Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy

BACKGROUND: The objective of the study was to evaluate the feasibility of radio-guided occult lesion localization (ROLL) in breast-conserving surgery for nonpalpable breast cancer. METHODS: Altogether 215 breast cancer patients were included in a prospective study. Ultrasonographically guided intratumoral injection of radioactive tracer was used for tumor localization in 64 patients with nonpalpable tumors, visible in breast ultrasonography (the ROLL group). Nonpalpable tumors, visible only in mammography, were localized with a help of a guidewire in 14 patients (the WGR group). The remaining 137 patients had palpable tumors. RESULTS: The proportion of specimens with close or involved margins (0 to 3 mm) was the same in the ROLL group (6%) and among cases with palpable tumors (5%). In addition the median length of the closest margin did not differ significantly between the groups. CONCLUSIONS: The results of ROLL for nonpalpable breast cancer are comparable with those for resection of palpable tumors.     

Comparison of functional outcomes of Duhamel and transanal endorectal coloanal anastomosis for Hirschsprung's disease

Purpose

The aim of this study was to determine the morbidity and medium-term functional outcome of the Duhamel operation and laparotomy and transanal endorectal coloanal anastomosis (TECA) for Hirschsprung’s disease (HSCR).

Methods

The study populations were 34 consecutive children who underwent the Duhamel operation (or Lester Martin modification) and 37 who had the TECA. Demographic details were obtained by case note review, and functional outcome was determined by a combination of outpatient interview, questionnaire, and telephone enquiry.

Results

There was no difference between the groups with respect to age, gender, and length of aganglionic segment. Seventy percent presented as neonates (Duhamel, 24 of 34; TECA, 26 of 37). A single-stage primary pull-through was performed in 17 of 37 children in the TECA group, and in 1 of 34 from the Duhamel group. There was a single perioperative death in the Duhamel group and an unrelated, late death in the TECA group. Postoperative enterocolitis was seen in 13 of 37 TECA children and in a single child from the Duhamel group. A stricture of the pull-through segment was seen in 7 of 37 children after TECA and required temporary diversion in 2 of 9. Late division of a rectal spur was required in 6 of 33 Duhamel children. Requirement for late myectomy was the same in both groups (Duhamel 3 of 33, TECA 4 of 37). Complications requiring stoma formation occurred in 5 of 37 after TECA and 2 of 33 after the Duhamel operation. Two children from the TECA group and 1 from the Duhamel group remain diverted. One child from each group required a re-pull-through procedure. Two patients were lost to follow-up in the TECA group, leaving 34 children in this group and 33 in the Duhamel group in whom functional outcome could be assessed. Functional outcome was similar in the 2 groups.

Conclusions

TECA and Duhamel procedures have similar medium-term functional outcomes. TECA has a high incidence of postoperative enterocolitis and transient stricture formation but is suitable for single-stage neonatal treatment of HSCR.     

Accuracy of axillary staging using sentinel node biopsy or diagnostic axillary lymph node dissection--a case-control study

We aimed to compare the accuracy of axillary staging in breast cancer between sentinel node biopsy (SNB) and axillary lymph node dissection (ALND). The prevalence of axillary metastases was studied in 166 breast cancer patients with SNB and pair-matched control patients with ALND. The matching factors included age of the patient and grade, histological type and histological size of the tumour. There were 37% of patients with axillary metastases in the SNB group and 31% in the ALND group. Altogether, 57 pairs were discordant in relation to axillary metastases. In 34 discordant pairs the SNB patient and in 23 the ALND patient had axillary metastases, p=ns. Among the 36 discordant pairs with invasive ductal carcinoma (IDC), axillary metastases were detected as often in the SNB and the ALND patients. In the 21 discordant pairs with other histological types, the SNB patient had axillary metastases in 16 pairs and the ALND patient in 5 pairs, p<0.03. SNB seems to be as accurate a method for axillary staging as ALND. However, SNB generated no upstaging effect in IDC, only in other histological tumour types.     

