Problems in evaluating response of primary breast cancer to systemic therapy

Summary The evaluation of the response of primary breast cancer to systemic therapy is difficult. Evaluable primary lesions may be assessed both by physical and by mammographic examination. In this study, response to therapy was evaluated after 4 cycles of CMF or CMF plus tamoxifen in 49 patients with locally advanced breast cancer entering a prospective randomized trial. In 35 patients response was evaluated by both physical examination and mammography. In some cases there was disagreement between physical examination and mammograhy in quantifying the magnitude of response. In 8 of 35 (22.9%), the overall response was overestimated by physical examination versus mammography, while in 3 of 35 (8.6%) the reverse was true. Taking into consideration different criteria in attributing the overall response, i.e. selecting physical examination only, mammography only, or the most favorable or the least favorable response between the two methods of assessment, the objective remission rates were 65.7%, 54.3%, 71.4% and 45.7%, respectively. The data suggest that both physical examination and mammography should be used in evaluating the response of primary breast cancer to a systemic treatment. Should these two methods yield contrasting results, the data obtained with each method should be reported. The best observed response may be employed in determining the overall response.     

Long-term impact of previous breast biopsy on breast cancer screening modalities

Approximately 80% of breast biopsies are performed for what proves to be a benign process. The patients who undergo these procedures should continue screening with breast physical examination and mammography. The long-term impact of breast biopsy on these screening modalities has not been well studied. We performed a prospective, follow-up evaluation in 63 patients who underwent needle localization biopsy with benign histology at our institution between 6 and 7 years ago. This evaluation consisted of a directed history, breast physical examination, and follow-up mammogram. Two patients (3%) had undergone mastectomy for an interval breast cancer; 17 others (28%) had undergone subsequent biopsies. No patient had changes on physical examination of the biopsy site. All mammograms were evaluated as normal or as having benign abnormalities. Excisional breast biopsy does not generally produce long-term changes affecting the interpretation of breast physical examination or mammography.     

Detection of the first recurrence during intensive follow-up of breast cancer patients

BACKGROUND: Breast cancer patients are routinely followed after primary treatment. Many intensive diagnostic methods (tumor markers, chest X-ray, mammography, liver echography, bone scans) are performed periodically. However, it remains to be determined how often attempts should be made to detect the first recurrence of breast cancer by these methods. METHODS: To evaluate the effect of imaging diagnosis and tumor markers, we analyzed methods of detection of first recurrence sites during intensive follow-up of breast cancer patients. RESULTS: Of 550 female patients who had been surgically treated between July 1992 and December 1996, 65 recurrent cases had been diagnosed as of December 1997. Thirty cases (46%) had been found as a result of symptoms related to the site of recurrence and 14 cases (22%) were detected by physical examination. In the remaining 21 cases (32%), detection was by other methods: in eight cases by imaging diagnosis, in three cases based on abnormal tumor markers and in 10 cases by imaging diagnosis and abnormal tumor markers. Twenty-nine cases (45%) followed every 1-3 months had presented with symptoms at routine or interval appointments. There was a significant difference between first recurrence sites (loco-regional, bone and viscera) and the methods of detection (symptoms, physical examination and other diagnostic methods) (P < 0.0001). However, no statistical difference in overall survival after operation was observed between the 30 cases found as a result of symptoms and the 35 cases detected by physical examination or other diagnostic methods. CONCLUSIONS: Taken together with ASCO's surveillance guidelines (J Clin Oncol 1997;15:2149-56), intensive follow-up of breast cancer patients should be limited to high-risk breast cancer patients, especially those who enter randomized clinical trials. A careful history and physical examination are in practice indicated every 3-6 months for 3 years and then every 6 months for the following 2 years.      

What is the best test to detect prostate cancer?

The data accumulated during screening of these 300 men suggest that the digital rectal examination is the most efficient test for the diagnosis of prostate cancer. This test is universally available, because physicians believe that it should routinely be performed as part of the physical examination of every man, particularly for men over the age of 40. The digital rectal examination provides useful clinical information about the rectum, anal sphincter, and the quality of stool. Its diagnostic accuracy is unexcelled by more recent, complex, and expensive tests. Finally, in this age of escalating medical costs and physician accountability for these costs, you can't beat the price of the digital rectal examination.     

