Randomized clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery.

BACKGROUND: The aim of this randomized clinical trial was to determine whether a single intravenous dose of 2 g flucloxacillin could prevent wound infection after primary non-reconstructive breast surgery. METHODS: The study included 618 patients undergoing local excision (n = 490), mastectomy (n = 107) or microdochectomy (n = 21). Patients were randomized to receive either a single dose of flucloxacillin immediately after the induction of anaesthesia or no intervention. Wound morbidity was monitored by an independent research nurse for 42 days after surgery. RESULTS: The incidence of wound infection was similar in the two groups: 10 of 311 (3.2 percent) in the flucloxacillin group and 14 of 307 (4.6 percent) in the control group (chi(2) = 0.75, P = 0.387; relative risk 0.71, 95 percent confidence interval 0.32 to 1.53). The groups also had similar wound scores and rates of moderate or severe cellulitis. Wound infection presented a median of 16 days after surgery. CONCLUSION: The administration of a single dose of flucloxacillin failed to reduce the rate of wound infection after non-reconstructive breast surgery.

Locally advanced primary breast cancer: medium-term results of a randomised trial of multimodal therapy versus initial hormone therapy.

We report the medium-term (median follow-up=52 months) results of a prospective randomised trial of multimodal therapy (neoadjuvant chemotherapy, Patey mastectomy, postoperative radiotherapy and adjuvant hormone therapy) (n=56) versus initial hormone therapy (n=52) for locally advanced primary breast cancer. Compared with multimodal therapy, initial hormone therapy was associated with reduced number of therapies for disease control (mean=3.6 versus 4.9) and mastectomy rate (31%). Multimodal therapy conferred better initial locoregional control and a longer disease-free interval. Nevertheless, there was no statistically significant differences in the rates of survival, metastasis and uncontrolled locoregional disease, as well as in the time to metastasis between the two therapy groups. Regardless of the therapy groups, oestrogen receptor positivity conferred a lower metastasis rate, better survival and locoregional control. Thus, initial hormone therapy may be a reasonable option for managing locally advanced primary breast cancer, especially for oestrogen receptor-positive tumours.

Change in expression of ER, bcl-2 and MIB1 on primary tamoxifen and relation to response in ER positive breast cancer.

Pre-treatment oestrogen receptor (ER) expression in breast cancer predicts for rate of response to endocrine therapy but not for the quality or duration of response (DofR). ER is known to be down-regulated by anti-oestrogens. This study has tested the hypothesis that the degree of down-regulation of ER and the ER-regulated marker bcl-2 are associated with the quality and duration of tamoxifen response. 80 patients with ER+ve breast cancer (H-score > 10) receiving primary tamoxifen (n = 51 Stage I-II elderly; n = 29 Stage III) underwent sequential tumour biopsies for immunocytochemical assessment of ER, bcl-2 and the proliferation marker MIB1. Median follow-up is 45 months. By 6-months on therapy three patients had attained complete response (CR), 27 partial response (PR); 44 static disease (SD) and six progression (PD) by UICC criteria. Greater decrease in ER and bcl-2 H-score from pre-treatment to 6 weeks (p = 0.035, p = 0.037) and ER and bcl-2 H-score from pre-treatment to 6 months (p = 0.058, p = 0.036) were significantly associated with better quality of response (CR/PR vs SD/PD). Greater 6-week and 6-month reduction in bcl-2 H-score (p = 0.041, p = 0.036) and 6-week reduction in MIB1 (p = 0.013) were significantly correlated with longer DofR. This study demonstrates that greater down-regulation of ER and the ER-regulated protein bcl-2 on primary tamoxifen are significantly associated with a better quality of response and bcl-2 and the proliferation marker MIB1 a longer duration of response in ER+ve breast cancer.

Transperitoneal laparoscopic exposure for lumbar interbody fusion.

