Management of ductal carcinoma in situ with nipple discharge. Intraductal spreading of carcinoma is an unfavorable pathologic factor for breast-conserving surgery

BACKGROUND: Surgical management of ductal carcinoma in situ (DCIS) has been a controversial issue in the selection of breast-conserving surgery as a method of treatment. The definition of intraductal spreading of carcinoma becomes an important factor in the decision making process, but little is known about how much intraductal extension influences the spreading of tumor in the whole breast. To define any unfavorable pathologic factors existing in limited surgery for patients with DCIS, the authors investigated histopathologic characteristics using a sequential slicing of tissues. METHODS: Duct-lobular segmentectomy, a limited surgery, was performed on 110 patients with a bloody nipple discharge. Six patients with invasive carcinoma and 17 patients with DCIS subsequently received a total mastectomy. The specimens obtained by segmentectomy and mastectomy were histopathologically examined. Using subserial sections, the authors examined the relationship between intraductal spreading of carcinoma in the segmentectomy specimens and carcinoma residue in the mastectomy specimens. RESULTS: Among 16 mastectomy specimens, the authors found residual DCIS in 6, and atypical ductal hyperplasia in 4. Intraductal spreading of carcinoma was detected in 8 of 16 segmentectomy specimens. Six of eight patients with intraductal spreading had residual DCIS. The other two patients had atypical hyperplasia in breasts. No residual DCIS was detected in the other eight patients without intraductal spreading. Among 12 patients under observation who did not have a mastectomy, invasive carcinoma subsequently developed in 3. Two of three patients had intraductal spreading in segmentectomy specimens. Only 1 of 10 patients without intraductal spreading, however, developed carcinoma. CONCLUSIONS: Intraductal spreading of carcinoma is an unfavorable pathologic factor in breast-conserving surgery for patients with ductal carcinoma in situ with nipple discharge.     

Breast-duct endoscopy to study stages of cancerous breast disease

BACKGROUND: In breast-cancer research, we lack reproducible non-invasive access to breast tissue. Breast cancer is thought to start in the lining of the milk duct or lobule. We have had no direct access to this area other than in tissue removed surgically or by fine-needle aspiration. Our objective was to explore an intraductal approach to studying breast cancer and precancerous changes by duct cannulation and endoscopy. METHODS: In this pilot study, women in a university hospital were asked to participate. Nine patients with previously diagnosed ductal carcinoma-in-situ (DCIS) or invasive breast cancer who were about to undergo mastectomy under general anaesthesia agreed. After the patient was asleep but before the operation, we spent 15 minutes cannulating their ducts, obtaining washings, and attempting endoscopy. The ducts that had been cannulated were marked by instillation of dye or other materials, the nipple was sutured shut, and the mastectomy proceeded as planned. The mastectomy specimen underwent extensive histopathological examination. FINDINGS: We were successful in intraductal cannulation and endoscopy in seven of the nine patients. In five of the nine, we obtained epithelial cells in the washings. In one the cells were consistent with proliferative disease, in three there was atypical epithelium, and in one there was frank DCIS. With several different contrast materials injected into separate duct orifices, DCIS was confined to a single duct system. INTERPRETATION: We found that the intraductal approach is feasible for the study of the early changes of breast cancer Technical difficulties include identification of the breast duct orifices, determining the distensibility of the duct, and developing a reliable technique to obtain washings.     

