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Background: The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients., Methods: A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage., Results: Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence)., Conclusion: Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Traditional survival curves cannot easily be used to predict outcome for an individual patient on a year-to-year basis. This difficulty is partly overcome by yearly mortality analysis. This method was employed to analyse long-term follow-up of three cancers: colorectal, ovarian and breast cancer., Methods: The study used prospectively collected cancer registry data from geographically defined regions in Scotland. Cohort sizes were 7196 patients with breast cancer, 3200 with colorectal cancer and 1866 with ovarian cancer. Follow-up extended to 23 years., Results: Two distinct patterns of mortality emerged. Mortality rates for ovarian and colorectal cancer were initially high (41 and 21 per cent) but decreased rapidly; by 10 years patients had either died or were cured. The influence of stage diminished with follow-up. Breast cancer mortality was lower than that of colorectal or ovarian cancer, but remained raised in comparison to the general population throughout follow-up. The influence of breast cancer size reduced with follow-up, whereas that of nodal status persisted., Conclusion: Patients with breast cancer live at increased risk of death to the end of follow-up, supporting the concept of dormancy in breast cancer biology. This was not observed with colorectal or ovarian cancer., (Copyright (c) 2007 British Journal of Surgery Society Ltd.)

Background: Early trials that compared breast and axillary treatments showed differing recurrence rates without significant differences in survival. Consequently, there was a wide range of opinion and practice in the management of breast cancer. The present study explored this variability in surgical management to determine the impact of breast and axillary treatment on recurrence and survival., Methods: The records of 2776 women with histologically confirmed invasive breast cancer diagnosed between 1986 and 1991 were reviewed. The relationship between adequacy of breast and axillary treatment, recurrence and survival was examined in 2122 women who had surgery with curative intent. A Cox proportional hazards model that included tumour size, node status, grade, socioeconomic status and use of adjuvant therapy was used., Results: Inadequate treatment was associated with a significantly higher risk of local recurrence after breast-conserving surgery (relative hazard ratio (RHR) 4.19 (95 per cent confidence interval (c.i.) 2.73 to 6.43); P < 0.001). Inadequate axillary treatment was associated with a significantly higher risk of regional recurrence (RHR 2.29 (95 per cent c.i. 1.65 to 3.16); P < 0.001). The risk of death from breast cancer was significantly higher if locoregional treatment was inadequate (RHR 1.29 (95 per cent c.i. 1.07 to 1.55); P = 0.008)., Conclusion: Adequate surgery is fundamental to the optimal treatment of breast cancer. Inadequate surgery resulted in higher recurrence rates despite adjuvant treatments.

Background: Women undergoing surgery for primary breast cancer routinely have suction drains inserted deep to the wounds, which are removed approximately 6-8 days after operation, requiring a period of stay of that duration in hospital. The aim of this study was to perform a prospective randomized clinical trial to evaluate a new surgical technique of suturing flaps without wound drainage, combined with early discharge, in women undergoing surgery for breast cancer., Methods: A total of 375 patients undergoing surgery for breast cancer were randomized to conventional surgery or suturing of flaps with no drain. The main outcome measures were length of hospital stay, surgical morbidity, psychological morbidity and health economics., Results: Suturing of flaps and avoiding wound drainage in women undergoing surgery for breast cancer resulted in a significantly shorter hospital stay. Adopting this surgical technique with early discharge did not lead to any difference in surgical or psychological morbidity. Health economic benefits to the National Health Service resulted from saved bed days with no impact on community costs., Conclusion: Wound drainage following surgery for breast cancer can be avoided, thereby facilitating early discharge with no associated increase in surgical or psychological morbidity.

