METASTATIC ‘EARLY’ COLORECTAL CANCER

If colorectal carcinomas where the primary tumours are confined to the wall are considered ‘early’, the likelihood of lymph node metastasis in these tumours is 21 % and for those that do not extend beyond the submucosa it is 13%. Because of the renewed interest in local treatment of small accessible rectal tumours and the use of colonoscopy for the removal of ‘polyps’ with invasive carcinoma, we analysed our long-term cancer survival figures for‘early’ cancers in this combined surgical series spanning more than 30 years. The presence of regional lymph node metastasis in ‘early’rectal cancer was associated with a significantly (P= 0.001) reduced proportion of long-term survivors (56%) compared to those without nodal involvement (79%). Long term survival in ‘early’ colonic cancer was less influenced (P < 0.05) by whether lymph node metastasis was present (73%) or not (77%). The authors conclude that until more information is available with regard to the risk of lymph node spread from ‘early’ tumours, resection is advised for all invasive tumours of the colon in good risk patients, but the indications for local excision of ‘early’ rectal cancers can be extended in view of the ease of careful follow-up and the use of salvage procedures in those with recurrence.     

CRYOTHERAPY OF THE RESECTION EDGE AFTER LIVER RESECTION FOR COLORECTAL CANCER METASTASES

Background : An involved or inadequate (< 1 cm) resection margin is associated with a high rate of local tumour recurrence and reduced survival rates after liver resection for colorectal metastases. This paper assesses whether or not hepatic cryotherapy of the resection edge is suitable to improve local disease control. Methods : From April 1990 to May 1997, we performed cryotherapy of the resection edge in 44 patients after liver resection for colorectal liver metastases with an involved or inadequate resection margin. The reasons for performing edge cryotherapy instead of extension of resection were: proximity of hepatic veins or portal sheath (n= 12); avoidance of extended left or right hemihepatectomy (n= 15); inadequate liver tissue reserve after resection (n= 16); and patient unfit to undergo further major resection (n= 1). Histological examination showed the resection margin to be involved in 24 patients and close (< 1 cm) in 20 patients. Results : Two patients died after surgery. Morbidity consisted of intra-abdominal collections (n= 6), postoperative bleeding (n= 1), wound infection (n= 1) and transient liver failure (n= 1). At a median follow-up of 19 months, 16 patients are alive and disease-free, 26 patients developed recurrence and 15 of them died. Nineteen patients developed recurrence which involved the liver but only five of these were at the resection edge. Median overall and liver disease-free survival was 33 and 23 months, respectively. Conclusions : Cryotherapy of the resection edge after resection of colorectal liver metastases with involved or inadequate resection margins considerably improves local disease control and may allow a greater proportion of patients with liver metastases to undergo potentially curative treatment.     

31例肝内复发性肝癌的再切除治疗分析

目的：探讨肝内复发性肝癌的再切除治疗的价值。方法：对1980年至2000年31例肝内复发性肝癌的临床资料、手术方法及预后进行回顾性分析。结果：全组无手术死亡，术后1、3、5年生存率分别为93．5％，69．2％及50．1％，二次切除后的1、3、5年生存率分别为82．1％、32．8％及25．4％，最长一例已无瘤生存12年，而140例未再手术者的5年生存率仅9．3％，其中TACE组及PEI组的5年生存率相似，分别为12．2％及14．8％。结论：再手术切除是治疗肝内复发肝癌最有效的方法，对不能手术者，我们推荐使用PEI术。     

VIDEO-ASSISTED THORACOSCOPIC WEDGE RESECTIONS OF PULMONARY METASTATIC OSTEOSARCOMA: SHOULD IT BE PERFORMED?