Ductal carcinoma in situ of the breast: correlation of pathologic and mammographic features with extent of disease

Optimal treatment of ductal carcinoma in situ (DCIS) of the breast requires an improved understanding of its pathologic extent and propensity for local recurrence. This study was performed to analyze mammographic and pathologic features of DCIS that might predict the extent of disease within the breast and facilitate treatment selection between lumpectomy alone, lumpectomy and radiotherapy, and mastectomy. At our institution, 60 cases of DCIS were diagnosed in 59 patients from June 1985 to February 1995 and form the basis of this retrospective study. Demographic and treatment-related information was obtained from hospital and tumor registry records. Mammograms were reviewed and size estimates of the abnormalities were determined. Pathologic slides from all cases were reviewed and classified according to size group, focality, nuclear grade, necrosis, and histologic subtype. DNA ploidy status and proliferation indices were available for 28 patients. Pathologically, 43 (72%) cases were < 15 mm, 14 (23%) were 16 to 40 mm, and 3 (5%) were > 40 mm. Five (8%) of the lesions were multicentric, 28 (47%) focal, and 27 (45%) multifocal. Thirty-three (55%) patients were treated by mastectomy, 16 (27%) by lumpectomy alone, and 11 (18%) by lumpectomy and radiation therapy. Mammographic size, histologic grade, presence or absence of necrosis, histologic subtype, DNA ploidy, and proliferative index were compared with pathologic size and focality by chi 2 analysis. Mammographic size correlated significantly with pathologic size (chi 2 = 11.3; P = 0.02) but underestimated the extent of disease in 9 cases. Although focality correlated significantly with pathologic size (chi 2 = 15.8; P = 0.003), the remaining histopathologic features did not significantly correlate with pathologic size or focality. Histopathologic features, including DNA studies, do not reliably predict the pathologic extent of DCIS, but mammographic size and focality do significantly correlate with pathologic size. Nevertheless, most cases of DCIS are small focal or multifocal lesions that are amenable to breast conservation approaches; further studies are needed to determine the appropriate use of lumpectomy, radiation therapy, and mastectomy in the treatment of DCIS.     

Bilateral breast masses and bloody nipple discharge in a two year-old boy

Breast enlargement with bloody discharge is very rare in childhood. We report a two year-old boy with breast enlargement and bloody discharge. Because of persistent bloody discharge, subcutaneous mastectomy was performed. The specimen showed histologic changes identical to those seen in adult mammary duct ectasia. We suggested that the infant's own endocrine system is responsible for breast enlargement and mammary duct ectasia, possibly occurring as a result of a mechanism similar to that in adults.     

Diet induced hyperammonemia decreases neuronal nuclear size in rat entorhinal cortex

Nipple discharge was the presenting complaint in 104 patients (1.5%) from a series of 7000 women who were seen in a breast clinic over a 13-year period. Complete follow-up information was available in 66 Chinese patients. The mean age at presentation was 47 years. Twenty-six patients (39%) were postmenopausal. Unilateral discharge (92%) from a single duct (77%) was the main finding. There were five patients (8%) with proven breast cancer; benign duct papilloma was found in 17 patients. Multivariate analysis showed that cancer was most likely in women over the age of 55 (P < 0.05) and when the discharge was bloody (P < 0.05). Ductography was also found to be useful in the diagnosis of duct papilloma (P < 0.02).     

Ductography for nipple discharge: no replacement for ductal excision

BACKGROUND: Current management of nipple discharge depends on clinical history to distinguish pathologic from physiologic discharge. We investigated whether ductography supplied additional information in the decision for surgery and/or the localization of pathologic lesion. METHODS: A retrospective review of patients with a presenting complaint of nipple discharge seen at the Lynn Sage Breast Center was conducted from January 1995 to June 1996. Medical records, pathology, and ductograms were reviewed. RESULTS: Of 91 patients with nipple discharge, 49 met the criteria for physiologic discharge and 42 had pathologic discharge. Eleven with physiologic discharge had ductograms; none were abnormal. Four of 20 preoperative ductograms were normal but showed intraductal papillomas at the time of surgery; 6 of 20 (30%) had multiple lesions. Four lesions on ductograms did not demonstrate corresponding lesions in the surgical specimen. It is uncertain whether this is due to a missed lesion or a false-positive ductogram. CONCLUSIONS: Modern ductography does not reliably exclude intraductal pathology and is not a substitute for surgery in patients with pathologic discharge. Its utility is in identifying multiple lesions or those with lesions in the periphery of the breast.     