The Correlation Between Clinical Prediagnosis and Pathology Results in the Diagnosis of Neck Masses

The importance of clinical assessment and its contribution to the diagnosis of neck masses was investigated in patients presenting with a neck mass. In our study, we collected the medical history of a total of 127 patients, including 66 males and 61 females, who presented with a neck mass. Physical exams, endoscopic examinations, laboratory tests, a variety of imaging studies, and fine-needle aspiration biopsies were performed. The relationship between age, duration and location of the neck mass, FNAB results, and definitive histopathological diagnosis were investigated as well as the correlation between the consensus diagnosis reached after the evaluation of the medical history, physical examination and imaging studies, and definitive histopathological diagnosis. A strong and positive relationship (p < 0.01) was found between patients’ ages and the definitive diagnosis established by histopathological examination. There was no statistically significant relationship (p > 0.05) between the duration and location of the neck mass and definitive diagnosis established by histopathological examination. And no statistically significant relationship (p > 0.05) was found between FNAB results and definitive histopathological diagnosis. Although no statistically significant relationship was found between the characteristics of neck masses and age, duration and location of masses and FNAB results, there was a statistically significant correlation between the pre-diagnosis estimated by ENT specialists and definitive diagnosis established by histopathological examination. A strong and positive relationship (p < 0.01) was found between clinical pre-diagnosis and definitive diagnosis established by histopathological examination. In patients presenting with a neck mass, the diagnosis should be made based on the medical history, physical examination, radiologic imaging and FNAB results, treatment decisions should be based on those findings.     

The role of galactography in the detection of breast cancer

The authors report on a series of 529 consecutive patients examined on physical examination, mammography, nipple discharge cytology and galactography. The criterion for galactography was essentially bloody nipple discharge (73% of cases). Serous nipple discharge was not considered worthy of routine galactography since it is associated with an extremely low incidence of breast cancer. Surgical excision and histologic examination of the discharging duct was performed in 200 cases. Eighteen cases of breast cancer were detected (10 infiltrating, 8 intraductal) of which 9, 6, 7 or 7 were suspected on physical examination, mammography, cytology or galactography, respectively. All combined tests suspected 13 of 18 breast cancers; 3 intraductal breast cancers were biopsied because of evidence of multiple papillomas on galactography, and 2 infiltrating breast cancers were operated because of persistent bloody nipple discharge in the absence of any other sign. No breast cancer was suspected on galactography alone. Galactography is indicated in the presence of bloody nipple discharge, and a biopsy should be performed when breast cancer or multiple papillomas are suspected. The diagnosis and excision of a single papilloma (breast cancer was never misdiagnosed as a single papilloma on galactography) is not worthwhile since a single papilloma is a benign lesion, and the benefit of its excision is still unclear.     

Evaluation of the thyroid nodule.

BACKGROUND: Thyroid nodules are common, yet treatment modalities range from observation to surgical resection. Because thyroid nodules are frequently found incidentally during routine physical examination or imaging performed for another reason, physicians from a diverse range of specialties encounter thyroid nodules. Clinical decision making depends on proper evaluation of the thyroid nodule. METHODS: The current literature was reviewed and synthesized. RESULTS: Current evidence allows the formulation of recommendations and a general algorithm for evaluating the incidental thyroid nodule. CONCLUSIONS: Only a small percentage of thyroid nodules require surgical management. Diagnosis and treatment selection require a risk stratification by history, physical examination, and ancillary tests. Nodules causing airway compression or those at high risk for carcinoma should prompt evaluation for surgical treatment. In nodules larger than 1 cm, fine-needle aspiration biopsy is central to the evaluation as it is accurate, low risk, and cost effective. Subcentimeter nodules, often found incidentally on imaging obtained for another purpose, can usually be evaluated by ultrasonography. Other laboratory and imaging evaluations have specific and more limited roles. An algorithm for the evaluation of the thyroid nodule is presented.     

Clinical presentation and diagnostic workup for community-acquired pneumonia: the Gulf Corporation Council CAP Working Group consensus statement

Community-acquired pneumonia (CAP) is diagnosed on the basis of a suggestive history and compatible physical findings and new infiltrates on a chest radiograph. No criteria or combination of criteria based on history and physical examination have been found to be gold standard. With the rise in elderly Gulf Cooperation Council (GCC) residents, CAP is likely to present with non-classical manifestations such as somnolence, new anorexia, and confusion and carries a worse outcome than CAP in their younger counterparts. Tuberculosis should be considered in the differential diagnosis of unresolving CAP in the GCC region. Diagnostic work up depends on severity of CAP, clinical course and underlying risk factors.     

Retroperitoneal sarcomas

Retroperitoneal sarcomas comprise a rare, heterogeneous group of neoplasms. Routine workup should include the patient's medical history, a physical examination, and helical CT of the abdomen and pelvis, with selective use of MRI and preoperative tissue sampling. The primary treatment is complete surgical resection with a rim of normal tissue. The role of adjuvant therapy is evolving and at present should not be used outside the investigational setting.     

