G.T. Royle

Offering patients a choice of surgery for early breast cancer: A reduction in anxiety and depression in patients and their husbands

Thirty patients with early breast cancer have been studied prospectively to assess whether being offered a choice of surgery (simple mastectomy or wide excision plus radiotherapy) influences levels of anxiety and depression pre- and post-operatively. A significantly higher percentage of the patients not offered a choice of surgery experienced clinical levels of anxiety and depression pre-operatively and up to 2 months post-operatively compared with patients offered a choice; the results were also similar for the husbands of these patients. At 6 months, differences between the 2 groups were not statistically significant, although the trend remained the same with more patients not offered a choice of treatment showing high levels of anxiety and depression. Patients offered a choice of surgery had similar pre-operative levels of anxiety and depression to patients with benign breast disease and patients undergoing surgery for non-cancerous conditions. This study indicates that with proper counselling patients and husbands suffer less stress if they are allowed to take an active part in the treatment of their cancer.

Late Toxicity Is Not Increased in BRCA1/BRCA2 Mutation Carriers Undergoing Breast Radiotherapy in the United Kingdom

Purpose: To undertake the first substantial clinical study of breast radiotherapy toxicity in BRCA1 and BRCA2 mutation carriers in the United Kingdom. Experimental Design: Acute and late radiation effects were evaluated in a retrospective study of 55 BRCA1 and BRCA2 mutation carriers treated with radiotherapy for breast cancer at four centers between 1983 and 2002. Individual matching with controls who had sporadic breast cancer was undertaken for age at diagnosis, time since completion of radiation, and treatment variables. Detailed assessments were undertaken by one examiner. Median follow-up was 6.75 years for carriers and 7.75 years for controls. Rates of late events (rib fractures, lung fibrosis, necrosis of soft tissue/bone, and pericarditis) as well as LENT-SOMA scores and clinical photography scores of breast size, shape, and skin telangiectasia were the primary end points. Results: No increase in clinically significant late toxicity was seen in the mutation carriers. Conclusions: These data add substantial weight to the evidence that the outcomes in the treated breast from radiotherapy in women with BRCA1 or BRCA2 mutations are comparable with those in women with sporadic breast cancer.

Patterns of clinical metastasis in breast cancer: an analysis of 100 patients.

Many patients diagnosed with breast cancer will develop metastases and these have diverse presentations. We have reviewed 100 consecutive patients who have died with metastatic breast cancer, to determine the frequency, sites and mode of presentation of recurrent disease. The commonest site of failure was loco-regional (n = 61), this usually presented with a mass, but a minority of patients also complained of pain. Bone metastases developed in 60 patients and produced bone pain, pathological fracture (n = 6) or cord compression (n = 5). Pulmonary metastases producing shortness of breath were diagnosed in 34 patients and were asymptomatic in a further 10. Intra-abdominal metastases were found at some time in 23 patients, most commonly in the liver (n = 20) and the majority complained of epigastric pain (n = 17). Brain metastases occurred in 23 patients and produced a wide range of symptoms including those of a space-occupying lesion (n = 10), cranial nerve palsy (n = 7), diabetes insipidus (n = 3), focal limb weakness (n = 2) and meningitis (n = 1). Three patients had choroid metastases producing reduced visual acuity. Recurrent breast carcinoma can present in a variety of ways, therefore any new symptom or sign should be considered to represent recurrence until proved otherwise.

Acute chemotherapy-related toxicity is not increased in BRCA1 and BRCA2 mutation carriers treated for breast cancer in the United Kingdom

Purpose: To evaluate acute toxicity induced by chemotherapy for breast cancer in a retrospective study of 62 BRCA1/2 mutation carriers matched 1:1 with women who had treatment for sporadic disease in the United Kingdom between 1983 and 2003. Experimental Design: All participants were interviewed by one of two researchers using standardized questionnaires, and their medical records were reviewed by one research nurse. The two main regimens received were cyclophosphamide, methotrexate, and fluorouracil and fluorouracil, epirubicin, and cyclophosphamide. The proportion of cases and controls receiving anthracycline-based treatment was equivalent, but fewer BRCA1 cases received this treatment than did BRCA2 mutation carriers. Toxicity was documented using the Eastern Cooperative Oncology Group Common Toxicity Criteria for hematologic, infective, and gastrointestinal toxicities. No increase in toxicity was seen in BRCA1/2 mutation carriers. Results: The only significant difference was that neutropenia was less evident in BRCA2 mutation carriers than in either BRCA1 mutation carriers or controls. As a result, there was no requirement for dose reduction among BRCA2 mutation carriers, in contrast to 10 of 39 BRCA1 carriers and 16 of 62 controls (P = 0.02). Conclusions: This result has implications for therapy and indicates that women with mutations in BRCA1 and BRCA2 may be given the same doses of chemotherapy as noncarriers.