A structured educational model to improve pressure ulcer prevention knowledge in veterans with spinal cord dysfunction

OBJECTIVE: This paper describes an educational model for increasing and retaining the knowledge of pressure ulcer prevention and management in veterans with spinal cord injury (SCI) or multiple sclerosis (MS) who have had surgical repair of a pressure ulcer. It also describes the correlates of pressure ulcer knowledge at admission and discharge. METHODS: Before pressure ulcer surgery, 41 male veterans with SCI or MS were randomized to either an intervention group or a control group. A pressure ulcer prevention knowledge test was administered before surgery and at discharge from the hospital, as well as at 3, 6, 12, and 24 months after discharge for the intervention group and at the end of participation for the control group. Other measures obtained at admission included health locus of control and health beliefs. Near the end of their hospital stay, participants of the intervention group received 4 hours of structured, individualized education on the prevention of pressure ulcers while participants of the control group received standard education. RESULTS: Results indicated that participants in the intervention group gained more knowledge during hospitalization than did those in the control group. Lower admission knowledge scores were related to the "chance" dimension of locus of control, nonbelief that an ulcer would interfere "a lot" in one's life, and nonbelief that daily skin checks make "a lot" of difference in whether one gets an ulcer. Lower discharge knowledge scores were related to older age, older age at onset, a greater number of previous pressure ulcer surgeries, and nonbelief that daily skin checks make "a lot" of difference in whether one gets an ulcer. Both groups retained most of their discharge knowledge up to 24 months postdischarge or to discontinuation because of recurrence. CONCLUSIONS: Enhanced, individualized education about pressure ulcer prevention and management was effective in improving pressure ulcer knowledge during hospitalization for surgical repair of a pressure ulcer. The effect of the intervention on recurrence of pressure ulcers will be addressed in future reports.     

Endoscopic follow-up in esophageal atresia-for how long is it necessary?

Purpose: The aim of this study was to find out how long it is necessary to follow-up esophageal atresia patients endoscopically to prevent irreversible mucosal changes. Methods: Seventy-four of 79 long-term survivors with esophageal atresia and primary anastomosis underwent a total of 322 esophagogastroduodenoscopies during a follow-up period of 0.5 to 19 years (mean, 10.3) after the primary operation. For analysis, the biopsy findings were divided into 2 groups: good, histologically normal or only mildly inflamed mucosa; unfavorable, moderate or severe esophagitis or gastric metaplasia. Fundoplication irrespective of indications was considered unfavorable. The results were analyzed using actuarial survival analysis; the changing point was when a [ldquo ]good[rdquo ] turned into [ldquo ]unfavorable.[rdquo ] Results: Forty-five patients (61%) remained in the [ldquo ]good[rdquo ] group throughout the study period; 15 of those (20%) had completely normal findings. Nine patients (12%) had moderate, one (1%) had severe esophagitis, and 13 patients (18%) had gastric metaplasia. Fundoplication was performed on 21 patients (28%). Conclusions: About 40% of esophageal atresia patients eventually have significant esophageal mucosal pathology or need to have a fundoplication. The majority of these changes appear before the age of 3 years. Routine endoscopic follow-up of esophageal atresia patients is recommended at least to the age of 3 years. J Pediatr Surg 38:702-704. [copy ] 2003 Elsevier Inc. All rights reserved.     

Alternating mitomycin C and BCG instillations versus BCG alone in treatment of carcinoma in situ of the urinary bladder: a nordic study

OBJECTIVES: To evaluate whether, in patients with carcinoma in situ (CIS) of the urinary bladder, alternating instillation therapy with mitomycin C (MMC) and bacillus Calmette-Guerin (BCG) was more effective and less toxic than conventional BCG monotherapy. METHODS: Patients were stratified prospectively for primary, secondary, and concomitant CIS and randomized to one of two regimens. Patients in the alternating group received six weekly intravesical instillations of MMC 40 mg, followed by alternating monthly instillations of BCG 120 mg and MMC for one year. In the monotherapy group, only BCG was instilled on the same schedule. RESULTS: Of 323 enrolled patients, 304 were eligible for analysis. After an overall median follow-up of 56 months, the Kaplan-Meier disease-free estimate for BCG monotherapy was significantly better than that for alternating therapy (p=0.03; log rank test). Risk for progression appeared lower in the BCG monotherapy group (p=0.07), but no differences existed in survival. Besides the regimen, CIS category also predicted outcome to some extent. BCG monotherapy caused significantly more local side-effects and premature cessation of instillation treatment than did the alternating therapy. However, no differences were observed in the number of serious side-effects. CONCLUSION: One-year BCG monotherapy was more effective than the alternating therapy for reducing recurrence and compared well with the best regimens reported from substantially smaller series. The alternating therapy was better tolerated.     

