repeated as needed for surveillance. The authors suggest that this procedure should be evaluated further to determine whether a policy of individual selection for lymphadenectomy can be implemented based on this technique.

Quantitative changes in cytological molecular markers during primary medical treatment of breast cancer: a pilot study.

AIM: To quantify the changes in biological molecular markers during primary medical treatment in patients with operable breast cancer and to assess their possible relationship with response to treatment. METHODS: The treatment group consisted of 31 patients with operable breast carcinomas, median age 57 years (range 41-67), treated with four 3-weekly cycles of chemotherapy with Mitoxantrone, methotrexate (+/- mitomycin C), and tamoxifen before surgery. Fine needle aspiration (FNA) was used to obtain samples from patients prior to and at 10 or 21 days post-treatment. The following molecular markers were assessed: estrogen receptor (ER), progesterone receptor (PgR), p53, Bcl-2, and Ki67 measured by immunocytochemistry, and ploidy and S-phase fraction (SPF) by flow cytometry. To evaluate the reproducibility of the technique, repeat FNA was performed in a separate non-treatment control group of 20 patients and the same molecular markers assessed, two weeks after the first sample with no intervening treatment. RESULTS: The non-treatment control group showed a high reproducibility for the measurement of molecular markers from repeat FNA. In the treatment group there was a non-significant reduction in SPF and a significant reduction (p = 0.005) in Ki67. Patients who responded to neoadjuvant therapy were more likely to have a reduction in these two markers than those who failed to respond. Similarly, a reduction in ER scores was observed between the first and second samples (p = 0.04). For PgR, the change between the first and second samples was not significant although there was a significant difference between responders and non-responders (p = 0.03). All nine patients with an increase in PgR were responders. No significant changes in p53 or Bcl-2 were observed during treatment. CONCLUSION: Molecular markers can be adequately measured from FNA samples prior to and during neoadjuvant therapy. Changes in cellular proliferation and hormone receptors have been shown that may be related to tumour response. These relationships should be assessed in a larger cohort of patients.

Cost evaluation of a telepsychiatry service in northern Queensland.

We conducted a simple comparison of the costs associated with delivering a mental health service by telepsychiatry and by conventional methods. The telepsychiatry rural outreach service was delivered to a mining town 900 km from the regional hospital in Townsville. When the telemedicine service was well established, 40 cases a month were seen for general adult psychiatry, four for child and adolescent mental health, four for psychology and two for forensic services. Costs and quality-of-life issues were considered. The savings to the health authority were estimated to be $85,380 in the first year and $112,790 in subsequent years, not allowing for maintenance and equipment upgrading. We also estimated a 40% reduction in patient transfers due to the introduction of telemedicine. Based on the previous year's figures of 27 transfers at $8920 each, this would produce an annual saving of $96,336 for the Royal Flying Doctor Service. The results of the study showed considerable savings from reduced travel by patients and health-care workers.

Cytological evaluation of biological prognostic markers from primary breast carcinomas.

This study was undertaken to evaluate our ability to detect multiple molecular markers of prognosis and response to treatment in fine needle aspirates (FNA) from patients with primary breast carcinomas. 147 patients with operable primary breast carcinomas who had been recruited to a randomized trial of primary medical therapy (PMT) versus adjuvant chemoendocrine therapy were analysed. FNAs were taken prior to therapy and from this multiple slides were produced using cytospin cytocentrifugation and stored at -80 degrees C for subsequent immunocytochemical analysis (ICA). ICA was performed for oestrogen receptor (ER), progesterone receptor (PgR), p53, Ki67, and Bcl-2. Part of the aspirate was snap frozen and used for flow cytometric analysis of ploidy and S-phase fraction (SPF). In a subgroup of 50 patients who had surgery prior to systemic therapy, as well as FNAs, sections were also taken from paraffin-embedded blocks and stained by ICA for ER, PgR and p53 for validation. In these patients ER was additionally measured by enzyme immunoassay (EIA) from frozen tissue taken at surgery. ER, PgR, p53, Bcl-2, and Ki67 were successfully detected by ICA while ploidy and SPF were successfully measured by flow cytometry from FNA material. The percentage positive values obtained were reasonable and as follows: 74% for ER, 70% for PgR, 36% for p53, 80% for Bcl-2,68% of tumours were aneuploid and 32% diploid. Significant relationships between these measurements were observed in accordance with expectations. The concordance for ER, PgR, and p53 from FNA when compared to ICA of matching histological sections was 91.5%, 75.5%, and 75% respectively. For ER the concordance between measurement by ICA of cytological and histological samples and by EIA of frozen tissue was 82.5% and 84% respectively. These results indicate that multiple molecular markers can be adequately tested on cytological preparations from primary breast tumours. These markers can be used to determine prognosis and predict response to PMT.