The significance of involved tumour bed biopsy following wide local excision of breast cancer

AIM Following wide local excision of breast cancer approximately 25% of patients have residual disease in the tumour bed. The aim of this study was to determine whether positive bed biopsy correlated with either local recurrence or overall survival. METHOD Following wide excision bed biopsies were taken at four separate sites from the tumour bed. Histopathological assessment of the bed biopsies was made and compared to features within the primary tumour. Patients were followed-up over a median period of 6.17 years and local recurrence and survival data documented. RESULTS Two hundred and sixty-eight patients were included in the study and 63 had positive bed biopsies. In all, 85 patients had a recurrence of breast cancer and 69 died. Kaplan-Meier plots showed no evidence of a difference in survival between bed biopsy positive and negative patients. Bed biopsy positive patients were at greater risk of local recurrence. CONCLUSIONS These findings suggest that positive bed biopsy is associated with an increase in local recurrence rates but has no effect on overall survival following wide excision of breast cancer.

Ultrasonic attenuation in fibroadenoma of the breast

Fifteen patients are described who attended out Breast Screening Programme, and were found to have sclerosed fibroadenomas, the imaging of which raised the possibility of carcinoma. In six of these a reflective zone between a mass lesion and distal acoustic shadowing might have been used to infer the benign diagnosis.

Comparison between low and high pressure suction drainage following axillary clearance

AIM We report the comparison of low (Exudrain) and high pressure (Redivac) drains in 69 patients following mastectomy and axillary clearance. METHODS Volume of drainage was recorded daily for 8 days postoperatively. RESULTS Comparison of daily drainage revealed no statistically significant difference between the two groups of patients (P>0.05). There were no complications specific to the drains and we found similar numbers of infective complications in both groups. Hospital stay was also similar in the two groups (P=0. 70). CONCLUSIONS We conclude that the two drainage systems are equally effective in their drainage abilities although use of the low pressure may have an advantage over the high pressure system as it obviates the need for bottle changes and therefore requires less time and effort to manage.

The effect of fine needle aspiration cytology on the number of diagnostic biopsies and time to diagnosis in a breast screening programme

Abstract Two centres (A1 and A2) which used fine needle aspiration cytology (FNAC) for investigation of abnormal screening mammograms were compared with one centre (C) which did not. The object was to determine the effect of FNAC on the number of diagnostic biopsies and on the time to women being told that they had cancer or reassured that they did not. A total of 1908 women aged 50–64 who first attended for assessment of a screen-detected abnormality between 1 September 1988 and 31 August 1989 were followed-up until January 1992. The proportion of women with breast cancer who had a diagnostic biopsy at Centre A1 was found to be significantly lower than at the comparison Centre C (p The time to women being told of their breast cancer was lower in both centres where FNAC was carried out (p ≤ 0.001). The difference in time from first assessment to histology for women who had benign biopsies appeared to be due to a difference in the length of waiting lists after a decision for surgery, rather than to the use of FNAC. For women who did not have surgery, a significantly lower proportion of women at Centres A1 and A2 had been reassured and discharged to routine recall by 1 year than at Centre C (p FNAC can reduce the number of diagnostic biopsies both for women with and without cancer. It can reduce the period of uncertainty for women with cancer, but in this study it did not reduce the period of uncertainty for women without cancer.

Giant cell carcinoma of the breast

Abstract The breast is an extremely rare site for primary giant cell carcinoma. Two such cases are presented. The significance of giant cells in breast neoplasms is discussed.

Sclerosing lymphocytic lobulitis. A benign breast condition simulating carcinoma

Abstract Four cases of sclerosing lymphocytic lobulitis are presented and the clinical features of this condition, which can mimic carcinoma, are reviewed. Greater awareness of this condition would result in it being considered more frequently pre-operatively. This may avoid excisional biopsy in some patients and permit less radical surgery in others.