Surgical anatomy of the common iliac veins during para-aortic and pelvic lymphadenectomy for gynecologic cancer

Objective

Compression of the left common iliac vein between the right common iliac artery and the vertebrae is known to be associated with the occurrence of left iliofemoral deep vein thrombosis (DVT). In this study, we described the variability in vascular anatomy of the common iliac veins and evaluated the relationship between the degree of iliac vein compression and the presence of DVT using the data from surgeries for gynecologic cancer.

Methods

The anatomical variations and the degrees of iliac vein compression were determined in 119 patients who underwent systematic para-aortic and pelvic lymphadenectomy during surgery for primary gynecologic cancer. Their medical records were reviewed with respect to patient-, disease-, and surgery-related data.

Results

The degrees of common iliac vein compression were classified into three grades: grade A (n=28, 23.5%), with a calculated percentage of 0%-25% compression; grade B (n=47, 39.5%), with a calculated percentage of 26%-50% compression; and grade C (n=44, 37%), with a calculated percentage of more than 50% compression. Seven patients (5.9%) had common iliac veins with anomalous anatomies; three were divided into small caliber vessels, two with a flattened structure, and two had double inferior vena cavae. The presence of DVT was associated with the elevated D-dimer levels but not with the degree of iliac vein compression in this series.

Conclusion

Although severe compression of the common iliac veins was frequently observed, the degree of compression might not be associated with DVT in surgical patients with gynecologic cancer. Anomalous anatomies of common iliac veins should be considered during systematic para-aortic and pelvic lymphadenectomy in the gynecologic cancer patients.     

Improved liquid cholesterol ester crystal thermography of the breast

The infrared detection apparatus used in breast thermography is relatively costly and therefore is not widely available to less populated areas in the country. The use of liquid cholesterol crystals, applied to the breast (applied over a water-base black dye) has already been described in the literature as an effective substitute for infrared instrument thermography. This method, however, has been hampered by the time and troublesome effort necessary for removal of the substances upon completion of the study. The object of this study was to devise a feasible method of cutaneous breast thermography using liquid cholesterol esters, as in prior studies, but by applying them to an easily removable black base. As a result the length of the examination has been shortened, and patients have found the examination to be aesthetically more acceptable. With this improved method, liquid crystal thermography of the breast (and other areas) should become more widely applicable.     

中心体相关激酶Nek2与乳腺癌前病变及早期癌变的相关性研究

目的:探讨中心体相关蛋白激酶Nek2蛋白及DNA水平在乳腺上皮恶变过程中各阶段的作用。方法:选取正常乳腺组织20例、重度不典型导管上皮增生/外周型乳头状瘤病伴导管上皮不典型增生20例、导管内癌20例,浸润性导管癌20例。采用免疫组织化学的方法分别检测4组样本组织冻切片Nek2蛋白的表达情况,采用荧光实时定量聚合酶链式反应检测4组样本组织Nek2拷贝数扩增情况。结果:Nek2蛋白表达在4组样本之间差异性显著(P=0.000)。荧光实时定量PCR结果显示Nek2的DNA拷贝数在各组之间的表达有统计学差异(P=0.000)。Nek2蛋白表达随着肿瘤恶性程度的提高而增加,同时DNA拷贝数随着肿瘤恶性程度的提高而扩增,二者存在正相关性(r=0.887,P<0.01)。结论:Nek2蛋白表达在导管内癌组显著高于癌前病变组,说明Nek2蛋白表达免疫组化检测结果可作为乳腺癌早期诊断和高危人群筛选的辅助指标。Nek2基因扩增同蛋白表达呈正相关性,变化趋势一致,提示蛋白过表达可能来自于基因扩增。Nek2异常同中心体异常变化趋势一致,作为中心体相关激酶,通过对中心体的调节作用,可造成中心体数量、结构和功能的异常,从而导致肿瘤的发生。     

The impact of bilateral breast cancer on the prognosis of breast cancer: a comparative study with unilateral breast cancer