Background: Although it is becoming more common, previous surveys have identified concerns regarding the safety of immediate reconstruction following mastectomy. The aims of this study were to define current practice of breast reconstruction in the UK and Ireland, and to identify the characteristics of surgeons who use immediate breast reconstruction., Methods: : A postal questionnaire survey of 498 consultant breast surgeons in the UK and Ireland was performed in January 2000., Results: There were 376 responses (response rate 76 per cent). Eighty-eight per cent of surgeons 'always' or 'usually' discuss reconstruction with patients due to undergo mastectomy; clinicians with a heavy caseload were significantly more likely to discuss it (odds ratio (OR) 18.45 (95 per cent confidence interval 1.99 to 171.07)). The majority of respondents (57 per cent) preferred delayed to immediate breast reconstruction; 70 per cent believed that immediate reconstruction has disadvantages, most commonly that it interferes with adjuvant therapy (56 per cent). Older surgeons were significantly less likely to perform immediate reconstruction (OR 5.18 (2.21 to 12.11)), and were significantly more likely to believe that immediate breast reconstruction has disadvantages (OR 2.02 (1.01 to 4.05)). Surgeons from Ireland were less likely to discuss and perform breast reconstruction (OR 0.20 (0.10 to 0.43) and 0.27 (0.12 to 0.60) respectively), or to have access to a plastic surgeon (OR 0.22 (0.11 to 0.44))., Conclusion: : Significant variation exists in the delivery of breast reconstruction after mastectomy in the UK and Ireland. The age, workload and personal characteristics of the surgeon are important in determining reconstructive practice.

A case of oesophageal obstruction after ingestion of a granular laxative in a 91-year-old man is presented. There was no predisposing oesophageal disease. The severity of obstruction prevented endoscopic clearance and the patient required gastrotomy and manual disimpaction of the lower oesophagus.

Background: Local recurrence after breast-conserving surgery is associated with a short distant disease-free survival, particularly if it occurs early. Early recurrence is caused by residual disease left at the time of surgery. Previous studies have demonstrated that disease in the tumour bed is a common finding after breast-conserving surgery., Methods: The follow-up (mean 4.4 years) of 300 patients who had tumour bed analysis performed by the cavity shaving technique following breast-conserving surgery is presented. Postoperative radiotherapy was administered to all patients., Results: The incidence of tumour bed positivity was 39.3 per cent. With a selective re-excision policy the local recurrence rate was 2.0 per cent and distant recurrence rate 10.4 per cent. Multivariate analysis identified lymphovascular invasion, oestrogen receptor status and tumour bed status as independent predictors of time to distant recurrence., Conclusion: A low rate of local recurrence can be achieved using this technique of margin assessment. Tumour bed status may be a useful prognostic factor following breast-conserving surgery.

Local recurrence following breast-conserving surgery for breast cancer is a significant failure of local treatment. This article reviews the mechanisms, risk factors and overall significance of such local recurrence. The presence of disease at excision margins, an extensive intraduct component, lymphatic vessel invasion, tumour grade and tumour size are currently the best predictors of risk for local recurrence. Early local recurrence is due to residual disease and is associated with both decreased distant disease-free survival and overall survival; it appears to reflect aggressive biological characteristics of the primary tumour. The importance of adequate local treatment for breast cancer is discussed.

Background: The molecular genetic analysis of invasive breast cancer has identified breast cancer as a genetically complex disease. Ductal carcinoma in situ (DCIS) is thought to represent a preinvasive step in breast cancer progression, yet we know little about its biologic behavior or the genetic alterations present. Because of the increasing diagnosis of DCIS by mammography screening and the debate over how DCIS should be managed, there is a clear need to define the molecular events underlying the development of DCIS., Purpose: Our purpose was to identify patterns of genetic alterations in DCIS., Methods: A group of 30 formalin-fixed, paraffin-embedded blocks of tissue collected from 1987 through 1989 from 21 patients with DCIS was studied. Chromosomal imbalances were determined by interphase cytogenetic analysis using the fluorescence in situ hybridization (FISH) technique. DNA probes were used that recognize chromosome-specific repetitive sequence loci at the centromeres of chromosomes 1, 3, 4, 6, 7, 8, 9, 10, 11, 16, 17, and 18. FISH was also used to detect ERBB2 gene amplification in DCIS. To complement the FISH studies, microsatellite analysis of markers near the BRCA1 region of chromosome 17 was done on tissue microdissected from multiple areas of DCIS. Chromosomal imbalances were determined by comparisons of chromosomal indices (total number of hybridization spots per total number of nuclei counted) of normal and DCIS tissue, using the two-sided Mann-Whitney test., Results: Using FISH, we have identified patterns of DNA loss and gain of certain chromosome-specific centromeric markers in DCIS. We observed frequent gains of markers on chromosomes 3, 10, and 17 as well as loss of chromosome 18-specific centromeric sequences. ERBB2 gene amplification was detected in tumors from four of 15 patients studied and was clearly limited to the tumor cells within the ducts. Because of the availability of topologically distinct regions of tumors from individuals, we were able to show that paired tumor specimens from individuals share genetic alterations and also have unique ones, suggesting clonal diversity within tumors. The combination of FISH and microsatellite analyses suggested that alterations in chromosome 17 may be quite complex; three of five patients whose samples were analyzed had allelic imbalance at markers on the long arm of chromosome 17., Conclusions: FISH and microsatellite analyses are useful in detecting extensive genetic alterations in DCIS. Examinations of DCIS tissue using these techniques have identified chromosomes 1, 3, 10, 16, 17, and 18 as candidate sites worthy of immediate study., Implications: This approach may give direction to future research aimed at precisely mapping loci altered in DCIS and help in understanding the biologic events associated with tumor progression or recurrence.

