Guidelines on the standards for the training of specialised health professionals dealing with breast cancer.

According to EUSOMA position paper 'The requirements of a specialist breast unit', each breast unit should have a core team made up of health professionals who have undergone specialist training in breast cancer. In this paper, on behalf of EUSOMA, authors have identified the standards of training in breast cancer, to harmonise and foster breast care training in Europe. The aim of this paper is to contribute to the increase in the level of care in a breast unit, as the input of qualified health professionals increases the quality of breast cancer patient care.

Prednimustine combined with mitoxantrone and 5-fluorouracil for first and second-line chemotherapy in advanced breast cancer.

A total of 60 patients with advanced breast cancer were treated with a combination of prednimustine (P: 110 mg/m2, days 1-5), mitoxantrone (M: 12 mg/m2, day 1) and 5-fluorouracil (F: 500 mg/m2, day 1) (PMF). Treatment was repeated every 3 weeks. In all 53 patients were evaluable for response. A total of 12 subjects had failed prior chemotherapy for metastatic disease. In response to PMF treatment we observed 21 partial remissions and 3 complete remissions, amounting to a total response rate of 45%. The median duration of response was 39 weeks, and median survival was 56 weeks. Dose-limiting side effects were leukopenia (40 cases) and thrombocytopenia (11 patients). Nausea and vomiting was experienced by 93% of subjects; in 56% of cases it reached WHO stage II-III. Alopecia occurred in 18% of our patients. Our results suggest that PMF represents an active regimen in the treatment of advanced breast cancer and yields a response rate of 45%. Considering that the majority of our patients had not received prior chemotherapy, the question remains open as to whether a 45% response rate outweighs the observed toxicity.

4'-O-tetrahydropyranyl-doxorubicin in advanced breast cancer: a phase II study.

In a phase II study, 35 patients with advanced breast cancer were treated with 4'-O-tetrahydropyranyl-doxorubicin (THP-DXR) (70 mg/m2 i.v. on day 1); treatment was repeated every 3 weeks. Eight patients had failed prior chemotherapy for advanced disease. A total of 34 patients were evaluable for response. After a median of 10 treatment courses (range, 3-15), objective tumor response was seen in 59% (20 of 34 patients) (95% confidence limits, 42%-75%). In all, 17 partial remissions and 3 complete remissions were observed; stable disease occurred in 13 patients. The median duration of response was 42+ weeks (range, 21 - 77+ weeks). The dose-limiting side effects were leukopenia (26 patients, WHO grade III-IV) and thrombocytopenia (9 patients, WHO grade II-IV). Nausea/vomiting was experienced by 34 patients; in 18, it reached WHO grade II-III. Other treatment-related side effects included alopecia (WHO grade II-III) in 26 patients and stomatitis and diarrhea (WHO grade I-III) in 9 patients. At cumulative doses of THP-DXR of at least 700 mg/m2 (range, 700-1,050 mg/m2), no signs of congestive heart failure were observed. We conclude that THP-DXR is effective for first- and second-line chemotherapy in advanced breast cancer and that side effects are manageable.

Surgical treatment of dermatofibrosarcoma protuberans. A retrospective study of 20 cases with review of literature.

The clinicopathological features and results of surgical treatment of 20 patients with dermatofibrosarcoma protuberans (DFSP) were reviewed. All patients have been observed until the present time or death. The primary treatment usually consisted of marginal, wide or radical excision. Re-excision because of recurrence was performed in six of the 20 patients who were treated primarily only by marginal excision. Following re-excision two patients have remained disease-free until the present, the other four of these six patients had a second recurrence. Three of these four patients with a second relapse were successfully treated by excision. Although six patients out of 20 had 13 recurrences at the site of primary therapy, no patient developed lymph node or distant metastases. To date, none of the remaining 14 patients has had recurrence, all having been treated by excision of from 1 to 5 cm, the mean follow-up time was 8.75 years. Based on our data, the high recurrence rate after marginal surgical treatment implies an initial radical resection.

Principles and guidelines for surgeons--management of symptomatic breast cancer. European Society of Surgical Oncology.

