Distant metastasis after radical treatment of breast cancer: risk factors and their prognostic relevance in 378 consecutive patients.

PURPOSE: To evaluate the prognostic significance of 16 clinical, pathomorphological and immunohistochemical features for predicting distant metastasis (DM) and 5-year overall survival (OS) in breast cancer (BC) patients. PATIENTS AND METHODS: A retrospective study of 378 patients with invasive BC (T1-3N0-3M0), who were operated between 2000 and 2003 at our Institution, was carried out. Almost 80% had undergone modified radical mastectomy (MRM). Tumor size (T), axillary lymph nodes status (N), age, menstrual status, histological type, grade (G), lymphovascular invasion (LVI), in situ component, estrogen receptor (ER), progesterone receptor (PgR) content, HER-2, Ki-67, p53, bcl-2, cathepsin D and E-cadherin were evaluated. Mean follow- up time was 56 months (range 1-88). RESULTS: During the follow-up period 66 (17.4%) patients developed DM and 76 (20.1%) patients died. Univariate analysis showed that T (p=0.0001), N (p=0.0001), presence of comedo type in situ component (p=0.0001), LVI (p=0.016), Ki-67 (+) (p=0.007) and cathepsin D (+) (p=0.013) were independent prognostic indicators for increased risk for DM. After multivariate analysis only N (+) status (odds ratio/OR 8.8; 95% confidence interval/ CI 3.5- 21.77; p=0.0001) and presence of comedo type in situ component (OR 2.4; 95% CI 1.19-4.74; p=0.015) retained their significant association with DM development. The same 2 factors also influenced 5-year OS: N(+), OR 3.8; 95% CI: 1.36-10.56; p=0.011; and comedo type in situ component, OR 3.3; 95% CI: 1.61-6.56; p=0.001. CONCLUSION: N (+) status and presence of comedo type in situ component are the most reliable predictors of unfavorable events in BC patients. Our study is among the first ones to find a relationship between the presence of in situ component and risk for DM in patients after MRM. The results also show that comedo type intraductal component, no matter how extensive it is, bears high risk for DM equal to N1 axillary status and patients with presence of such intraductal component should be treated as N(+). The evaluation of optimal number of risk markers is substantial for making an individualized decision regarding adjuvant therapy, especially in N0 group.

[Surgical treatment of gastric outlet obstruction].

Today surgery for peptic ulcer disease is largely restricted to the treatment of complications. About two-thirds of operations for complicated peptic ulcer disease are due to perforations, about one-third of operations are necessary to stop peptic ulcer bleeding, despite endoscopic treatment. In rare cases, peptic ulcer penetration requires surgery. Approximately 1-2% of patients with peptic ulcer disease develop gastric outlet obstructions (GOO), and about 80% of GOO due to peptic ulcer disease are caused by duodenal ulcers. Through retrospective analysis authors make it one's aim to investigate indications, methods of treatment and outcome of treated patients, based on contemporary principles. Over a 12 year period (1993-2004) in the third surgical clinic of the Emergency Medicine Institute "Pirogov" a total of 126 patients presenting GOO are operated. There is a 4:1 male to female ratio. The middle age group is the most frequently affected (58.7%). The following operations have been done: Resection of the stomach--122 (Bilroth I--109: Billroth II--13). Gastro-entero anastomosis--2; Gastro-entero anastomosis with Vagotomia truncularis --2. The main factors to influence mortality are the presence of serious concurrent medical illnes and age above 70 years (average age of dead patients--76.3 year). Follow-up between 1 to 5 years is done according to Vizic on 40 resected patients. Authors accept resection of the stomach as a method of choice for treatment of GOO. The highly per cent of reconstruction according to Billroth 1 (86.5%) is realized by modification Haberer-Andreoiu (60 patients). Preserving the normal passage through the duodenum decreases frequency of postresection syndromes (97.5% excellent results according to Vizic).

[Is the Gail model for breast cancer risk assessment valid for the Bulgarian women?].