STUDY DESIGN: A prospective clinical trial of the transperitoneal laparoscopic approach to the lumbar spine in a consecutive series of patients undergoing anterior lumbar interbody fusion. OBJECTIVES: To determine safety and effectiveness, and to document technique and perioperative complications of a laparoscopic exposure for lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: With the widespread adoption of laparoscopic techniques, the benefits of minimal access surgery are now well recognized--in general, gynecologic and urologic surgery. Only recently have minimal access techniques been applied to spinal procedures. METHODS: Forty-seven patients with symptomatic degenerative disc disease underwent transperitoneal laparoscopic exposure of the lumbar spine to facilitate implantation of cylindrical threaded interbody fusion cages. These patients were prospectively followed and all perioperative considerations and complications were documented and analyzed. The surgical technique of laparoscopic exposure will be described. RESULTS: The laparoscopic approach was attempted in 47 consecutive patients. Forty-four were completed laparoscopically--36 single level fusions, seven two level fusions, and one three level fusion. Early in the series, conversion to open surgery was required in one patient (case #3) because of bleeding from the presacral veins which hindered the view. In one case, mobilization of the great vessels proved to be difficult, and in one other case the patient could not tolerate abdominal insufflation. The mean blood loss for the entire group was 105 mls. Complications related to the endoscopic exposure were few. There were no injuries to major vascular structures or to bowel, and no mortalities. In two patients, the cages were malpositioned necessitating repeat endoscopic exposure for cage realignment. One patient required a laparotomy for a postoperative small bowel obstruction. The median postoperative stay was 4 days. CONCLUSIONS: Transperitoneal laparoscopic exposure for single or multiple level, anterior lumbar interbody fusion can be performed with low risk. Experience in open anterior spinal surgery and laparoscopic general surgery is vital in minimizing the risks.

Onapristone, a progesterone receptor antagonist, as first-line therapy in primary breast cancer.

The progesterone receptor antagonist, Onapristone, is an effective endocrine agent in experimental breast cancer models. This study aimed to investigate this agent as first-line endocrine therapy in patients with breast cancer. However, owing to the recognition in this and other clinical studies that some patients on Onapristone developed liver function test abnormalities, the development of this drug and recruitment to the study stopped in 1995. 19 patients either with locally advanced breast cancer (n = 12) or who were elderly, unfit patients with primary breast cancer (n = 7) received Onapristone 100 mg/day. Seventeen of the 19 tumours expressed oestrogen receptors (ER) whilst 12 of the 18 tumours tested expressed progesterone receptors (PgR). Tumour remission was categorised by International Union Against Cancer criteria. One patient was withdrawn after 4.5 months while her disease was static. Of the remaining 18 patients, 10 (56%) showed a partial response and 2 (11%) durable static disease (> or = 6 months), giving an overall tumour remission rate of 67%. The median duration of remission was 70 weeks. Transient liver function test abnormalities developed in a number of patients, mainly during the first 6 weeks of treatment. In conclusion Onapristone can induce tumour responses in human breast cancer.

Early laparoscopic cholecystectomy for acute cholecystitis: a safe procedure.

Acute cholecystitis is increasingly managed by laparoscopic cholecystectomy. Some reports have shown conversion and complication rates that are increased in comparison to elective laparoscopic cholecystectomy. This study reviews the combined experience of two hospitals where the intention was to perform early laparoscopic cholecystectomy for acute cholecystitis. A total of 152 cases of laparoscopic cholecystectomy for acute cholecystitis (evidence of acute inflammation clinically and pathologically) were identified. Conversion to open cholecystectomy was required in 14 cases (9%) in the total series. Laparoscopic cholecystectomy was performed within 2 days of admission in 76% (115 of 152) of patients. Conversion was significantly less likely in patients undergoing laparoscopic cholecystectomy within 2 days of admission (4 of 115) compared to those undergoing surgery beyond 2 days (10 of 37; P<0.0001). Eleven patients (7%) had postoperative complications; however, there were no cases of injury to the biliary system and no perioperative deaths. This series shows that laparoscopic cholecystectomy can be performed safely in patients with acute cholecystitis and suggests that early laparoscopic cholecystectomy is preferable to delaying surgery. Although the conversion rate to open surgery is higher than for elective cholecystectomy, the majority of patients (91%) still derive the well-recognized benefits of laparoscopic cholecystectomy. Early laparoscopic cholecystectomy is an acceptable approach to acute cholecystitis for the experienced laparoscopic surgeon.