Randomised controlled trial of effects of early discharge after surgery for breast cancer

OBJECTIVE: To determine the effect of early discharge from hospital after surgery for breast cancer on physical and psychological illness. DESIGN: Randomised controlled trial comparing discharge two days after surgery (before removal of drain) with standard management (discharge after removal of drain). SETTING: Regional breast unit. SUBJECTS: 100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80). MAIN OUTCOME MEASURES: Physical illness (infection, seroma formation, shoulder movement) and psychological illness (checklist of concerns, Rotterdam symptom questionnaire, hospital anxiety and depression scale) preoperatively and at one month and three months postoperatively. RESULTS: Women discharged early had greater shoulder movement (odds ratio 0.28 (95% confidence interval 0.08 to 0.95); P = 0.042) and less wound pain (odds ratio 0.28 (0.10 to 0.79); P = 0.016) three months after surgery compared with women given standard management. One month after surgery scores were significantly lower on the Rotterdam symptom questionnaire in patients who were discharged early (ratio of geometric mean scores 0.73 (0.55 to 0.98) P = 0.035), but rates of psychological illness generally did not differ between groups. CONCLUSIONS: Increased rates of physical or psychological illness did not result from early discharge after surgery for breast cancer. This policy can be recommended for patients with support at home.     

Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast

BACKGROUND: Few women with locally advanced breast cancer remain disease-free, even for 2 years. Response to induction chemotherapy may be associated with longer disease-free and overall survival rates. The role of breast conservation in selected patients with response to induction chemotherapy was evaluated. METHODS: Since 1979, patients with Stages IIB and III breast cancer have undergone induction chemotherapy; patients with response continued chemotherapy until a plateau of regression was achieved. Before 1983, all patients having a response to chemotherapy underwent mastectomy; since 1983, selected patients have undergone breast conservation. Outcomes were tallied comparing these two groups of patients. RESULTS: The study group included 189 women, who were followed up for 12-159 months (median, 46 months) after diagnosis. Of the patients, 85% had a response to induction chemotherapy. Patients with no response were excluded from additional consideration in this study. One hundred three (64%) women underwent mastectomy; 55 (36%) were treated with breast conservation. The disease-free 5-year survival rate was 61% for all patients with a response to chemotherapy; 56% for those having mastectomy and 77% for those having breast conservation. The overall 5-year survival rate was 69% for all patients with a response to chemotherapy, 67% for those undergoing mastectomy and 80% for those having breast conservation. CONCLUSIONS: Induction chemotherapy achieves significant tumor regression in most women with locally advanced breast cancer, permitting subsequent breast conservation or mastectomy with a greater expectation of long-term success. Breast conservation is used more frequently with the same expectation of success as mastectomy, presuming careful selection based on response to chemotherapy.     

Results of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS)

PURPOSE: The role of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS) is controversial. In particular, there is little data for outcome with radiation in a group of patients comparable to those treated with local excision and surveillance (mammographic calcifications < or = 2.5 cm, negative resection margins, negative postbiopsy mammogram). This study reports outcome of conservative surgery and radiation for mammographically detected DCIS with an emphasis on results in patients considered candidates for excision alone. METHODS AND MATERIALS: From 1983 to 1992, 110 women with mammographically detected DCIS (77% calcifications +/- mass) and no prior history of breast cancer underwent needle localization and biopsy with (55%) or without a reexcision and radiation. Final margins of resection were negative in 62%, positive 7%, close 11%, and unknown 20%. The median patient age was 56 years. The most common histologic subtype was comedo (54%), followed by cribriform (22%). The median pathologic tumor size was 8 mm (range 2 mm to 5 cm). Forty-seven percent of patients with calcifications only had a negative postbiopsy mammogram prior to radiation. Radiation consisted of treatment to the entire breast (median 50.00 Gy) and a boost to the primary site (97%) for a median total dose of 60.40 Gy. RESULTS: With a median follow-up of 5.3 years, three patients developed a recurrence in the treated breast. The median interval to recurrence was 8.8 years and all were invasive cancers. Two (67%) occurred outside the initial quadrant. The 5- and 10-year actuarial rates of recurrence were 1 and 15%. Cause-specific survival was 100% at 5 and 10 years. Contralateral breast cancer developed in two patients. There were too few failures for statistical significance to be achieved with any of the following factors: patient age, family history, race, mammographic findings, location primary, pathologic size, histologic subtype, reexcision, or final margin status. However, young age, positive or close margins, and the presence of a mass without calcifications had a trend for an increased risk of recurrence. There were no recurrences in the subset of 16 patients who would be candidates for surveillance by Lagios' criteria. CONCLUSION: For selected patients, conservative surgery and radiation for mammographically detected DCIS results in a low risk of recurrence in the treated breast and 100% 5- and 10-year cause-specific survival. Improved mammographic and pathologic evaluation results in better patient selection and reduces the risk of the subsequent appearance of DCIS in the biopsy site. The identification of risk factors for an ipsilateral invasive breast recurrence is evolving.     