Between March 1988 and April 1992, in 264 patients undergoing breast-conserving surgery for stage I and II cancer, the tumour bed was analysed for residual disease. After a conventional breast-conserving operation the entire wall of the cavity from which the lumpectomy specimen had been taken was excised. This was involved with disease in 38 per cent of patients. Additional random biopsies of the secondary cavity were performed in 130 patients and were involved with disease in 13 per cent. Residual disease was detected in the tumour bed of 37 per cent of patients with screen-detected tumours.

The purpose of this study was to compare surgical stapling and manual suturing techniques with respect to the incidence of tumour recurrence in patients with colorectal cancer: 294 patients undergoing potentially curative resections for colorectal cancer were randomly allocated to receive sutured (n = 142) or stapled (n = 152) anastomoses. The mean (s.e.m.) incidence of tumour recurrence at the end of 24 months was 29.4(4.4) per cent in the sutured group, compared with 19.1(3.9) per cent in the stapled group (P less than 0.05). The corresponding rates for cancer-specific mortality at 24 months were 22.3(4.1) per cent and 10.9(3.0) per cent respectively (P less than 0.01). A multiple regression analysis revealed that the influence of anastomotic technique on recurrence and mortality rate was independent of tumour stage. These results suggest that in colorectal cancer surgery the use of stapling instruments for anastomotic construction could be associated with a reduction in the incidence of recurrence and mortality rate by as much as 50 per cent.

Gastric emptying of isotopically labelled solid meals was studied in normal human subjects and in 30 patients who had had an operation for chronic duodenal ulcer. Each patient had a vagotomy of the whole stomach combined with either a Finney pyloroplasty to produce a large gastric outlet or a Heineke-Mikulicz pyloroplasty to produce a relatively small outlet. At 10-22 days after operation gastric emptying was equally and significantly slowed in both groups when compared with the normal controls. This delay occurred regardless of whether the vagotomy was complete or incomplete. At 4-6 months after operation emptying had returned to normal in the patients who had had a Finney pyloroplasty but remained significantly slowed after Heineke-Mikulicz pyloroplasty. Mild symptoms of gastric stasis frequently occurred in both groups in the early postoperative period, but were rare 4-6 months after operation. There was no correlation between the incidence of these early symptoms of stasis and the size of the gastric outlet constructed.

Suture implantation of viable exfoliated malignant cells may be responsible for local recurrence (implantation metastasis) of colorectal cancer. In this study, four anastomotic materials (braided polyamide, braided polyglycolic acid, monofilament polypropylene and monofilament stainless steel) were compared with respect to their ability to entrap and transfer free Mtln3 carcinoma cells from the colonic lumen of a rat. The braided materials transferred greater numbers of cells than did the monofilament sutures (P less than 0.001), but significant differences were also observed between polyglycolic acid and polyamide (P less than 0.001) and between polypropylene and stainless steel (P less than 0.05). Secondly, the firm adherence of tumour cells to the suture materials was assessed by an in vitro technique. The Mtln3 cells were found to adhere in significantly greater quantities to the braided sutures than to the monofilaments (P less than 0.001) and this was supported by in vivo tumour growth studies. These findings may have implications for colorectal cancer surgery in man.