We studied the use of video-assisted thoracoscopic (VAT) surgery in the management of metastatic osteosarcoma. From September 1993 to March 1994, we performed a total of 11 VAT wedge resections of pulmonary metastatic osteosarcoma in seven patients (six males, one female, age 12 to 46 years). Three patients had bilateral procedures performed either under the same anaesthesia or in stages. One patient had two operations on the same side. The average number of nodules excised was three. Two patients subsequently required formal lobectomies when the metastatic tumours were either too big or too close to the hilum for safe wedge resections. There was one death on postoperative day 3 due to dysrrhythmia. One patient died 5 months later from a progression of his underlying disease. Two patients remained disease free up to 8 and 12 months, respectively, from their first operations. The average postoperative chest drain duration was 1.4 ± 0.7 days and hospital stay 2.3 ± 1.1 days. The procedure was well tolerated and postoperative morbidity was minimal. We conclude that although VAT wedge resection of pulmonary metastatic osteosarcoma is feasible technically and is associated with a short hospital stay and minimal morbidity, this approach cannot be recommended when complete resection of all metastases is the goal as the technique relies heavily on computed tomographic scans to detect nodules. Recurrence of metastasis from 4 to 6 months in three of seven patients argues against VAT surgery being an adequate procedure. The high cost of the staplers, in addition, is a secondary consideration.     

不同分型的高位胆管癌手术切除方式的选择

１９９１年１月至１９９５年１２月，本院收治高位胆管癌５２例，手术切除１７例，切除率３２．７％。切除组中２例Ｉ型和１例Ⅱ型肿瘤行单纯局部切除，１４例行联合肝叶切除；其中１例Ⅱ型行尾叶切除，１例Ⅱ型和３例ⅢＡ型行肝中叶切除，８例ⅢＢ型行左半肝切除，１例ⅢＡ型行右半肝切除。镜下治愈性切除率为１５．４％（８／５２）。治愈性切除组平均生存期为２１．１月，姑息性切除组则为７．５个月（Ｐ〈０．０５）。切除组手术     

BREAST CANCER OUTCOMES AT THE STRATHFIELD BREAST CENTRE

Background: Breast cancer is the most commonly diagnosed cancer and the most common cause of cancer death in women. This report presents outcomes from a multidisciplinary breast clinic established in 1989 with the specific aim of providing a rapid, integrated assessment service for patients with breast disease. Methods: A prospective data collection and analysis using a Microsoft Access^TM (Microsoft Corp., North Ryde, NSW, Australia) database was established and has collected information on all patients presenting for diagnosis or ongoing management of breast cancer. Data on survival were obtained by routine follow-up visits or contact with the patient'general practitioner. Results: Patient age, mode of presentation and histopathology were similar to other population-based studies in Australia. Ninety-three per cent of the patients had a diagnosis confirmed on the day of consultation. The average time between diagnosis and surgery was 11.9 days. Breast preserving surgery was attempted in 68% and achieved in 50% of cases, 67% of patients had one stage surgery. Five-year disease-free survival was 74% and is comparable with other reports. Conclusions: The centralization of services and expertise has enabled us to provide efficient service and achieve internationally comparable outcomes.     

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.     

LONG TERM FOLLOW-UP OF SURGICAL ADRENALECTOMY FOR BREAST CANCER

A long term follow-up of 300 patients treated by bilateral adrenalectomy for advanced breast cancer is presented. The notable features are the lengthy remissions and survival times which occurred in some patients. This is further evidence of at least two important biological subsets within the general population of breast cancers. Of the responders, 11% were still in remission at four years and 10% were alive at 10 years. Responders also enjoyed a good quality of life. These results are of considerable importance in assessing the relative merits of newer methods of treatment.     

隐性乳癌（附6例报告）

从１９７９年至１９９４年，共收治６例隐性乳癌。其中以有腋下肿块为首发症状５例，以肱骨，椎体转移为首发症状１例，４例行根治术后生存已超过８年、４年３年以上各１例，另１例术后２５个月死于肺转移。１例行改良根治术后２３个月死于脑转移。１例单纯乳房切除术后１６个月死于全身骨和肺转移。     

乳癌根治术后并发臂丛神经损伤

乳癌根治术是治疗乳腺癌的主要手段,但并发臂丛神经损伤的报道却很少,总结从1989年10月～1991年2月华山医院诊治的9例,3例门诊治疗,6例住院治疗。其中5例行神经松解后,皮瓣或肌皮瓣转移覆盖神经瘢痕区。随访到8例,疼痛改善3例,感觉和运动改善2例,疗效不理想,认为寻找预防措施是减少乳癌根治术后臂丛损伤的根本办法。     