Nasal symptoms among residents in moldy housing

OBJECTIVES: The aim of this study was to determine whether mold allergy mediated through immunoglobulin E (IgE) was responsible for the chronic nasal symptoms experienced by residents of moldy dwellings. A secondary aim was to investigate whether nasal mucosal findings were a possible reflection of other pathological mechanisms of chronic rhinitis. METHODS: Sixteen adults living in moldy housing and complaining of chronic rhinitis were compared with sixteen healthy referents without any known mold exposure. All the buildings were surveyed for visible signs of moisture and mold. Microbial measurements were performed in the damp buildings with mold problems and in half of the reference buildings. The clinical study consisted of an otorhinolaryngological examination, nasal cytology, and skin prick tests. In the study cases, nasal provocation tests with fungi cultured from the homes and nasal mucosal biopsy were performed. RESULTS: In the housing with signs of moisture and mold, the concentrations of microorganisms were elevated, but were within the normal range of those of the reference buildings. The only positive skin reaction for molds was detected in one referent. No reactions were elicited in the nasal provocation tests with molds. Squamous metaplasia were detected in four biopsies and three cytograms of the cases but not in the nasal smears of the referents. CONCLUSIONS: In this material, the respiratory symptoms reported by occupants of moldy residences were not caused by mold allergy but were apparently related to nonspecific inflammation following irritation.     

Physical activity and breast cancer risk among female physical education and language teachers: a 34-year follow-up

The cohort consisted of 1,489 Finnish female physical education and 8,560 language teachers born after 1920 and alive in 1967. The 2 study populations were similar in social class and way of living and clearly discordant in physical activity both during their university studies and later in life. The incidence of breast cancer among these teachers up to the year 2000 was assessed through a record linkage with the Finnish Cancer Registry. The number of breast cancer cases among physical education teachers was 61 in 32,862 person-years and among language teachers was 404 in 177,188 person-years. In Poisson-regression analysis, the incidence rate ratio--adjusted for age, calendar time, number of children and age at first birth--for physical education vs. language teachers was overall 0.83 (95% confidence interval 0.63-1.09). This relative rate was 0.79 (0.46-1.36) in ages <50 years and 0.86 (0.62-1.18) in ages > or =50 years. Our study is concordant with the hypothesis that life-long physical activity may reduce the risk of breast cancer.     

Cardiovascular and renal effects of cyclooxygenase inhibition in transgenic rats harboring mouse renin-2 gene (TGR[mREN2]27)

The present study examined the role of cyclooxygenase-synthetized prostanoids in the pathogenesis of angiotensin-II-induced inflammatory response and vascular injury in transgenic rats harboring mouse renin-2 gene (mREN2 rats). Five- to six-week-old, heterozygous mREN2 rats received the following drug regimens for 8 weeks: (1) controls; (2) cyclooxygenase-2 inhibitor (MF-tricyclic [3-(3,4-difluorophenyl)-4-(4-(methylsulfonyl) phenyl)-2(5H)-furanone], 14 mg kg(-1) p.o.); (3) cyclooxygenase-1/cyclooxygenase-2 inhibitor (sulindac, 14 mg kg(-1) p.o.); (4) angiotensin II receptor antagonist (losartan 40 mg kg(-1) p.o.); (5) MF-tricyclic + losartan; (6) sulindac + losartan. Normotensive Sprague-Dawley rats served as controls. mREN2 rats developed pronounced hypertension, cardiac hypertrophy, and albuminuria as compared to normotensive Sprague-Dawley controls. mREN2 rats showed pronounced perivascular inflammation and morphological damage in the kidneys and the heart. Both MF-tricyclic and sulindac further increased blood pressure and albuminuria in mREN2 rats. Neither MF-tricyclic nor sulindac were able to prevent angiotensin-II-induced perivascular inflammation and morphological changes in the heart or in the kidneys. Myocardial and renal cyclooxygenase-2 mRNA expressions were decreased in mREN2 rats, whereas no difference was found in cyclooxygenase-1 mRNA expressions. Sulindac increased both cyclooxygenase-1 and cyclooxygenase-2 gene expressions, whereas MF-tricyclic increased only cyclooxygenase-2 gene expressions. Losartan normalized blood pressure, cardiac hypertrophy, albuminuria, inflammatory response and morphological changes in mREN2 rats, both in the presence and absence of cyclooxygenase inhibitors. Our findings indicate that cyclooxygenase does not play a central role in the pathogenesis of angiotensin-II-induced inflammatory response and vascular injury in mREN2 rats.     

The Nordic experience of cooperative urinary bladder cancer trials

The Nordic Urological Association Urothelial Group has been organizing phase 3 trials in urinary bladder cancer therapy since 1986. In total, around 1,000 patients from three countries have entered these studies. The results of the different trials are reviewed, and the problems with cooperative trials are discussed. The importance of these kind of trials in setting up management guidelines is underscored.