Modifications of the learning curve guidelines for breast cancer sentinel node biopsy.

BACKGROUND: Guidelines for the learning period of sentinel lymph node biopsy in breast cancer do not address important details such as the false negative rate way of calculation and the number of patients with positive axilla that should be included among the cases of this period. The aim of this study was to identify refinement points which should be included in the guidelines. METHODS: We studied 138 breast cancer cases of the sentinel lymph node biopsy learning period of three surgeons. The sentinel node was identified using isosulfan blue or technetium sulfur colloid or both. All patients underwent complementary axillary dissection. RESULTS: All three surgeons (A, B, C) fulfilled the guidelines' false negative rate criteria of 5, 0 and 5%, respectively, after 20 cases. However, only six, 10 and 10 cases with positive axilla, respectively, were included and the false negative rates using only these cases were 17, 0 and 10%, respectively. CONCLUSIONS: Current guidelines may lead surgeons to inappropriate conclusions about their ability to perform sentinel lymph node biopsy with an acceptable false negative rate. The learning period should include as many cases with positive axilla as possible and the false negative rate should be calculated only on those patients.

Contribution of 99mTc-anti-carcinoembryonic antigen antibody and 99mTc-sestamibi scintimammography in the evaluation of high risk palpable breast lesions.

Mammography is the screening test of choice for breast cancer. Its low specificity leads to a large number of unnecessary biopsies. Scintimammography, with either Tc-sestamibi (MIBI) or Tc-anti-carcinoembryonic antigen (CEA) Fab', has been proposed as a non-invasive test to lower the high false positive rate of mammography in certain patients. The two agents have not been compared, nor has their combined application been evaluated. We performed a prospective, non-randomized, open-label, single-centre study of 32 women with clinically and mammographically suspected breast cancer [Breast Imaging Reporting and Data System (BI-RADS, American College of Radiology) 4 or 5]. All patients underwent Tc-MIBI and Tc-anti-CEA Fab' scintimammography, and the results were correlated with histopathology. Overall, the accuracies for MIBI and CEA scans were 90.3% (28/31) and 77.4% (24/31), respectively. The probability of disease after mammography was 0.939+/-0.081 (95% confidence interval, CI). The post-mammography probabilities after positive MIBI or CEA scan were 0.965 and 0.960, respectively, and after negative MIBI or CEA scan 0.750 and 0.875, respectively. None of the above differences is significant. The post-test probability when both scans were positive (irrespective of which was performed first) was 0.977. It can be concluded that there are indications that scintimammography with Tc-MIBI is superior to that with Tc-anti-CEA Fab' when these tests are used as screening tests for breast cancer. However, mammography remains the screening test of choice for highly suspicious clinically palpable breast lesions. In this group of patients, the application of scintimammography with either Tc-MIBI or Tc-anti-CEA Fab' (alone or in combination) offers no additional advantage.

Organisation of a trauma registry in a regional Greek university hospital: the first two years experience.

OBJECTIVE: To design and implement a hospital trauma registry so as to be able to monitor the care of injured patients. SETTING: Teaching hospital, Greece. SUBJECTS: All patients admitted with trauma from January 1997. MAIN OUTCOME MEASURES: Design of a suitable form, establishment of inclusion and exclusion criteria, injury severity scoring, finding money and personnel, and getting suitable computer hardware and software for reliable collection and analysis of data. RESULTS: We experienced great difficulty in getting funding, so were unable to employ dedicated staff to collect the data, though we have had a part-time secretary to coordinate the registry whose salary has been paid by a pharmaceutical company. We have to rely on junior doctors to collect the data, which works well when they are enthusiastic (though not all are). We decided to use the data collection form used by the UK Trauma Network. We are trying to collect sufficient data to code severity by more than one system, but at present this is causing problems because busy nurses and doctors do not like filling in forms. Software has also been a problem as most of it is in English and translation is a considerable workload. The calculations are still being done manually while we work with two computer programmers to develop our own. We have submitted a research protocol to the Ministry of Health which has been accepted and this will guarantee our expenses for the next two years. CONCLUSIONS: Implementing a philosophy of continuous quality improvement is never easy, and we expect funding to be a permanent source of anxiety. Our progress so far has been good, but not as good as we hoped; however, we are optimistic that as people see the value of continuous monitoring of the system they will become more enthusiastic and supportive.

Emphysematous cystitis after orchiectomy.

A 59-year-old man developed emphysematous cystitis 3 weeks after undergoing left orchiectomy because of suppurative epididymitis. The case is presented because of its unusual cause and to emphasize the high degree of suspicion required for the diagnosis.

Expression of the c-erbB-3 gene product in gastric cancer.

The pattern of c-erbB-3 gene product was studied in 91 advanced gastric carcinomas, adjacent hyperplastic mucosa, intestinal metaplasia and dysplasia and in normal controls, using immunohistochemistry in archival material. All tumours showed positive c-erbB-3 staining in both cytoplasm and membrane. No significant differences of expression were observed between intestinal and diffuse-type carcinomas or any other clinical parameters. Of interest is the expression in the adjacent mucosa, which is extensive, cytoplasmic, and of lower intensity than in the tumours. Further studies are currently being carried out to clarify the role of this protein in tumour behaviour and gastric carcinogenesis.

The influence of undergraduate medical cancer education on students' sensitivity towards cancer.

Cancer is a disease that doctors will have to face for many years to come. Our Department of Surgical Oncology is particularly interested in altering undergraduate students' and junior doctors' performance with respect to cancer and cancer patients' care. We believe that a solid base of knowledge gained during the undergraduate period with appropriate guidance will equip doctors with the necessary discipline towards cancer and its prevention. Cancer education must be ongoing and supported by all specialists, since cancer is a disease requiring multidisciplinary attention. This survey was conducted to evaluate the oncologic aspects of the undergraduate curriculum of our medical school.