Endocrine response and resistance in breast cancer: a role for the transcription factor Fos.

We have previously demonstrated that elevated Fos expression may be important in de novo endocrine resistance in breast cancer. However, changes in Fos expression during endocrine response and subsequently on acquisition of resistance are unknown. This study immunocytochemically monitors Fos protein within sequential biopsies from primary human breast cancer patients obtained pre-treatment (T1), during tamoxifen therapy (T2, T3) and on disease progression (T5), examining in parallel proliferation [i.e., MIBI (Ki67) immunostaining, mitotic activity], cellularity and endocrine response. Significantly diminished Fos, proliferation and cellularity were observed after 6 weeks of therapy in patients exhibiting a better quality and/or duration of response, while modest Fos increases and a maintained proliferation and cellularity were seen in poorer responders. Decreases in Fos, proliferation and cellularity at 6 months similarly hallmarked better responders. We confirmed a significant association between de novo resistance and elevated Fos and proliferation. Additionally, however, these parameters increased at the time of disease relapse over pre-treatment and "on therapy" values. Our data indicate that tamoxifen response involves a reduction in both tumor cell proliferation and cell survival, potentially entailing diminished Fos protein expression in better-responding patients. Our data are also supportive of elevated Fos expression being involved in the departure from endocrine control inherent in both primary and acquired resistance.

C-erbB2 expression predicts response to preoperative chemotherapy for locally advanced breast cancer.

BACKGROUND: Previous work suggests that the presence of c-erbB2 oncoprotein immunostaining and the proliferation rate of tumours, may be relevant to chemo-sensitivity in breast cancer. PATIENTS AND METHODS: To investigate this we assessed pretreatment biopsies from 50 patients with locally advanced breast cancer for expression of c-erbB2 and MIB1 (proliferative marker) in relation to clinical response after 3 months preoperative chemotherapy. RESULTS: Objective response was significantly more likely (22/30, 73%) for tumours negative for c-erbB2 membrane staining, compared to positively staining tumours (6/20, 30%, p = 0.0025). The percentage of cells staining positively for MIB1 was not predictive of response (p = 0.56). CONCLUSIONS: This study has shown an increased likelihood of response to preoperative chemotherapy for breast cancers negative for c-erbB2 staining. Previous studies have shown that c-erbB2 immunostaining can correlate with either chemo-resistance or chemo-response. We postulate that this conflict may be due to differences in the type of chemotherapy administered. This raises the possibility of biological markers being use to assist in the selection of the type of chemotherapy regimen administered to particular tumour biological phenotype.

Predictors of response to second-line endocrine therapy for breast cancer.

This study reports on factors predicting response to second-line endocrine therapy in 250 patients with breast cancer for which they were assessable for response by the International Union Against Cancer (UICC) criteria. Clinical details relating to first-line endocrine therapy were available for all patients. We have not included in this study patients who received first-line endocrine therapy but did not or have not yet proceeded to second-line hormone therapy--e.g. died from rapidly progressive disease, started chemotherapy for rapidly progressive disease, or remained in long-term remission on first-line endocrine therapy. One hundred and fifty nine patients (72%) achieved remission (objective response and static disease [OR + SD]) on first-line endocrine therapy with a median duration of 19 months. For second-line endocrine therapy the remission rate was 53% (132/225) with a median duration of 15 months. Tumour grade and oestrogen receptor status of the primary tumour were shown to be independent predictors of response to second-line endocrine therapy while response to first-line endocrine therapy was a predictor of the duration of response to second-line endocrine therapy. In the sub-group of patients who showed OR or SD to both first and second-line therapies, there was no correlation between the time to progression (TTP) on first and second-line therapies.

Audit of a conservative management policy of the axilla in elderly patients with operable breast cancer.