BACKGROUND: The clinical significance of bilateral breast cancer is unclear and its influence on prognosis is controversial. We assessed the impact of synchronous and metachronous bilateral breast cancer on the prognosis compared with unilateral breast cancer. METHODS: Between January 1, 1960 and December 31, 2001, 1,214 women were treated for primary operable breast cancers. Thirteen (1.1%) had synchronous bilateral breast cancer; 33 (2.7%) had a metachronous contralateral breast cancer. We compared age at operation, menopausal status, clinical stage, tumor size and histology, lymph node status, hormone receptor status, and use of adjuvant chemotherapy or hormone therapy, and we analyzed the impact of these factors on recurrence and survival in the 46 patients with bilateral breast cancer and the 1,168 patients with unilateral breast cancer. RESULTS: The 5-and 10-year disease-free survival rates, respectively, were 65% and 65% in metachronous cases, 85.7% and 64.3% in synchronous cases, and 77.9% and 72.1% in unilateral cases. There was no significant difference in overall survival among the three groups. On multivariate analysis, metachronous bilaterality, tumor size, lymph node status and adjuvant hormone therapy were each independent risk factors for recurrence, whereas bilaterality of breast cancer did not influence overall survival. CONCLUSIONS: Our data suggest that metachronous bilateral breast cancer is associated with shorter disease-free survival than synchronous bilateral or unilateral breast cancer, although overall survival does not differ among the 3 groups. Patients with metachronous bilateral breast cancer should be followed particularly closely in order to detect recurrence early and maximize quality of life.     

The value of ultrasound in the assessment of incompetent perforating veins

To determine the value of ultrasound in identifying significant perforator disease we assessed 121 perforators in 90 legs of 61 consecutive patients referred for assessment of varicose veins over a 6 month period. Perforators greater than 4 mm in diameter demonstrated reflux in approximately 60% of cases, perforators 3-4 mm in diameter demonstrated reflux in approximately 45% and perforators less than 3 mm in diameter demonstrated reflux in approximately 25% of cases. From correlation with previous published data we recommend that all perforators greater than 4 mm in diameter be considered incompetent regardless of whether reflux is demonstrated.     

乳腺原发性印戒细胞癌与乳腺黏液腺癌分子指标及预后的比较

目的 比较乳腺原发性印戒细胞癌与乳腺黏液腺癌的分子特点及预后.方法 对6例乳腺原发性印戒细胞癌患者和25例乳腺黏液腺癌患者的临床病理资料进行回顾性分析,比较其分子分型特点及生存情况.结果 乳腺原发性印戒细胞癌与乳腺黏液腺癌患者在发病年龄、肿瘤大小、TNM分期、雌激素受体(ER)、孕激素受体(PR)、人表皮生长因子受体2(HER2)表达及分子分型方面,差异均无统计学意义(P≥0.05);在淋巴结转移、Ki-67表达方面,差异有统计学意义(P﹤0.05).乳腺原发性印戒细胞癌与乳腺黏液腺癌患者的5年无病生存率分别为66.7%、80.0%.结论 乳腺原发性印戒细胞癌比乳腺黏液腺癌更具侵袭性,淋巴结转移率高,Ki-67表达水平高,预后差.     

The efficacy of breast MRI in predicting breast conservation therapy

BACKGROUND: Breast conservation therapy (BCT) has equal efficacy compared to mastectomy in treating breast cancer. Accurate pre-operative measurement of tumor size can limit re-excision procedures. Breast MRI may improve pre-operative evaluation of extent of disease. OBJECTIVE: To examine the correlation of extent of disease on breast MRI with pathologic data to determine the utility of breast MRI in surgical planning of BCT. METHODS: We retrospectively reviewed our prospective database of women undergoing breast MRI. We identified 115 women with breast cancer who underwent a breast MRI and a surgical resection from 2000 to 2003. We compared patients with high-grade tumors (HG, n = 40) to patients with low grade (LG, n = 75). RESULTS: The size of the tumor on MRI correlated with the pathologic size for HG tumors (HG R = 0.76 vs. LG R = 0.45, P = 0.033). Mastectomy was performed in 53 patients. In 10 patients with LG tumors, the MRI findings overestimated their disease. In 11 out of 115 patients the primary tumor or a second tumor was only seen by MRI. CONCLUSION: Breast MRI does change surgical management by detecting additional malignancies. Breast MRI is accurate in staging extent of disease in the breast in patients with HG tumors.     

Medullary carcinoma of the breast. Prevalence and prognostic importance of classical risk factors in breast cancer

In an earlier study of 235 breast cancers with medullary features, we concluded from a multivariate Cox regression analysis that only four histopathological features contained significantly positive prognostic information. In the present study, continuing our work on the same population base, we used these histological characteristics (predominantly syncytial growth pattern, no tubular component, diffuse stromal infiltration with mononuclear cells and sparse necrosis (< 25%), as diagnostic criteria for medullary carcinoma of the breast (MC). We found a significantly better prognosis for patients with MC than those with non-medullary carcinoma (NMC) or infiltrating ductal carcinoma (IDC). All tumours in the MC group were grade II or III (96% grade III). A significantly different distribution of general risk factors such as lymph node status, invasion, steroid receptor status, and menopausal status, was found between the group of MC and the control group of IDC grades II + III. Further, general risk factors, which are found to be of major prognostic importance in IDC, had little prognostic impact in MC. We found MC to be biologically unique, and patients with MC have a better than average prognosis compared to that of IDC. We propose a new histological definition of MC, but stress that prospective studies have to be performed.     