乳癌改良胸膜外扩大根治术的应用

１９８６年至１９９４年，作者施行保留胸肌的乳癌改良扩大根治术２８例。作者认为此术式能保持术后较好的廓壁外形和上肢功能，可适用于病灶位于中央和内侧的Ⅱ期，或少数Ⅰ期以及部分Ⅲ期乳癌患者；并强调配合化疗和放疗以提高疗效。     

VALUE OF CEA IN BREAST CANCER*

Plasma carcino-embryonic antigen (CEA) is elevated in a small percentage of patients with early breast cancer and in about 60% of patients when the disease is disseminated beyond regional lymph nodes. It is neither sufficiently sensitive or specific a test to be used for mass screening and is of limited use as a diagnostic aid. Monitoring of patients following mastectomy with serial estimations of plasma CEA is of little value in detecting disease recurrence before it becomes clinically apparent. Monitoring of CEA levels may be helpful in objectively assessing response to treatment in patients with disseminated breast cancer.     

结肠癌根治术的远期疗效

报道我院1964～1989年363例结肠癌根治术后远期效果.全组手术死亡率0.3%.随访率99.2%.术后5、10、15、20、25年生存率分别为74.7%、65.5%、59.0%、49.9%和31.7%.分析了影响手术疗效的各种因素,资料表明结肠癌术后生存率与性别、淋巴结转移、病期和肠腔化疗等有关,其中,淋巴结转移和病期是影响术后生存率的最主要因素.     

HORMONE RECEPTORS IN MALE BREAST CANCER

Hormone receptor assays were performed on specimens of breast cancer from 19 male patients over a six year period. Ninety-four per cent were positive for oestrogen receptor, 93% for progesterone receptor and 57% for androgen receptor. Eight patients had hormonal treatment for advanced disease and five (62.5%) responded. Duration of response ranged from six months to 23 months. There appeared to be no clear relationship between hormone receptor status or quantitative receptor level and response to treatment in this small series. It is unlikely that oestrogen and progesterone receptors will be of value as discriminators because of their high incidence and it is suggested that further study of androgen receptor is indicated.     

MAMMOGRAPHICALLY NEGATIVE BREAST CANCER AT THE STRATHFIELD BREAST CENTRE

Background: The current diagnostic modalities used to detect breast cancer are mammography, together with clinical examination, ultrasound and fine needle aspiration biopsy (FNAB). The accuracy rates for each modality varies and a combination of the modalities is recommended to detect cancer early. Some authors have suggested that mammography should be used primarily as a screening tool because of the false negative mammography results that have been reported in the past 10 years. The records of patients at the Strathfield Breast Centre were reviewed to determine the accuracy of the practice and to compare it with the accuracy of other modalities. Methods: The records of 371 breast cancer patients treated at the Strathfield Breast Centre in the 6 years from 1989 to 1994 were reviewed to determine the accuracy of mammography, ultrasound, clinical examination and fine needle aspiration biopsy. Of the 371 women with histopathologically diagnosed breast cancer, 349 had mammography. Results: The accuracy rate of mammography in the present study was 91% with a false negative rate of 9%. It was found that there was no significant delay in the treatment of breast cancer in mammogram-negative patients. Conclusions: Mammographically negative breast cancer was found to be more common in younger women, to be similar in size to mammogram-positive cancer, to occur in all histological types and grades and was usually invasive rather than noninvasive. The rate of lymph node involvement was similar to the mammogram-positive group.     