Epidemiological studies have consistently suggested an aetiological relationship between certain dietary constituents, faecal bile acid (FBA) concentration and colorectal cancer. This study was designed to examine the effect of the dietary manipulation of fat and fibre on tumour induction and on various faecal characteristics in Albino Swiss rats. A total of 232 animals were maintained on one of four different diets for 4, 20 and 28 weeks respectively. The diets were classified as high fat high fibre, low fat high fibre, high fat low fibre and low fat low fibre. The groups were further sub-divided according to the administration of systemic azoxymethane (10 mg/kg per week) or saline over 12 consecutive weeks. The high fat low fibre diet was associated with the highest risk for tumour production and the low fat high fibre diet with the lowest risk. Statistically significant differences between all the diets were noted with the exception of a comparison between the high fat high fibre and low fat high fibre diets. The highest total concentration of free FBA was found in the faeces from animals fed low fibre containing diets. The results show a clear influence of both fat and fibre on tumour induction while, in this model, fibre was the principle determinant of faecal bile acid concentration.

The results of pre-operative staining of fine needle aspirate (FNA) samples from 48 breast cancers, with a polyclonal antibody raised against highly purified oestrogen receptor (ER) protein, have been compared with our standard biochemical method for measurement of cytosol and nuclear ER. FNA antibody staining correctly predicted the presence of ER in 20 of 21 ERC +/N+ tumours. There were 2 false positive results in 24 ER C-/N-tumours though both these tumours showed marked heterogeneity of staining. Three ER C+/N- tumours were negative by antibody staining, in keeping with the tendency for such tumours to be hormone independent in behaviour. This pre-operative method for ER determination appears to be a reliable alternative to other micro-assays for oestrogen receptors.

Warfarin inhibits metastasis in animal models by mechanisms that remain unclear. A better understanding of this phenomenon may clarify processes underlying metastasis in human cancer. We have studied the effects of warfarin on metastasis in a rat model by intravenous injection of Mtln3 mammary carcinoma cells and subsequent counting of pulmonary seedlings. To determine whether warfarin acts principally on the tumour cells or the host, we pretreated either cells or animals with warfarin before intravenous injection of 10(4) Mtln3 cells. Pretreatment of tumour cells had no effect, whilst pretreatment of the host reduced median seedlings from 67 to 4.5 per animal (P less than 0.005). To determine whether warfarin was acting via its anticoagulant action, we reversed warfarin anticoagulation by intravenous injection of coagulation factors II, VII, IX and X. Restoration of coagulation for 12 h immediately after injection of cells completely reversed the warfarin effect (P less than 0.001), but if the injection of factors was delayed for 12 h it had no effect (P = 0.1753). We conclude that warfarin acts principally on the host, not the tumour cell, and that it acts via its effect on coagulation. The restriction of the effect to the first 12 h after tumour cell injection suggests a mechanism involving intravascular processes such as tumour cell survival or endothelial adhesion.

The estrogen receptor content and the thymidine labelling index have been correlated in a series of primary cancers of the breast. Receptor was assayed in tumours of 409 patients with operable breast cancer. Recurrence rates were significantly higher in patients whose tumours did not contain receptors than in those whose tumours did. Women without axillary node involvement whose tumours lacked oestrogen receptors showed the same high rate of recurrence as all women with axillary involvement. The oestrogen receptor status of metatases was similar to that of the primary tumours. The thymidine labelling of 83 tumours was inversely related to their receptor content. Tumours without receptors had the highest indices and therefore the highest potential tumour growth. These results have been discussed in relation to selection of systemic adjuvant therapy.

The feasibility of screening for breast cancer by clinical examination and X-ray mammography has been studied. The results suggest that a breast screening programme is safe from dangers of irradiation and can be conducted by non-medical staff. The response of women at risk suggests that the service is acceptable to the general public. The hospital service could deal with the additional surgical work.