Trends in the management of breast cancer

Responses of general surgeons to a questionnaire on breast cancer were analyzed to determine the current trends in the management of this disease. A 21-item questionnaire was mailed to members of the New Jersey Chapter of the American College of Surgeons in 1982 and the responses, received on noncoded, anonymous answer sheets, were analyzed for frequency distribution. These responses were compared to previously recorded responses to the same questions for 1971 and 1977. Seventy-six percent of the respondents in 1982 performed needle aspirations often or always, compared to 36% in 1971 and 80% in 1977. The use of routine mammography has increased from 16% in 1971 and 20% in 1977 to 38% in 1982. Modified radical mastectomy is now the most common type of procedure employed in the management of stage I breast cancer, with 89% of respondents in favor of this approach compared to 15% in 1971 and 60% in 1977. Fifty-nine percent of the respondents are not opposed to breast reconstruction following mastectomy versus 14% in 1971 and 49% in 1977. For patients with axillary nodes, chemotherapy with multiple agents was recommended by 76% of general surgeons in 1982, compared to 58% in 1977. These results indicate a continuing trend towards increasing use of needle aspiration and routine mammography for diagnosis and for employment of chemotherapy with multiple agents in the adjuvant treatment of patients with positive axillary nodes. Furthermore, modified radical mastectomy is the operation of choice for stage I cancer of the breast for increasing numbers of surgeons.     

The luteal heat cycle of the breast in disease

Wearing a special thermometric brassiere, selected women self-measured their breast surface temperature. These measurements were made during one hour each evening at home for one menstrual cycle under standard conditions of overclothing and room temperature. To stage their cycle they also collected daily samples of saliva in their freezer for immuno-assay of progesterone concentration in the laboratory. A total of 82 women participated, most having young families. This total included four groups, a control group (N = 25) and three disease groups, namely: family history of breast cancer (14); benign breast disease (12); and a cancer-associated group (31) who had had previous cancer surgery. A significant breast temperature rhythm with a period at or about 28 days was found not only in the controls but also in the three groups of breasts designated disease. Nevertheless, consistent rhythm abnormalities were found in all the disease groups. Most evident was a hyperthermia throughout the cycle, a reduction in the rhythm amplitude, and a tendency for the breast temperature rhythm to be manifest 1–2 days earlier in the menstrual cycle.These data have been presented to the President Clinton's Cancer Panel's Special Commission on Breast Cancer, Miami, March 1993     

女性乳腺导管的铸型解剖学初步研究

目的应用乳腺导管系统铸型技术研究女性乳腺导管系统的解剖结构。方法对11例成年女性乳房铸型标本进行观察和测量。结果整个乳腺导管系统呈树状分支,分布均匀,上下级导管管径过渡平缓,于分叉处管径略膨大。以输乳管为第1级,多见14级分支,最多可达19级分支。分支类型以2分支型为主,最多可见6分支型。分支导管与上一级导管主轴延长线的夹角〈90°的占96．4％（106／110）,其中夹角介于40°～70°之间的占81．8％（90／110）。导管分支间未见吻合现象。4—6级乳腺导管的管径均值依次为（7．3±0．6）×10-1、（6．1±0．7）×10-1及（4．3±0．7）×10-1mm。经扫描电镜观察发现末梢小导管管壁光滑,多呈盲管状,大部分腺泡萎缩、消失,但仍有部分末端小导管与腺泡相连。每个腺泡均呈小囊状,表面较光滑。结论乳腺导管系统铸型技术为临床上安全使用纤维乳管镜提供了客观数据,并为乳头溢液的发生提供了解剖学依据。     

Prospective analysis of the long-term effect of teaching breast self-examination and breast awareness

Breast cancer is the most common cancer in women in the industrialized world and a leading cause of death. Breast self-examination (BSE) is one of the methods for an early detection of breast cancer. In the present study the effectiveness of a campaign promoting BSE and breast awareness was analysed. Seminars were conducted in 2003 in Lower Saxony, Germany by a female gynaecologist and a social pedagogue and included a lecture, an individual training in BSE in a separate room and a talk about the importance of regular BSEs. Questionnaires were handed out immediately after the seminar and were sent by post 1 year later. Attendance of the seminar resulted in a significantly higher percentage of monthly BSEs (21.4% before vs. 61.9% after the teaching). Furthermore, 92.1% of the women who did not perform a monthly BSE stated that at least they examined their breasts more frequently after attending the seminar. The data demonstrate that the seminars in BSE had profound effects on the compliance of women in carrying out BSE regularly and correctly, without influence of age or education.     