High-dose multimodality therapy with autologous stem-cell support for stage IIIB breast carcinoma

PURPOSE: Women with locally unresectable and inflammatory breast carcinoma (IBC) have an approximately 30% 5-year disease-free survival (DFS) rate with conventional multimodality therapy. A short but dose-intensive multimodality phase II trial was designed in an attempt to improve outcome in stage IIIB disease. Mastectomy was performed after high-dose therapy to evaluate pathologic response to treatment. METHODS: Women with newly diagnosed disease received four 2-week cycles of doxorubicin 90 mg/m2 with granulocyte colony-stimulating factor (G-CSF), followed by cyclophosphamide 6,000 mg/m2, thiotepa 500 mg/m2, and carboplatin 800 mg/m2 (CTCb) with marrow and peripheral-blood progenitor cell (PBPC) support. Local therapy consisted of mastectomy and radiotherapy. Tamoxifen (5 years) was begun if the patient was estrogen receptor-positive (ER+). RESULTS: Fifty women (46 stage IIIB [91% IBC], four stage IIIA) entered the study and 47 are assessable. Ten had mastectomy before any systemic therapy (seven with pathologic IBC, three with residual tumor after mastectomy). Eighty percent received full-dose doxorubicin with 60% on schedule. Clinical response rates to induction were 15% complete response (CR), 5% very good partial response (VGPR), 59% partial response (PR), and 21% minor response (MR)/stable disease (SD). Mastectomy after CTCb in 37 patients showed a 14% pathologic CR rate, 29% microscopic foci in breast and/or axilla, and 57% gross tumor. Fifteen (32%) patients have relapsed (median, 17 months post-CTCb). The 30-month DFS is estimated at 64%. For those in pathologic CR, with microscopic, or with gross disease remaining after CTCb, the 30-month DFS is estimated at 100%, 70%, and 38%, respectively. Those with zero, one to three, or > or = four positive nodes at axillary dissection had a median DFS of 31, 18, and 13 months, respectively. CONCLUSION: This short but dose-intensive multimodality approach for stage IIIB breast carcinoma is feasible with encouraging results to date.     

Breast conservation and prolonged chemotherapy for locally advanced breast cancer: the University of Michigan experience

