Does radical surgery to the axilla give a survival advantage in more severe breast cancer?

There is some evidence that more radical treatment of the axilla may improve survival in node-positive disease, but there are concerns about the resultant morbidity from axillary surgery and radiotherapy. The aim of this study was to compare the outcome of axillary node clearance with axillary sampling in similar patients by comparing loco-regional recurrence and overall survival. Patients with invasive breast cancer undergoing axillary surgery between 1986 and 1997 were included. The axillary procedure performed in these patients was either an axillary sample or a level III axillary clearance. To compare like with, the patients were separated into good, moderate and poor prognostic groups by the Nottingham Prognostic Index (NPI) and overall survival was compared by a Kaplan-Meier life table analysis and the log rank test. 734 consecutive patients with operable invasive breast cancer were treated by axillary clearance n=350 or sampling n=384. The mean follow-up in the clearance group was 65 months versus 66 months in the sampled group. Local recurrence in the clearance group was 11% versus 6% in the sampled group, regional recurrence 2% versus 3% and distant metastasis 28% versus 13%. Kaplan-Meier analysis of the three prognostic groups for the clearance versus sampled groups showed no differences in the absolute survival (log rank: P=0.3, P=0.8 and P=0.6 for the good, moderate and poor prognostic groups, respectively). A conservative surgical approach to the axilla did not significantly increase the incidence of local or regional recurrence and the expected survival benefit from a radical axillary clearance was not apparent.

An evaluation of thallium imaging for detection of carcinoma in clinically palpable solitary, nonfunctioning thyroid nodules.

OBJECTIVE: An evaluation of thallium imaging for differentiating benign from malignant lesions in clinically palpable solitary, nonfunctioning, thyroid nodules. METHODS: Seventy-eight patients presenting with a clinically palpable solitary nonfunctioning thyroid nodule were imaged with 3 mCi thallium-201 with a pinhole acquisition at 20 minutes and 3 hours after injection. Thallium uptake was assessed as grade 1, less than the rest of the gland; grade 2, same as the rest of the gland; and grade 3, more than the rest of the gland. All patients underwent surgery and the histology was compared with the thallium scan results. RESULTS: Of the 78 patients presenting with solitary thyroid nodule, 13 were malignant and 65 were benign. Twenty-four patients with benign disease showed no uptake of thallium at 3 hours (grade 1). Thirty-two patients with benign disease and 2 patients with malignant lesion had grade 2 uptake at 3 hours. Eleven patients with malignant disease and 9 with benign disease had grade 3 uptake at 3 hours. CONCLUSIONS: All malignant lesions had at least grade 2 and most had grade 3 uptake at 3 hours. All lesions with grade 1 uptake at 3 hours were benign, enabling malignancy to be excluded in one-third of cases. Thallium imaging is a useful adjunct to fine-needle cytology in evaluation of solitary thyroid nodules especially when the latter is inconclusive.

Does routine grading of invasive lobular cancer of the breast have the same prognostic significance as for ductal cancers?

AIM: The routine tumour grading of invasive ductal carcinoma of the breast has been shown to be a robust determinant of outcome but pathologists have been reluctant to grade lobular cancers. The aim of this study was to determine the prognostic significance of the routine reporting of lobular grade. METHODS: All patients with invasive lobular carcinoma (ILC) treated between 1981 and 1996 were reviewed. Patients with ILC which had been graded were included in the study. These cases were matched with two control patients with invasive ductal carcinoma (IDC) who were operated on in the same year and were closest to the patients in age. Recurrence-free survival was compared with grade for ILC cases and IDC controls using life-table analysis. Similar comparisons were made with the Nottingham Prognostic Index (NPI) between the different prognostic groups. RESULTS: Of 139 cases with ILC, 33 were excluded from the study because 24 were ungraded, five had advanced disease and four had mixed tumours. The mean length of follow-up for ILC cases was 75 months vs 70 months for IDC controls. Recurrence rates for grade I were 10% ILC vs 24% IDC, for grade II 32%vs 32% and for grade III 33%vs 49%. The reported grades for ILC and IDC both showed the expected trend for an increased recurrence rate with more severe tumour grade, but this was only significant for IDC grade II vs grade III (P<0.02) on life-table analysis; only 6% of lobular cancers were reported as grade III. However, there was significant separation of the survival curves when NPI was compared for both lobular and ductal cancers. CONCLUSION: The routine reporting of tumour grade for ILC did not show significant difference in outcome between grade I and grade II, and very few tumours were rated grade III. The validity of grading lobular cancer of the breast requires further evaluation.

Dehydroepiandrosterone sulfate and psychiatric measures in a frail, elderly residential care population.

BACKGROUND: Previous reports have found low levels of dehydroepiandrosterone sulfate (DHEA-S) in association with physical illness, and with frailty in the elderly. In a preliminary study, we also found low DHEA-S associated with increased disability and number of pain sites. However, we found the opposite relationship between DHEA-S and cognitive impairment. Therefore, we conducted a study of a second sample to confirm this unexpected finding and the expected inverse correlations between DHEA-S levels and increased disability and number of pain sites. METHODS: Psychiatric symptoms and disorders were correlated with DHEA-S and related steroid levels in a second convenience sample in the nursing home population. RESULTS: This sample confirmed the previous finding of a positive association of cognitive impairment with higher DHEA-S levels but the inverse association of DHEA-S levels with the numbers of pain sensations did not reach statistical significance. Cognitive impairment was also positively associated with higher dehydroepiandrosterone (DHEA) and estradiol levels (women only). Cortisol levels were inversely associated with depressive symptoms. CONCLUSIONS: The anomalous positive correlation between cognitive dysfunction and DHEA-S levels, and the inverse correlation between cortisol levels and depressive symptoms, suggests that the relationships between psychiatric symptomatology and levels of steroids that are part of the hypothalamic-pituitary adrenal axis are different in the frail elderly population from that of younger and heartier populations.

Traumatic pseudocyst of the spleen.

Four patients with pseudocyst of the spleen gave histories of abdominal trauma. In one patient the pseudocyst had ruptured, necessitating emergency splenectomy 34 years after the original injury. In a second patient the pseudocyst was discovered incidentally, and was managed by spleen-preserving excision; and the third and fourth presented with abdominal pain and had splenectomy and spleen-preserving surgery, respectively. All patients with conservatively treated splenic injury are at risk of developing a pseudocyst of the spleen, and the lesion can be detected by computed tomography or ultrasound. When there are no symptoms the natural history is unknown; but if surgery is necessary, splenectomy can sometimes be avoided.

Effect of physostigmine on ventricular fibrillation and myocardial glycogen in hypothermic dogs.

1. Physostigmine (0.1 mg/kg i.v.) given at 37 degrees C and 25 degrees C rectal temperatures, completely protected the hypothermic dog heart against ventricular fibrillation.2. Pentolinium, atropine, vagotomy and reserpine did not significantly alter the incidence of ventricular fibrillation.3. The incidence of ventricular fibrillation under hypothermia could be significantly increased by ligating the anterior descending branch of the left coronary artery. The incidence of ventricular fibrillation in coronary ligated hypothermic dogs was reduced to half by physostigmine pretreatment.4. Hypothermia produced ventricular glycogen depletion and physostigmine prevented ventricular glycogenolysis under hypothermia. However, in the normothermic state physostigmine itself produced a significant decrease in cardiac glycogen.5. The relation between the antifibrillatory and antiglycogenolytic effects of physostigmine under hypothermia are discussed.