INTRODUCTION: The quantitave assessment of the breast cancer risk is a fundamental for the process of preventation and early diagnosis. AIMS: The aim of present study is to determinate the validity of the Gail model used in USA for the Bulgarian population, and to assess the relative influence of each risk factor over the common breast cancer risk. MATERIALS AND METHODS: The object of our study were 315 women with histologically proved breast cancer. Retrospectively breast cancer rick was assessed for all patients by using Gail model. The following data were used: family history, previous benign biopsies, proved atypia, age of menarche, age of first birth and patient's age at the moment of detecting the breast cancer. RESULTS: In 186 (59%) patients no high risk is present after Gail model assessment and in the others 129 (41%) patients high risk for development of breast cancer is detected (> 1.7% for 5 years). Statistical reliability for the influence of each factor was found except for the previous benign biopsies. CONCLUSION: The results give us a reason to recommend Gail model as routine method for breast cancer risk assessment for the Bulgarian population for patients between 35 and 70 years old.

Intraductal aspiration cytology and galactography for nipple discharge.

The objective of this study was to assess the diagnostic value of preoperative cytology and galactography in women with nipple discharge using a simple intraductal aspiration method. From May 1997 to February 2002, 172 patients with unilateral, spontaneous nipple discharge without palpable masses underwent intraductal aspiration cytology followed by galactography. Major duct excision was performed in 133 of 155 successful cases. Pathological findings showed solitary papilloma in 65 cases, breast cancer in 16 cases, fibrocystic disease in 17 cases, papillomatosis in 12 cases, ductal hyperplasia in 11 cases, and finally, duct ectasia in 12 cases. Our results showed sensitivity of 75.0% and 68.8%, specificity of 86.3% and 62.4%, and overall accuracy of 85.1% and 63.2%, respectively, for cytological analysis and galactography. This suggests that the intraductal aspiration method for preoperative cytology and galactography is a minimally invasive and well-tolerated procedure that seems to be useful in differentiating between benign and malignant lesions in patients with unilateral, spontaneous nipple discharge.

Intraoperative sentinel lymph node examination by imprint cytology during breast surgery.

BACKGROUND: Sentinel lymph nodes (SLNs) predict the axillary status and may allow lymphadenectomy on a selective basis. The aim of this study was to assess the accuracy of intraoperative imprint cytology (IC) analysis of sentinel nodes in patients with early breast cancer. METHODS: A total of 128 SLNs from 87 cases that had been identified with Patent blue dye were bisected for hematoxylin and eosin stained touch preparations. Intraoperative evaluation of sentinel node involvement by IC was compared with the final histopathological results of permanent sections. Tumour-negative nodes in standard paraffin sections were further studied using an anticytokeratin antibody (CK-IHC). RESULTS: Thirty-six of all SLNs contained metastases in paraffin sections, of which 32 were detected by IC procedure (sensitivity 88.8%). Three sentinel nodes were tumour-positive on imprint cytology and tumour-negative on stained paraffin sections. Comparison of the results of the imprints with the final histology (H&E and CK-IHC) showed a sensitivity of 83.3% and a negative predictive value of 92.5%. The specificity and positive predictive value were 100%. CONCLUSION: Touch imprint cytology is a simple and quick method of intraoperative screening of SLNs for the presence of metastases in patients with breast cancer. Results may be improved by an appropriate enlargement of the surface sampled and the use of rapid CK-IHC on the touch preparations.

Perioperative locoregional application of mitoxantrone in patients with early breast carcinoma.

The aim of this study was to investigate the clinical and morphological aspects of drug diffusion and efficacy after perioperative locoregional application of mitoxantrone in patients with early breast cancer. Mitoxantrone was injected at a dose of 0.5 ml (1.0 mg) in two sites around the tumor in 37 patients. Intraoperative inspection of mitoxantrone diffusion in breast and axillary tissues was carried out by blue color of the chemotherapeutic drug. Investigations of reactive morphological changes in axillary nodes were determined intraoperatively by blue stained lymph capillaries identified 2-4 cm laterally from the application sites and in 30 patients a mean of 1.5 stained axillary nodes was found. The light microscopy in the metastatic blue lymph nodes showed circulatory changes, dilatation of marginal sinus and inflammatory alterations. It was concluded that lymphotropic locoregional application of mitoxantrone results in diffusion of the drug in the regional lymph drainage and in cytotoxic effects on axillary nodes.