PURPOSE: To determine whether breast conservation and prolonged neoadjuvant chemotherapy have efficacy in locally advanced breast cancer (LABC), as measured by survival and rate of breast conservation. MATERIALS AND METHODS: Eighty-nine patients with stage III disease were enrolled at the University of Michigan (UM) onto a prospective nonrandomized trial. Patients received nine 21-day cycles of neoadjuvant chemohormonal therapy that consisted of doxorubicin 30 mg/m2 and cyclophosphamide 750 mg/m2 intravenously on day 1, conjugated estrogens 0.625 mg orally twice daily on days 6 to 8, methotrexate 40 mg/m2 and fluorouracil 500 mg/m2 intravenously on day 8, and tamoxifen 10 mg orally twice daily on days 9 to 14. Patients with a negative biopsy received radiation only, while those with residual disease underwent mastectomy and postoperative radiotherapy. Eight more cycles of chemohormonal therapy were administered after local-regional therapy. RESULTS: The clinical response rate to neoadjuvant therapy was 97%, 28% of patients had a complete pathologic response evaluated at biopsy. Five-year overall and disease-free survival probabilities were 54% and 44%, respectively. The median disease-free survival time was 2.4 years. The 5-year actuarial rates of local-regional control with local failure as only first failure were 82% and 78% following radiotherapy, and mastectomy and radiotherapy, respectively (P = .99). CONCLUSION: Prolonged neoadjuvant chemohormonal therapy and biopsy-driven local therapy have efficacy in LABC, with 28% of patients being candidates for breast conservation and a 5-year overall survival rate of 54%.     

Long term follow-up of children hospitalized with respiratory syncytial virus lower respiratory tract infection and randomly treated with ribavirin or placebo

PURPOSE: To determine how many cases of breast cancer might be found if women not known to have the disease were thoroughly examined (the disease "reservoir"). DATA SOURCES: MEDLINE search from 1966 to the present. STUDY SELECTION: Hospital-based and forensic autopsy series examining women not known to have had breast cancer during life. DATA EXTRACTION: Observed prevalence of occult invasive breast cancer or ductal carcinoma in situ (DCIS) in which the number of women who were given a diagnosis was the numerator and the number of women examined was the denominator. For each autopsy series, we attempted to ascertain the level of scrutiny (sampling method, number of slides examined) given to the pathologic specimens. DATA SYNTHESIS: Among seven autopsy series of women not known to have had breast cancer during life, the median prevalence of invasive breast cancer was 1.3% (range, 0% to 1.8%) and the median prevalence of DCIS was 8.9% (range, 0% to 14.7%). Prevalences were higher among women likely to have been screened (that is, women 40 to 70 years of age). The mean number of slides examined per breast ranged from 9 to 275; series that reported higher levels of scrutiny tended to discover more cases of cancer. CONCLUSIONS: A substantial reservoir of DCIS is undetected during life. How hard pathologists look for the disease and, perhaps, their threshold for making the diagnosis are potentially important factors in determining how many cases of DCIS are diagnosed. The latter has important implications for what it means to have the disease.     

Mammary ductal carcinoma in situ with microinvasion

BACKGROUND: The natural history of patients with intraductal carcinoma (DCIS) and microinvasion is poorly defined, and the clinical management of these patients, with particular reference to management of the axilla, has been controversial. Previous studies of this lesion have used varied and/or arbitrary criteria for the evaluation of microinvasion. METHODS: Thirty-eight DCIS lesions with microinvasion (n=29) or probable microinvasion (n=9), diagnosed during the period 1980-1996, were retrospectively analyzed after cases not treated with mastectomy and axillary lymph node dissection were excluded. Microinvasion was defined as a single focus of invasive carcinoma < or = 2 mm or up to 3 foci of invasion, each < or =1 mm in greatest dimension. RESULTS: The patients were all females with a mean age of 56.4 years. DCIS was of comedo (n=31) or papillary (n=7) subtype. Microinvasion was often associated with an altered, desmoplastic stroma (55%) or a lymphocytic infiltrate (39%). The foci of microinvasion ranged from 0.25 to 1.75 mm (mean, 0.6 mm), with an aggregate mean size of 1.1 mm (range, 0.25-2.25 mm). Foci of microinvasion, ranging from 1 to 3 (mean, 1.7), were adjacent to DCIS in 95.3% of cases. The extent of DCIS did not correlate with the number of foci of microinvasion. Axillary lymph node dissections yielded a mean of 19.3 lymph nodes (range, 7-38), and all lymph nodes were negative for metastasis. None of 33 patients, followed for a mean of 7.5 years (range, 1.0-14.4 years), developed local recurrence or metastasis. CONCLUSIONS: The cases of microinvasive carcinoma examined in this study, as defined above, were not associated with axillary lymph node metastases and appeared to be associated with an excellent prognosis. Further study is indicated to determine the appropriate management and long term prognosis of patients with this lesion.     

Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17

PURPOSE: In 1993, findings from a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial to evaluate the worth of radiation therapy after lumpectomy concluded that the combination was more beneficial than lumpectomy alone for localized intraductal carcinoma-in-situ (DCIS). This report extends those findings. PATIENTS AND METHODS: Women (N = 818) with localized DCIS were randomly assigned to lumpectomy or lumpectomy plus radiation (50 Gy). Tissue was removed so that resected specimen margins were histologically tumor-free. Mean follow-up time was 90 months (range, 67 to 130). Size and method of tumor detection were determined by central clinical, mammographic, and pathologic assessment. Life-table estimates of event-free survival and survival, average annual rates of occurrence for specific events, relative risks for event-specific end points, and cumulative probability of specific events comprising event-free survival are presented. RESULTS: The benefit of lumpectomy plus radiation was virtually unchanged between 5 and 8 years of follow-up and was due to a reduction in invasive and noninvasive ipsilateral breast tumors (IBTs). Incidence of locoregional and distant events remained similar in both treatment groups; deaths were only infrequently related to breast cancer. Incidence of noninvasive IBT was reduced from 13.4% to 8.2% (P = .007), and of invasive IBT, from 13.4% to 3.9% (P < .0001). All cohorts benefited from radiation regardless of clinical or mammographic tumor characteristics. CONCLUSION: Through 8 years of follow-up, our findings continue to indicate that lumpectomy plus radiation is more beneficial than lumpectomy alone for women with localized, mammographically detected DCIS. When evaluated according to the mammographic characteristics of their DCIS, all groups benefited from radiation.     

Breast cancer in patients treated for Hodgkin's disease: clinical and pathological analysis of 76 cases in 63 patients

In a retrospective multicentric analysis, 63 women treated between 1941 to 1988 for Hodgkin's disease (HD) subsequently developed 76 breast cancers (BC). The median age at diagnosis of HD was 26 years (range 7-67), and 22 women (35%) were 20 years old or less. Exclusive radiotherapy (RT) was used in 36 women (57%) and combined modalities with chemotherapy (CT) in 25 (39%). Breast cancer occurred after a median interval of 16 years (range 2-40) and the median age at diagnosis of the first BC was 42 years (range 25-73). TNM classification (UICC, 1978) showed 10 T0 (non-palpable lesions) (13%), 20 T1 (26%), 22 T2 (29%), 8 T3 (11%), 7 T4 (9%) and 9 Tx (12%), giving altogether a total of 76 tumours, including, respectively, 5 and 8 bilateral synchronous and metachronous lesions. Among the 68 tumours initially discovered, 53 ductal infiltrating, one lobular infiltrating and two medullary carcinomas were found. Moreover, two fibrosarcomas and 10 ductal carcinoma in situ (DCIS) were also found. Among 50 axillary dissections for invasive carcinomas, histological involvement was found in 31 cases (62%). 45 tumours were treated by mastectomy, without (n = 35) or with (n = 10) RT. 27 tumours had lumpectomy, without (n = 7) or with RT (n = 20). 2 others received RT only, and one only CT. 7 patients (11%) developed isolated local recurrence. 20 patients (32%) developed metastases and all died; 38 are in complete remission, whereas 5 died of intercurrent disease. The 5-year disease-specific survival rate by the Kaplan-Meier method was 61%. The 5-year disease-specific survival rate for pN0, pN1-3 and pN > or = 3 groups were 91%, 66% and 0%, respectively (P < 0.0001) and 100%, 88%, 64% and 23% for the T0, T1, T2 and T3T4 groups, respectively. These secondary BCs seem to be of two types: a large number of aggressive tumours with a very unfavourable prognosis (especially in the case of pN > 3 and/or T3T4); and many tumours with a 'slow development' such as DCIS and microinvasive lesions, especially in patients treated exclusively by RT. Moreover, a very unusual rate of bilateral tumours (21%) was observed. These secondary BC could be 'in field', in 'border of field' or 'out of field'. However, a complete analysis of doses delivered by supradiaphragmatic irradiation was often very difficult, due to large variations in several parameters. We conclude that young women and girls treated for HD should be carefully monitored by clinical examination, mammography and ultrasonography.     