The European Society of Surgical Oncology is actively involved in the promotion of a high standard of surgical oncology throughout Europe. Such an ambition involves recognition of Centres of Excellence in the management of cancer patients throughout Europe. These centres have a multi-disciplinary system involved in the total care of patients with cancer and are concerned with the delivery of care to the highest available standards. It is accepted that not all patients with cancer can, nor should, necessarily be treated in such highly specialized centres. Yet all cancer patients should be guaranteed a high standard of care. High surgical standards can be ensured if surgeons treating cancer are trained in specialist centres and, when in independent practice, follow established guidelines or protocols of treatment. In common with many national surgical oncology societies, the European Society of Surgical Oncology is in the process of establishing good practice guidelines in the treatment of solid tumours. This document on the management of symptomatic breast cancer is the first of a series of guidelines to be proposed by ESSO. It draws heavily on excellent documents already in existence from the British Association of Surgical Oncology and from the Danish Breast Cancer Co-Operative Group. It is hoped that this document will be sufficiently clear and purposeful to be of help to the individual surgeon and yet sufficiently flexible to allow it to be adopted in the different medical systems throughout Europe.

The impact of resection margins in the treatment of primary sarcomas of the breast. A clinicopathological study of 8 cases with review of literature.

We reviewed the clinical and pathological features of eight patients (seven females, one male), who underwent surgery for sarcomas of the breast, to evaluate the effect of the margins of resection and histological tumor type on survival. Patients with carcinosarcoma, cystosarcoma phyllodes or dermatofibrosarcoma protuberans were excluded. Tumor size ranged between 4.5 and 26 cm (median 12.8 cm); there were three grade 3, four grade 2 and one grade 1 lesions. Of the five patients treated by radical resection margins, two with large grade 3 sarcomas died of distant metastasis 3 and 10 months later. One patient out of the five radical resected patients developed a local recurrence 96 months later. The recurrence was resected radically, radiotherapy was administered, and the patient is still alive at 168 months. The remaining four radical resected patients are free of disease until now. One of three patients, treated by wide or marginal resection, received adjuvant radiotherapy. This patient developed local recurrence and solitary distant metastasis at 26 and 49 months, respectively, and died of multiple distant metastasis at 54 months. Regional axillary lymph node metastasis was not observed in five patients in whom lymph node dissection was performed, with a median of 14.2 dissected lymph nodes. Two of eight patients received preoperative chemo- or radiotherapy because of large tumor size; five of eight received postoperative radiotherapy. Local tumor control was achieved in six of eight patients. The median follow-up time was 53.9 months (3-168 months), of all survivors median 72.2 months. Recurrence and disease-free survival rates were analysed according to histologic grade, tumor size, stage, surgical and adjuvant treatment.

Experience with a high speed biopsy gun in breast cancer diagnosis.

Pre-operative determination of histology and receptor status is important in optimizing the management of breast cancer. The purpose of our study was to evaluate the high speed biopsy gun in 109 patients with palpable breast tumours. High speed biopsies were performed using the system BIP High Speed Multi 22 with 16-gauge-needles at a speed of 30 m/s. All biopsies could be used for frozen sections and for determination of receptor status. In 81 patients (74.3%) malignant breast tumours were diagnosed, and three patients (2.8%) had highly suspicious lesions. The oestrogen receptor status was negative in 32%, progesterone receptor status negative in 41%. In one patient (0.9%) a high grade non-Hodgkin's lymphoma of B-cell-type was diagnosed. In 21.1% benign tumours were found. In one patient a malignant tumour was missed at biopsy (0.9% false-negative). It was concluded that high speed biopsy is a reliable and simple method for preoperative sampling of breast lesions.

Multiprogrammable pacemakers: are their advantages fully employed?

Out of 1265 pacemakers implanted between 1981 and 1987 in our center, 50 (4.0 percent) were of SSI M mode. Utilization of the programming capability of these multiprogrammable single-chamber pulse generators was investigated. All devices were programmed to the "energy saving mode" ensuring the longest lifetime possible. Half of them did not have to be reprogrammed for any other reason, the other half had to be programmed for cardiological and/or technical dysfunctions. Full utilization has been made of the programmability of these sophisticated and expensive units and their wide application is justified.

[Perioperative subjective emotional state]. / Perioperative subjektive Befindlichkeit.

The aim of adequate preoperative medication is to minimize the patient's anxiety level. Preoperative anxiety can be consciously and specifically orientated or it can be masked. This double-blind study was performed to evaluate the effects of an anxiolytic drug in comparison with a placebo perioperatively and to assess the post-operative course of the important factors anxiety, depression and asthenia. The Mannheim inventory for subjective state and STAI (State-Trait-Anxiety-Inventory) were offered. The study was undertaken in 60 female patients, who were operated for suspected carcinoma of the breast. We conclude that in such a specific group of patients extensive preoperative psychological preparation must be backed up by the administration of an anxiolytic drug.

[Breast cancer in the catchment area of the Graz Institute of Pathology. Evaluation of morphologic parameters based on 1,510 cases]. / Das Mammakarzinom im Einzugsgebiet des Grazer Instituts für Pathologie. Evaluierung morphologischer Parameter an Hand von 1510 Fällen.