BREAST CANCER IN YOUNG WOMEN

Background : It is believed that cancer of the breast is more difficult to diagnose in young women and it has long been disputed whether breast cancer occurring in women aged 40 years is more aggressive than that occurring later in life. A number of reports in the literature suggest that the disease is of similar aggressiveness in the young patients and older age groups, while other reports suggest that it is more aggressive and carries a higher mortality in young women. Methods : To address these aspects of breast cancer we have undertaken a review of the cases treated at The Strathfield Breast Centre between 1989 and 1996 and compared the disease in the young and old groups with particular reference to the modes of diagnosis, the pathological staging and types of tumour and the outcomes of treatment. Results : The accuracy of ultrasound and fine needle aspiration biopsy were similar in both groups, but the false negative rate of mammography in the young patients was 15% or 50% greater than that which was observed in the older patients. The incidence of histopathological type, bilaterality, size of lesion and receptor positivity were the same in both groups. In the young group, 40% had Grade 3 tumours compared with 27% in the older group. Nineteen per cent of young patients had 4 or more lymph nodes involved while only 10% of the older patients had similar lymph node involvement. Overall 5-year survival was 79% in the older patients compared with 90% in the young patients. Conclusions : The spectrum of disease is similar in both the young and older patient and the prognosis is no worse for the young group but mammography is less effective in the diagnosis of the young patient.     

THE ASSESSMENT OF HISTOLOGICAL DIFFERENTIATION IN BREAST CANCER*

Morphological tumour differentiation has been shown in numerous studies to give a good prediction of prognosis in breast cancer. In the Nottingham/Tenovus study, tumour differentiation (histological grade) is assessed as part of a routine analysis of potential prognostic factors. Three features are analysed, the degree of tubule formation, variation in the size and shape of nuclei and mitotic rate. Each feature is given a score of 1–3 and grade is assigned as follows: Grade I, well differentiated, 3–5 points; Grade II, moderately differentiated, 6–7 points; Grade III, poorly differentiated, 8–9 points. Histological grade has been assessed in 625 patients with primary breast carcinoma and there is a strong correlation with prognosis; patients with well differentiated tumours have a significantly better survival than those with poorly differentiated tumours (P < 0.0005). Grade forms an important part of the Nottingham/Tenovus prognostic index together with tumour size and lymph node stage. It is suggested that factors such as these should be used to stratify patients for appropriate therapy.     

COSMESIS FOLLOWING COMPLETE LOCAL EXCISION OF BREAST CANCER

Background : With the establishment of the safety of breast conservation in early breast cancer, cosmesis has become an increasingly important end-point of treatment. The aim of the present study was to establish a model to assess breast cosmesis after complete local excision and to assess cosmesis achieved in patients who had surgery using the seroma technique. Methods : A total of 42 patients were retrospectively reviewed and assessed by independent clinical assessment by a surgeon, structured questionnaire and clinical photography. Results : A total of 86% of patients were rated by surgeon and patient as having a good or excellent cosmetic outcome. There was a high degree of concordance between independent clinical assessment and clinical photographic analysis. Conclusions : A model has been established for the assessment of breast cosmesis; the technique of seroma formation without reconstruction of the defect results in good or excellent cosmesis in the majority of patients.     

METASTATIC CARCINOID TUMOUR: STABILITY THROUGHOUT PREGNANCY

A patient with asymptomatic histologically proven extensive hepatic metastases of carcinoid turnour had no progression of disease for over 4 years without specific treatment. Throughout a normal pregnancy the hepatic metastases remained stable by clinical, computerized tomography and biochemical criteria.     

PCNA IMMUNOSTAINING IN BREAST CANCER

Expression of proliferating cell nuclear antigen (PCNA) has been shown to be of prognostic value in patients with certain types of cancer. The aim of this study was to determine if the abundance of PCNA is inversely correlated with survival of patients with breast cancer. Paraffin blocks were available from 68 patients, all of whom had been followed clinically for at least 5 years. Sections from 20 patients showed no reactivity to PCNA and were excluded from the study because it was not possible to distinguish between true negatives and false negatives (those due to poor fixation of the original specimens). The PCNA index (the number of stained cancer cells as a percentage of the total number of cancer cells present) was calculated for the remaining 48 patients. Results were analysed by Wilcoxon's rank sum test (two tailed) and Pearson's correlation coefficient. There was no statistical difference between the PCNA indices of those patients dead from their disease within 5 years of diagnosis compared with those alive and without signs of breast cancer at 5 years. There was also no correlation between PCNA index and size of the cancer, involvement of axillaly lymph nodes, time to recurrence or time to death. There was, however, a significant correlation between PCNA index and histological grade (P= 0.029). It appears that PCNA staining of stored paraffin sections is of little prognostic value in patients with breast cancer.