Syringomatous tumor of the nipple. A case report and review of the literature]

The authors report a case of syringomatous tumor of the nipple in a 35-year-old woman, discovered incidentally during investigation of dysmenorrhea. After limited resection-biopsy of a cystic nipple tumor, histological results indicated the need for a partial central mastectomy with areola and nipple amputation. Although this tumor is classified as an adenoma, considered to be a benign lesion, syringomatous adenoma of the nipple is a potentially locally aggressive tumor, at risk of local recurrence and deep invasion of the mammary gland. This is a rare tumor (only 18 cases have been reported in the literature), and the histological diagnosis can be difficult, with possible confusion with a nipple duct adenoma, or tubular carcinoma.     

Knowledge base and use in the management of pressure sores

OBJECTIVE: To determine whether early discharge (< 72 hours) after childbirth increased the risk for women developing postnatal depression. DESIGN: Prospective cohort design consisting of an initial interview, and six-weekly assessments for 24 weeks using a self-report questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Women discharged within 72 hours were compared with the remaining women. SETTING: Tertiary referral hospital in western Sydney, New South Wales, 1993. PARTICIPANTS: All 749 women delivering over a three-month period were recruited. Of the 522 participants, 425 women completed the study. MAIN OUTCOME MEASURES: Women scoring > 13 on the EPDS on two or more occasions were considered potential "cases" of postnatal depression. The diagnosis was confirmed using the Structured Clinical Interview for DSM-III-R disorders (SCID). RESULTS: Of the 153 women (36%) discharged early, 22 women (14.4%) developed postnatal depression over the study period compared with 20 of the 272 women (7.4%) who had standard length of stay. Women who were discharged within 72 hours had a significantly increased risk for developing postnatal depression (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.07-4.21). This risk persisted when other sociodemographic, obstetric and psychosocial risk factors were controlled for in a logistic regression analysis (OR, 3.06; 95% CI, 1.22-7.69). CONCLUSION: Women planning early discharge after childbirth should be carefully assessed before discharge and follow-up should be rigorous. The potential to develop postnatal depression should be considered in all women choosing early discharge from hospital.     

Pharmacokinetics of recombinant human interferon-alpha 2a combined with 5-fluorouracil in patients with advanced colorectal carcinoma

A cohort study was conducted to estimate the risk of breast cancer recurrence among women diagnosed with ductal carcinoma in situ (DCIS) and to identify tumor or patient characteristics that influence that risk. A population-based cancer registry was used to identify a cohort of 709 female residents of western Washington who were diagnosed with DCIS between January 1980 and June 1992 and were treated with breast-conserving surgery. Information about breast cancer recurrences, treatment, and several patient characteristics and exposures was obtained from postal questionnaires. Recurrences were confirmed using information from the cancer registry or hospital pathology reports. Approximately 15% of women experienced a recurrence within the first 5 years after diagnosis [95% confidence interval (CI), 12-18%]; 31% had a recurrence within 10 years (95% CI, 24-38%). There was a suggestion that risk was slightly elevated for women with larger tumors (> or =1.5 cm) and tumors of comedo subtype. Relative risks (RRs) were elevated for women who were premenopausal at diagnosis of DCIS (RR = 2.3; 95% CI, 1.1-5.0). Women in the upper decile of body mass index were at twice the risk of a recurrence as those women in the lower four deciles (RR = 2.3; 95% CI, 1.1-4.8). There was also a suggestion that women who used menopausal hormones for at least 2 years after their diagnosis of DCIS were at increased risk of recurrence compared to nonusers of menopausal hormones (RR = 1.8; 95% CI, 0.7-5.0). Our results suggest that the risk of recurrence may be related to some tumor characteristics as well as the hormonal milieu of the patient at or after her diagnosis of DCIS. However, larger studies are needed to more clearly document predictors of disease recurrence after DCIS.     