Between April 1982 and February 1994, 344 women aged > 70 years with cancers < 5 cm in diameter were treated at the City Hospital Breast Unit. The majority were enrolled in two successive randomized trials. One hundred and sixty patients had primary therapy with tamoxifen alone and were subsequently treated with mastectomy if the primary cancer progressed. Fifty-three women with a high oestrogen receptor (ER) status in the tumour received mastectomy and post-operative tamoxifen. One hundred and thirty-one patients underwent primary surgery (104, mastectomy; 27, wide local excision) and did not receive adjuvant tamoxifen. Only the 184 (131 + 53) patients who underwent primary definitive surgery have been included in this study. Patients undergoing primary surgery without palpable lymph nodes (n = 159) did not undergo axillary exploration. Twenty-five women who were noted pre-operatively to have clinically palpable lymph nodes underwent excision of obviously enlarged lymph nodes in the axilla in addition to primary surgery; small nodes that measured less than around 1 cm were left in place. None received axillary clearance or axillary irradiation. The median follow-up is 54 months. Twenty-three of 159 (14%) patients without palpable nodes, and four of 25 (16%) with palpable nodes, have subsequently developed axillary recurrence. Grade 3 tumours were associated with a higher rate of regional recurrence. Regional relapse was treated successfully with different therapeutic modalities (surgery, radiotherapy or endocrine manipulation) and none have died from uncontrolled regional disease.

Male breast cancer: pathological and immunohistochemical features.

BACKGROUND: male breast cancer is uncommon and studies regarding the potential clinical relevance of the histopathological and immunohistochemical features are infrequently reported. MATERIALS AND METHODS: We investigated the biological characteristics of forty-one male patients with invasive breast cancer by assessing histopathological and multiple immunohistochemical features. RESULTS: The majority were no special type (ductal) (37/41), lobular cancer was not seen. 73% were histological grade 3, 93% were positive for oestrogen receptor and 73% for progesterone receptor. The proportion of cancers positive for c-ebB-2 (45%), EGFR (20%), p53 (58%), MiB1 (40%), NCRC11 (78%), were similar to reports for female breast cancer. Nonsignificant associations between poor survival outcome and grade 3 tumours, and positive tissue staining for MiB1 and p53 were seen. CONCLUSION: While there ar similarities in the biological features of breast cancer in males and females, some differences were identified. Male breast cancer is more likely to be grade 3 tumours and hormone receptor positive.

Omental transposition flap for gross locally recurrent breast cancer.

BACKGROUND: The omentum has been employed to cover the defect produced after resection of gross breast cancer recurrence for nearly three decades. METHODS: A series of 11 patients undergoing omental transposition flap for very wide resection of gross local recurrence (LR) of breast cancer is reported. The median age was 39 years, with a short interval (median = 21 months) from the treatment of the primary tumour to LR. Local recurrence was gross and predominantly inflammatory. RESULTS: All except one patient had lymphovascular invasion in the recurrent tumour. The omental graft was 100% viable but one patient required re-application of further split-thickness skin graft. The mean hospital stay was 16 days. Two cases of seroma formation were encountered. New recurrence developed around the periphery of the flap in eight patients after a median duration of local control of only 2.5 months. Eight patients died with metastatic disease after a median period of 6 months, six patients with uncontrolled local disease. Five patients were free from LR in over half of their remaining period of life. CONCLUSION: Omentoplasty is a safe and reliable procedure but the length of palliation achieved is often far from satisfactory.

A comparison outcome of male breast cancer with female breast cancer.

BACKGROUND: It is unclear whether breast cancer has a similar prognosis in males and females. METHODS: A 20-year retrospective study of all male breast cancer patients in our region was undertaken. We compared this series with a group of females matched for the major prognostic factors and an unmatched series of female patients treated over the same period. RESULTS: Forty-one patients with invasive cancer and 2 with ductal carcinoma in situ were identified. One invasive cancer was treated with radiotherapy, 40 had surgery. Local recurrence occurred in 23% and axillary recurrence in 40% of cases. Male and female patients (n = 123) matched for the major prognostic factors showed a similar outcome for disease-free interval (P = 0.90) and survival (P = 0.27). However, both the above groups had a significantly worse outcome than the unmatched series of female patients with breast cancer. CONCLUSIONS: When prognostic factors are allowed for, male and female breast cancer patients have a similar outcome. This suggests that such features should be taken into account when determining management for males with breast cancer just as they are in females.