The patient's age, tumour size, histological type and degree of differentiation as well as involvement of axillary lymph nodes are decisive for prognosis and therapy of breast cancer. Moreover these parameters reflect the achievement of early diagnosis and the surgical standard of treatment of breast carcinomas. Therefore we retrospectively reviewed 1510 cases diagnosed from 1984-1987. Non-invasive carcinomas were diagnosed in 4%. 75% of them were classified as intraductal carcinoma and 25% as lobular carcinoma in situ. 96% of the tumours were invasive at time of diagnosis. Invasive ductal carcinoma (NOS-type) was found in 70.2%, invasive lobular carcinoma in 12.3%. 3.2% of the tumours showed both ductal and lobular differentiation and 2.3% corresponded to invasive ductal carcinoma with a predominantly intraductal component. Medullary and mucinous carcinomas were detected in 2.1% and 2% of cases, respectively. Papillary carcinomas were observed in 0.9%, the frequency of other histological types was less than 1%. 44% of the tumours corresponded to UICC-category pT1, 38% to pT2, 6% to pT3 and 8% to pT4. A meaningful correlation of tumour size and axillary lymph node involvement was possible in only 906 cases, in which 10 or more lymph nodes were verified histologically. Lymph node metastases were detected in 23% of tumour category pT1 and in 47% of category pT2. PT3- and pT4-tumours metastasized to axillary lymph nodes in 77 and 86% of cases, respectively.

[Stewart-Treves syndrome and lymphangiosarcoma]. / Stewart-Treves-Syndrom und Lymphangiosarkom.

Lymphangiosarcomas represent the most dangerous complication of chronic lymphedema usually following mastectomy and irradiation therapy on account of breast carcinoma, well-known as Stewart-Treves syndrome. Still more rarely documented are lymphangiosarcomas arising in chronic lymphedema due to other causes. Two cases of Stewart-Treves syndrome on the forearm and one case of lymphangiosarcoma of the hand following a fifty-year existing chronic lymphedema after burn injury in childhood are reported. Clinical description and illustrations of all three cases are given, including list of references. Therapeutic procedures are described.

[Stonefish stab injury of the hand]. / Steinfisch-Stichverletzung an der Hand.

The authors report a sting injury by a stonefish in the hand. First aid and surgical treatment are discussed. The biology of the stonefish is reviewed.

[A rare tumor of the sciatic nerve--myxoid neurofibroma. A case report]. / Seltener Tumor des N. ischiadicus--myxoides Neurofibrom. Ein Fallbericht.

The surgical resection of soft tissue tumors in peripheral nerves often poses problems, since the extent of resection depends on tumor dignity, determined by incisional biopsy. This case report is about a myxoid neurofibroma of the sciatic nerve. In the literature, this rare entity is a precursor of malignant neurilemoma. The choice is difficult between radical resection in view of possible locoregional recurrence or possible malignant transformation and preservation of the nerve. In this case, the sciatic nerve was encased in the pseudocapsule of the tumor and was nearly totally spared during surgical resection. Following surgery, there were no neurological defects.

[Complications and failures in free-flap transplantations]. / Komplikationen und Misserfolge bei freien Lappentransplantationen.

Complications and failures in nine cases of free flap transfer are reported. With increasing experience the number of failures declines. In six of seven cases with total flap necrosis technique and tactics in microsurgical procedure were responsible for the disaster. The failure in the other case was due to thrombosis of an axillary vein and thoracodorsal vein leading to necrosis of a latissimus dorsi flap. A dorsalis pedis flap was saved by arterial inflow through a flap vein. The fact that not one flap could be saved by revision is accounted for by the circumstance that the monitoring looks at capillary filling alone. It is possible that the Laser-Doppler-flowmetry is a useful and practical method for objective monitoring.

[Multiple symmetrical lipomatosis. A retrospective study of 14 cases and review of the literature]. / Multiple symmetrische Lipomatose. Eine retrospektive Studie über 14 Fälle mit Literaturübersicht.

"Multiple symmetric lipomatosis" is an accumulation of fatty tissue in upper areas of the body mainly effecting middle aged men. It is a rare benign disease connected with differing disorders. We report 14 male patients suffering from "multiple symmetric lipomatosis" and focus on the etiology and on associated disorders. Differential diagnosis, pathohistological considerations, clinical behaviour, and operative treatment are discussed. A review of the literature is presented.

[Compartment syndrome as a complication of surgical position in penis replantation]. / Kompartmentsyndrome als Lagerungskomplikation bei Penisreplantation.