Diagnostic Ultrasound for Thyroid Tumor: Grey Scale Echography in the Diagnosis of Thyroid Cancer

The diagnostic value of B-mode water immersion scanning of ultrasoundgrey scale echography for the thyroid is evaluated on 112 caseswith palpable thyroid tumors. Differential diagnostic criteriafor the echo-signal distributions, such as the boundary echo,internal echoes and retrotumorous echoes, are proposed and itsclinical significance is assessed in this study. Exact differentiationbetween a solid thyroid tumor and a cystic lesion was easilymade with this technique, whereas it may be possible to differentiatethe thyroid adenoma and carcinoma in fairly good accuracy. Theadvantages of this echography include short examination time.Also there is no known physical hazard to the patient, and theprocedure is comfortable and well tolerated by the patient.This examination should be performed routinely on patients withpalpable thyroid nodular tumors.     

Value of ultrasonography compared with physical examination for the detection of locoregional metastases in patients with cutaneous melanoma

In several studies the early detection of locoregional metastases in patients with cutaneous melanomas has been shown to be of prognostic value. Physical examination alone often fails to detect locoregional metastases or cannot unambiguously classify palpable lymph nodes. This study aimed to evaluate the usefulness of high resolution ultrasonography for the early detection of locoregional metastases and to compare the sensitivity and specificity of ultrasound and physical examination. A prospective study was performed between January 1997 and June 1999 in 1395 patients (721 men and 674 women) with invasive cutaneous melanoma, treated and followed up at the Department of Dermatology and Allergology, Ludwig-Maximilian-University, Munich, Germany. A total of 2650 physical and ultrasound examinations of lymphatic drainage areas were performed, and lesions suspicious for metastases were excised and diagnosed by histopathology. The results of physical and ultrasound examinations were compared. Of the 2650 ultrasound examinations, metastases were suspected in 153, whereas 290 of the 2650 physical examinations were suspicious for metastatic disease. A total of 168 patients with suspicious lesions underwent surgery; histopathological examination revealed 112 melanoma metastases and 56 other diagnoses, including one second malignancy, one neurinoma, one haemangioma and 54 reactive lymph nodes. Ultrasonographic diagnosis of melanoma metastases had a sensitivity of 92.2% and a specificity of 98.2%, whereas diagnosis by physical examination had a sensitivity of only 51.3% and a specificity of 90.9%. Thus ultrasound examination was found to be highly effective and superior to physical examination for the early detection of locoregional melanoma metastases.     

Post-treatment surveillance of breast cancer patients in an organized, multidisciplinary setting

Post-treatment surveillance protocols should include early detection of local, regional, and systemic recurrence, new primary tumors and should address treatment complications and psychosocial needs. In addition to annual mammography, history and physical examination in the treated, asymptomatic breast cancer patient surveillance visits should occur every 3-4 months for 3 years, every 6 months for the next 2 years, and annually thereafter. Scans and other tests should be reserved for high risk or symptomatic patients.     

Perceptions of follow-up care in women with breast cancer

One hundred one patients with breast cancer, 48 localized and 53 metastatic, were questioned about their perceptions of follow-up examinations. Patients with metastatic disease preferred more frequent follow-up. Most indicated that they wanted their physicians to ask them about pain and nutritional status at each follow-up visit and were aware of the tests they had received. Only a third of the patients recognized the value of the history in detecting recurrence, and two-thirds felt that the physical examination was helpful. Laboratory tests and imaging procedures were rated higher than the history in detecting recurrence. Most patients were unaware of the implications of a normal procedure or test and perceived "normal" as meaning an absence of cancer cells in the organ evaluated. Knowledge of the value and limitations of testing was not related to educational level or disease stage. Patients need to be educated about the effectiveness of follow-up examination. Greater emphasis should be placed on the history and physical examination, and the limitations of more costly laboratory and imaging procedures should be explained carefully.     

40例早期乳腺癌的临床X线分析

目的：通过对早期乳腺癌X线征象的认识，提高早期乳腺癌的诊断水平。方法：经手术病理证实的40例早期乳腺癌术前均行临床查体、X线摄片。结果：全组22例表现为肿瘤结节，19例表现簇样钙化，11例表现小灶致密影，7例局部结构紊乱，2例单支导管扩张。结论：早期乳腺癌无论在临床表现、影像学检查均可出现不典型特征，诊断早期乳腺癌除了重视特征性征象如毛刺状结节、簇样钙化外，还应重视小灶致密影、局部结构紊乱、单支导管扩张等间接征象。乳腺X线摄片及临床查体是发现早期乳腺癌的重要手段。     

Guidelines for the assessment of oral mucositis in adult chemotherapy, radiotherapy and haematopoietic stem cell transplant patients

Oral mucositis (OM) is a serious consequence of some chemotherapy and radiotherapy regimens. A number of reliable instruments are available to assess OM, but none are universally accepted. A unique collaboration of multi-disciplinary experts from Europe was formed to make recommendations on OM assessment, based on a systematic literature review and the experts' experience. The main recommendations are listed. There should be a comprehensive baseline assessment. OM should be frequently assessed using a standardised instrument, or a combination of instruments. Physical, functional and subjective changes should be measured. Subjective measures should be assessed prior to any physical examination. The use of pain scoring, in particular patient self-reporting, should form part of any OM assessment. Any assessment instrument should be validated, easy to use and comfortable for the patient. Training of, and monitoring in, the use of the instrument is vital to successful monitoring of OM.     