Locally advanced breast cancer: early results of a randomised trial of multimodal therapy versus initial hormone therapy.

The aim of this study was to investigate initial treatment of locally advanced breast cancer. Patients were randomised to "multimodal" therapy (pre-operative chemotherapy, Patey mastectomy, flap irradiation and adjuvant hormone therapy) (n = 55), or initial "hormone" therapy (n = 53) with further therapy upon tumour progression. The objective response to chemotherapy was 57% (31/54) after four cycles. Of patients on hormone therapy, 36% (19/53) had an objective response and 32% (17/53) disease stasis at a 6 month assessment. At a median 30 months follow-up, there was no notable difference in development of metastases or survival: only 6 patients have uncontrolled loco-regional relapse (4 "hormonal", 2 "multimodal"). The number of treatments per patient required for this loco-regional control was lower in the "hormone" group (mean 2.13 versus 4.20 in the "multimodal" group). This small study has shown that the use of consecutive therapies, with the aim of tumour control, does not appear to compromise outcome in comparison with initial "multi-modal" therapy. Adopting such a policy may allow some patients to avoid unnecessary treatments.

The clinical relevance of static disease (no change) category for 6 months on endocrine therapy in patients with breast cancer.

This study reports on the clinical relevance of the static disease (SD) category in 255 breast cancer patients on endocrine therapy. All patients had received first- and second-line endocrine therapy and were assessed for response by the International Union Against Cancer (UICC) criteria. We did not include patients who received first-line endocrine therapy but did not or have not yet proceeded to second-line hormone therapy, e.g. died from rapidly progressive disease, started chemotherapy for rapidly progressive disease, remained in long-term remission on first-line endocrine therapy. We analysed survival from initiation of first-line endocrine therapy by the remission criteria, i.e. complete response (CR), partial response (PR), static disease (SD) or progressive disease (PD), achieved on that therapy. Patients were divided into those with metastatic breast cancer (MBC) and non-metastatic disease. There was no significant difference in survival from starting first-line endocrine therapy between patients who obtained CR, PR or SD: all three groups of patients survived significantly longer than patients who showed PD within 6 months (all P < 0.0001 except CR versus PD [MBC] which was P < 0.002). Equally, for second-line endocrine therapy there was no difference in survival between patients who obtained CR, PR or SD: all three groups (CR, PR and SD) survived significantly longer than PD (all P < 0.0003 except for CR versus PD which was P < 0.003 for non-metastatic and P < 0.059 for MBC). Durable SD appears to be a clinically useful criteria of therapeutic remission.

Diagnosis of breast cancer with core-biopsy and fine needle aspiration cytology.

BACKGROUND: Patients who are elderly or who have locally advanced breast cancer may initially receive primary medical therapy. METHODS: In order to avoid open biopsy in such patients, we routinely perform both fine needle aspiration cytology (FNAC) and core-biopsy at the first clinic visit. RESULTS: A retrospective review showed that of 109 such patients, 87 (80%) had the diagnosis confirmed on FNAC and 96 (88%) on core-biopsy. Only eight patients did not have a diagnostic result from the first clinic visit, and five of these patients were diagnosed on a repeat core-biopsy or FNAC. The remaining three patients had suspicious FNAC. Overall 97% had one or both investigations positive. CONCLUSIONS: When considered alone core-biopsy was superior to FNAC. In this series the combined diagnostic approach of FNAC and core-biopsy has allowed outpatient diagnosis for virtually all patients.

'Idiopathic' chronic gastric volvulus.

Gastric volvulus usually occurs secondary to another condition such as hiatal hernia. We report a case of so-called "idiopathic' gastric volvulus where the only abnormality was laxity of the gastric attachments. Upper gastrointestinal endoscopy was unhelpful in making the diagnosis, but a barium meal clearly demonstrated the abnormality. The patient underwent a Polya gastrectomy with a retrocolic gastroenterostomy, which was thought to be the best method of ensuring gastric fixation.