An alternative technique in the management of bullous emphysema. Thoracoscopic endoloop ligation of bullae

OBJECTIVE: This study was undertaken to evaluate the mammographic features of local recurrence in women who have undergone breast-conserving therapy for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Retrospective review revealed 162 women with DCIS treated with breast-conserving therapy from 1978 to 1990 for whom follow-up data were available. Subsequent to therapy, 33 (20%) patients had a pathologically proven carcinoma in the treated breast. Mammograms at the time of local recurrence were available for 20 patients. We reviewed mammograms, clinical charts, and histopathologic findings in these 20 patients. For 14 of 20 patients, we also reviewed mammograms obtained at the time of the original DCIS. RESULTS: The median interval from diagnosis of the original DCIS to local recurrence was 26 months (range, 6-168 months). Recurrences were detected solely by mammography in 17 (85%) of 20 patients, by mammography and physical examination in two (10%), and solely by physical examination in one (5%). Eighteen (90%) local recurrence contained calcifications and eighteen (90%) involved the tumorectomy quadrant. When we compared available mammographic findings of the original DCIS and the local recurrence we found the mammographic pattern and calcification morphology to be the same in 11 (79%) of 14 DCIS and nine (82%) of 11 DCIS, respectively. Histopathologic analysis of recurrences found DCIS in 13 (65%) of 20 patients and DCIS and infiltrating carcinoma in the remaining seven (35%) patients. Of 13 pure DCIS recurrences, 12 (92%) were detected solely by mammography. CONCLUSION: In our study, local recurrence after breast-conserving therapy for DCIS invariably contained DCIS; 35% of recurrences also contained invasive carcinoma. The most common mammographic pattern of local recurrence was calcifications in the tumorectomy quadrant that were morphologically similar to the original DCIS. These findings suggest that many of these local recurrences reflect failure to eradicate the primary DCIS. Mammography achieved high sensitivity in revealing these lesions: 85% of local recurrences and 92% of recurrences that were pure DCIS were detected solely by mammography.     

Reciprocal expression of mRNA for inhibin betaC and betaA subunits in hepatocytes

OBJECTIVE: To quantify the risk of residual invasion when cervical conization reveals microinvasive squamous carcinoma and to determine whether any factors affect this risk. METHODS: We reviewed the charts and histopathology slides of 87 women who underwent a conization that contained microinvasive squamous carcinoma, followed by either a repeat conization or hysterectomy. Depth of invasion, number of invasive foci, and status of the internal margin and post-conization endocervical curettage (ECC) were assessed. The findings were correlated with the presence of residual invasion. RESULTS: Significant predictors of residual invasion included status of the internal margin (residual invasion present in 22% of women with an involved margin versus 3% with a negative margin; P < .03) and the combined status of the internal margin and post-conization ECC (residual invasion in 4% of patients if both negative, 13% if one positive, and 33% if both positive; P < .015). Depth of invasion and number of invasive foci in the conization specimen were not significant. The power of this study to detect a 25% difference in the risk of residual invasion was 73% for depth of invasion and 75% for number of invasive foci. CONCLUSION: Women with microinvasive squamous carcinoma in a conization specimen in which both the internal conization margin and post-conization ECC are negative have a low risk of residual invasion and are candidates for follow-up or simple hysterectomy. If either the internal margin or the post-conization ECC contains dysplasia or carcinoma, the risk of residual invasion is high and warrants repeat conization before definitive treatment planning.