A case report of a penis- and scrotum amputation in a 28-year old patient, caused by a moped accident, is presented. The penis replantation is discussed as are the postoperative problems.

[Is the response to cardiac pacing controlled by central venous temperature physiological?]. / Je reakce kardiostimulátoru rízeného centrální zilní teplotou fyziologická?

Rate responsive cardiac pacemakers are capable of adapting their pacing rate according to metabolic demands in the physical effort and some of the sensors in use even according to such physiological stimuli in which the level of metabolism remains unchanged. Central blood temperature (CVT) could possibly represent a much-needed and searched ideal sensor, which truly reflects physiological processes. In order to verify the response of the thermistor sensor under various physiological conditions, 10 single-chamber VVIR pacemakers Thermos M 02 (Biotronik) were implanted since 1993 through 1995. Our group of patients consisted of 9 men and 1 women. 8 patients had chronic atrial fibrillation with bradycardia and ventricular chronotropic incompetence, 2 patients suffered from the 3rd degree atrioventricular block. The mean age at the time of implant was 62.4 (52-72) years, the mean follow-up period has amounted to 23 (2-32) months. The CVT response to physical exercise was proportional and smooth, especially in the strenuous physical effort. In contrast to some other sensors, CVT exhibited the physiological reaction also in situations in which the metabolic level did not change. It displayed a physiological circadian fluctuation of the pacing rate. Nevertheless, a markedly prolonged reaction time at the onset of physical exercise in the patients who were still "cold" was a shortcoming of this principle. The special sensor lead is a must and only the ventricular pacing is possible. Isolated CVT is not the ideal sensor but it be combined with fast sensors. It will undoubtedly be one of the sensors within the automatic multisensor pacemaker in the forseeable future. (Tab. 1, Fig. 1, Ref. 15.)

[Dual-chamber rate-regulated cardiac pacing is aiming toward automatic pacemakers]. / Dvoudutinová frekvencne reagující kardiostimulace smeruje k automatickému stimulátoru.

DDDR cardiac pacemakers meet the demand of the two main goals of modern cardiac pacing enauring both the synchronization of atriums and ventricles and the frequency response to physical exercise. In this way they simulate the normal heart rhythm behaviour best of all pacemakers in use. Since 1992 through 1995 the DDDR pacemakers were implanted in 27 patients aged 20-79 (mean 59.9) years in our pacemaker centre. The follow-up period has amounted to 46 months. 26 patients suffered from advanced sinus syndrome with the chronotropic incompetence and with the atrioventricular block, the remaining young man was given the pacemaker because of congenital atrioventricular block. In one patient epicardial leads implanted by thoracotomy have been used. After the wound had healed and the pulse energy had been reduced, the pacemaker bearers underwent the stepwise symptoms limited bicycle or treadmill stress test. During the follow-up the incidence of particular complications was assessed. In comparison with the DDD mode without the sensor, the DDDR pacemakers exhibiting the rate adaptation did improve the working capacity in particular patients in the stress test. (Tab. 1, Fig. 5, Ref. 16).

[Primary malignant non-Hodgkin's lymphoma of the breast: breast preserving therapy in 3 patients]. / Primäres malignes Non-Hodgkin-Lymphom der Mamma: Brusterhaltende Therapie bei 3 Patientinnen.

Primary malignant non-Hodgkin lymphoma is rare. The mammographic appearance is unspecific. The final diagnosis can usually be made after examination of paraffin-embedded tissue only. There exists no therapeutic standard for this disease. In the case of 3 patients treated at our institution, tumorectomy only and adjuvant therapy have been performed because there is no survival advantage for patients who underwent radical surgery.

[Modern cardiac pacing. II. Rate responsive pacemakers: clinical experience]. / Moderní kardiostimulace. II. Stimulátory s frekvencní odpovedí: klincké zkusenosti.

Rate responsive cardiac pacemakers adapting their pacing frequency according to physical effort are able to solve not only a bradycardia, but a chronotropic incompetence too. 23 rate responsive pulse generators, implanted in 1987-1991 in our center, simulated the physiological conditions and in this way they significantly improved both working capacity in bicycle stress test (p < 0.0001) and well-being in comparison with ordinary demand pacers. The incidence of complications did not exceed that in simple common pacemakers, but the rate adaptive ones were expensive and their programming was time consuming. In all three rate adaptive principles used their non-specific response revealed some imperfection of sensor driven devices. In addition, both in QT and in respiratory dependent systems their pretty proportional frequency response was delayed, while the irregular pacing rate in body activity sensor was not very proportionate to the physical exercise. The non-specific sensor response may be reduced by a combination of biologic sensors.