乳腺密度与乳腺癌保乳术后局部复发的关系探讨

目的:探讨乳腺密度与乳腺癌保乳术后局部复发的关系。方法:收集2005年6月至2010年6月于我院肿瘤外科治疗的女性乳腺癌患者210例。所有患者均进行乳腺密度检测,对乳腺癌保乳手术后局部复发的危险因素进行单因素和多因素分析。结果:单因素分析结果显示局部复发与年龄、肿瘤直径、有腋窝淋巴结、术后放疗、乳腺百分比密度有关。多因素分析结果显示,术后放疗、乳腺密度是乳腺癌保乳手术术后局部复发的独立危险因素。结论:乳腺癌保乳术后局部复发与术后放疗、乳腺密度密切相关,但其复发的生物学机制尚需进一步研究。     

The influence of cosmetic breast augmentation on the stage distribution and prognosis of women subsequently diagnosed with breast cancer

This study aimed to determine whether cosmetic breast implants impair the early detection of breast cancer, and adversely influence survival. This analysis derives from a cohort of 24,558 women who received bilateral cosmetic breast implants, and 15,893 women who underwent other plastic surgery procedures at the same practices in Ontario and Quebec, Canada, between 1974 and 1989. Incident cancers and vital status through 1997 were determined by record linkage to the Canadian Cancer Registry and Canadian Mortality Database. Analyses are based on a total of 182 and 202 incident cases of breast cancer identified among the implant and control groups, respectively. Contingency table analyses were performed to test for differences in the stage distribution of breast cancers between the 2 groups. Potential differences in survival were evaluated using the Kaplan–Meier estimates and Cox proportional hazards models. Women who received breast implants were more likely to have advanced stage breast carcinoma relative to the other plastic surgery patients (crude and adjusted ps ≤ 0.01). No statistically significant differences in distributions between the implant and control patients were found for age at diagnosis, tumor size, histological type, period of diagnosis or length of follow‐up. The delayed diagnosis in augmented women did not appear to influence the overall prognosis. Breast cancer‐specific survival was similar in both groups (hazard ratio = 1.06; 95% confidence interval = 0.65–1.74). In conclusion, this study suggests that breast implants delay the detection of breast cancer, but there was no statistically significant difference in survival between the breast implant and other plastic surgery groups.     

Carcinoma of the axillary breast

A review of the world literature regarding carcinoma of ectopic breast tissue along with the addition of one cases is reported. A total of 90 cases of carcinoma of ectopic breast tissue were found, 64 of which occurred in the axilla. The combined survival beyond the 4-year post-treatment period was 9.4%. No survival advantage was found for radical or modified radical mastectomy over that of local excision combined with axillary dissection or radiation. The addition of radiation therapy to either type of mastectomy provided no additional benefit. The correct preoperative diagnosis was rarely made. Outcome was reported in 42 cases; 28 survived longer than 1 year, with 12 recurrences at the time of reporting, and 6 were alive with no evidence of disease at 4 years or longer. Improved prognosis requires diagnostic suspicion and early biopsy of unidentified lesions of the axilla or embryonic milk line.     

乳腺癌分子靶向治疗与生物化疗

乳腺癌的治疗,继手术、放疗和化疗三大传统模式之后,生物治疗已被公认为治疗恶性肿瘤的第四大模式;分子靶向治疗药物的出现和在临床的广泛应用,使得生物治疗在肿瘤的综合治疗中发挥了日渐重要的作用.生物治疗与化疗的结合,提出了恶性肿瘤的治疗的新概念-生物化疗的概念.     