New approaches to the imaging,diagnosis, and biopsy of breast lesions

Currently, breast cancer is detected and diagnosed by a combination of physical examination, imaging, and biopsy. Particularly for younger women, the limitations of these methods can cause a cancerous lesion to go undetected because neither physical examination nor imaging are infallible, and neither can promise the early detection of all breast cancers. Dense breasts make physical examination, mammography, and ultrasound less sensitive. Breast screening of all types generates over a million breast biopsies in the U.S. alone. This article reviews how to optimize the approach to breast biopsy using available methods to minimize the number of procedures a woman experiences, and describes tools in development that will hopefully improve our ability to diagnose and treat breast cancer.     

Metastatic cancer of unknown primary site

The history, physical examination, radiographic and laboratory studies and histological diagnosis must be completely evaluated to search for the primary tumor. For diagnosis of cervical lymph node metastasis, not only whole body examination but also head and neck examination is important in which quadrascopy (nasopharyngeal, laryngeal and esophageal fiberoscopy and bronchoscopy) must be performed. If the localized lymph node metastasis of unknown primary site (TxNl-3MO); especially neck node, is presented, radiotherapy has an important role in cure. Patients with metastatic cancer of unknown primary site should be considered for early diagnosis and aggressive therapy.     

The value of routine physical examination in the follow up of women with a history of early breast cancer

Purpose

Routine physical examination is recommended in follow up guidelines for women with a history of breast cancer. The objective of this paper is to assess the contribution of routine physical examination in addition to mammography in the early diagnosis of breast cancer recurrences.

Patients and methods

The medical follow-up documents of 669 patients were reviewed. 127 contra-lateral breast cancers (CBCs) and 58 loco-regional recurrences (LRRs) in 163 patients were included. The additional contribution of routine physical examination over mammography was evaluated with the proportions of CBCs or LRRs detected by physical examination alone. χ² tests were used to compare the difference of contribution of physical examination among subgroups.

Results

Seven (6%) out of 127 CBCs and 13 (22%) out of 58 LRRs were detected by routine physical examination alone. Six LRRs (17%; 6/35) were in patients after breast conserving surgery and seven LRRs (30%; 7/23) in patients after mastectomy. There was a trend that the contribution of physical examination is higher in women under 60 years of age in the detection of CBCs (9%; 5/57) and LRRs (28%, 8/29) than in women over 60 years of age (CBCs:3%; 2/70 and LRRs:17%, 5/29; χ² = 3.090, P = 0.079).

Conclusions

Twenty-two percent of loco regional breast cancer recurrences would have been detected later without physical examination. Routine physical examination may be most valuable for women with a history of breast cancer younger than 60 years at follow-up visit.     

Triple approach in the diagnosis of dominant breast masses: Combined physical examination,mammography, and fine-needle aspiration

In an attempt to reduce the number of breast biopsies done for benign breast disease in patients with breast lumps, we evaluated prospectively the sensitivity and specificity of the combination of three diagnostic modalities: clinical examination, mammography, and fine-needle aspiration cytologic examination (FNA). A total of 234 patients with a breast mass had a physical examination, a mammogram, and FNA, and were listed as malignant/suspicious or benign. All patients underwent a subsequent biopsy: 110 were found to have breast cancer, and 124 had a benign lesion. The sensitivity and specificity of the individual tests were as follows: 89% and 73%, respectively, for mammographic examination; 93% and 97% for FNA cytologic examination; and 89% and 60% for physical examination. For the combined triad of tests, the sensitivity was 100% and specificity 57%. All patients who had breast cancer had positive findings for malignancy in one or more of the diagnostic tests, i. e., 100% sensitively. All patients who had negative findings for malignancy in all three diagnostic tests had benign lesions, i. e., a negative predictive value of 100%. We conclude that breast masses can be diagnosed with a high degree of accuracy by combined physical, mammographic, and fine-needle aspiration cytologic examination. Patients in whom physical examination, mammography, and FNA were negative for malignancy can be safely observed, obviating the need for an open biopsy. © 1994 Wiley-Liss, Inc.