早期乳腺癌保乳术后的放疗时机

早期乳腺癌保留乳房手术加放疗的疗效与根治术相同。对术后放疗时机的问题有一些回顾性和随机性研究,但无明确结论,近期的一些随机研究尚需要长期随访。总的来说,对于无需术后化疗的病人应尽早放疗,建议手术放疗间隔最好不超过8周。术后放疗、化疗顺序对疗效无显著影响,先放疗或先化疗均可以。对于腋窝淋巴结转移数较多的远地转移高危病人,术后可先做辅助化疗,但放疗不应延迟到术后7个月以后。如果手术切缘阳性,放疗应尽早开始。同步放化疗可以在不延迟放化疗的基础上提高局部疗效,但疗效提高有限,同时会增加急性和晚期毒副作用,不宜作为常规治疗。特殊病人需要使用时,应选择有效低毒的化疗方案,以降低治疗带来的急性毒副作用和晚期并发症。缩短放疗总时间对需要化疗的病人可以缩短手术到化疗的时间间隔,目前可行的方式有大分割放疗和乳腺瘤床同步补量技术。缩短放疗总时间是否能对疗效改善有影响,有待于临床资料证实。     

The impact of breast reconstruction on the delivery of chemotherapy

BACKGROUND:

The purpose of this study was to evaluate the impact of postmastectomy breast reconstruction on the timing of chemotherapy.

METHODS:

The authors included stage I‐III breast cancer patients from 8 National Comprehensive Cancer Network institutions for whom guidelines recommended chemotherapy. Surgery type was categorized as breast‐conserving surgery (BCS), mastectomy alone, mastectomy with immediate reconstruction (M + IR), or mastectomy with delayed reconstruction (M + DR). A Cox regression analysis was used to assess the association between surgery type and timing of chemotherapy initiation.

RESULTS:

Of the 3643 patients, only 5.1% received it ≥8 weeks from surgery. In the multivariate analysis, higher stage, Caucasian and Hispanic race/ethnicity, lower body mass index, and absence of comorbid conditions were all significantly associated with earlier time to chemotherapy. There was also significant interaction among age, surgery, and chemotherapy delivery. Among women <60, time to chemotherapy was shorter for all surgery types compared with M + IR (statistical significant for all surgery types in the youngest age group and for BCS in women 40 to <50 years old). In contrast, among women ≥60, time to chemotherapy was shorter among women receiving M + IR or M + DR compared with those undergoing BCS or mastectomy alone, a difference that was statistically significant for the M + IR versus BCS comparison.

CONCLUSIONS:

Immediate postmastectomy breast reconstruction does not appear to lead to omission of chemotherapy, but it is associated with a modest, but statistically significant, delay in initiating treatment. For most, it is unlikely that this delay has any clinical significance. Cancer 2010. © 2010 American Cancer Society.     

早期乳腺癌患者术后放化疗后不同基因分型的预后分析

目的:评估早期乳腺癌患者术后不同基因分型放疗后的预后分析。方法:搜集我院2003年-2009年210例早期乳腺癌患者(TNM分期中II期患者,淋巴结转移数目3个以上和/或肿块直径大于5cm),回顾性分析其免疫组化信息及临床病理学资料,210例病人均进行了术后放疗,中位随访59个月(7-132个月),针对不同分型(luminal A、luminal B、HER-2和basal)分析疾病复发(disease recurrences,DR),局部和远处转移以及对侧乳腺癌(contralateral breast cancer,CBC)的发生。所有资料均用SPSS 17.0软件进行分析。结果:中位随访59个月,90%(189/210)病人存活。8年OS和DSS分别为94%(197/210)和96%(201/210)。DR发生率(P=0.004)和CBC发生率(P=0.003)在四种分型中具有统计学意义。HER-2和基底细胞型比luminal A和B型病人更容易复发(P<0.05),而基底细胞型比非基底细胞型更容易发生对侧乳腺癌(P<0.01)。结论:HER-2阳性型和基底细胞型比导管A型和导管B型更容易复发,而基底细胞型乳腺癌更容易发生对侧乳腺癌,基底细胞型预测对侧乳腺癌转移情况具有重要的意义。     

The relationship between holding back from communicating about breast concerns and anxiety in the year following breast biopsy

Purpose: Evidence suggests open communication about breast cancer concerns promotes psychological adjustment, while holding back can lead to negative outcomes. Little is known about the relationship between communication and distress following breast biopsy. Design/ Sample: Women (N = 128) were assessed at the time of breast biopsy and again one week and three, six, and 12 months post-result. Methods: Linear mixed modeling examined relationships between holding back and anxiety for women with benign results (n = 94) or DCIS/invasive disease (n = 34) following breast biopsy. Findings: Anxiety increased among women with a benign result engaging in high but not low or average levels of holding back. Holding back was positively associated with anxiety post-result in breast cancer survivors, with anxiety decreasing over time. Conclusions/ Implications: Interventions to enhance communication are warranted, and knowledge of the differences among women with benign results and/or DCIS/invasive disease may allow for the development of tailored interventions.