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ABSTRACT: There are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients.
We performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome.
Fifty-eight women (mean age 34.9 years, range 27-39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n=56) patients presented directly to our symptomatic clinic; 89.5% (n=51) patients had a palpable lump; 71.9% (n=41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13cm (2.58mm) for BCS and 3.95cm (6.38mm) for mastectomy. From a total of 55 primary resections, 85.5% (n=47) of tumours were invasive ductal carcinoma; 57.4% (n=31) and 40.7% (n=22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n=28) while 40.0% (n=22) were lymph node positive for metastatic disease. 76.8% (n=43), 39.3% (n=22) and 30.2% (n=16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2-8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n=5) and 80.0% (n=44) of surgically treated patients respectively while 76.4% (n=42) patients received adjuvant radiotherapy. 76.4% (n=42) of patients were treated with tamoxifen. Four patients received Herceptin therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p=0.038), administration of neo-adjuvant treatment (p=0.019), surgical intervention (p<0.001), progesterone receptor positivity (p=0.018) and tumour recurrence (p<0.001). 86.0% (n=49) patients were alive at mean follow-up of 52 months; 82.5% (n=47) remain disease free.
Our study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.
Breast (Edinburgh, Scotland) 04/2010; 19(2):97-104. · 2.09 Impact Factor
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ABSTRACT: Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years.
Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses.
A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34-89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p < 0.001). Ultrasound upgraded nine of 14 mammographically normal and 16 of 29 mammographically indeterminate X-rays to a cancer. Mammography appeared to be more sensitive in patients over 50 years compared with those patients under 50 years (62.5% vs. 45.7%, p = 0.10). The sensitivity of ultrasound was comparable between patients above and below the age of 50 years (82.8% vs. 77.1%, p = 0.60). Further subgroup analysis demonstrated a higher sensitivity with combined mammography and ultrasound compared with mammography alone in either patient group (below 50: 45.7%-->77.1% and above 50: 62.5%-->82.8%). These results also suggested that the difference in the sensitivities of mammography vs. the combined investigation approach was more marked in patients under 50 years of age (below 50 = 31.4% vs. above 50 = 20.3%).
Adjunctive ultrasound assessment improves breast cancer detection in women of all ages and should be routinely used in symptomatic breast clinics.
International Journal of Clinical Practice 08/2009; 63(11):1589-94. · 2.41 Impact Factor
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ABSTRACT: BackgroundAn 83-year-old lady was admitted with a 3-day history of non-specific abdominal pain that had rapidly increased in severity
on the day of admission necessitating an emergency laparotomy. Intra-operative findings demonstrated a mechanical small bowel
obstruction secondary to a chronically inflamed appendix acting as a tourniquet around a loop of terminal ileum.
Learning pointThis case highlights an extremely rare and life-threatening complication of appendicitis.
Literature reviewTrue mechanical small bowel obstruction secondary to an acutely or chronically inflamed appendix encircling the distal small
bowel remains extremely rare with only ten cases reported in the literature.
ConclusionClinical assessment remains paramount in the treatment of these patients to facilitate prompt diagnosis and treatment which
is vital to provide an optimal platform for post-operative recovery and survival. Although CT imaging is a highly effective
investigative modality in these cases, operative treatment should not be delayed for a radiological investigation in the presence
of abdominal peritonism.
Irish Journal of Medical Science 02/2009; 178(1):101-105. · 0.58 Impact Factor
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ABSTRACT: Background: Folate is required for DNA synthesis, repair and methylation, and low folate status has been implicated in carcinogenesis possibly as a result of higher rate of genetic damage.Aim: To investigate the relationship between DNA damage and folate status in breast cancer and benign breast disease control patients.Materials and methods: Fasting blood samples from 52 histologically confirmed untreated breast cancer patients (mean age: 57 years) and 30 benign breast disease control patients (mean age: 51 years) were obtained. Mononuclear cells were isolated for genetic damage analysis using basic alkaline comet assay (which detects DNA single-strand breaks) and modified comet assay (using endonuclease III and formamidopyrimidine glycosylase (FPG) to recognize oxidatively damaged pyrimidines and purines, respectively). Results are expressed as tail moment.Results: Results were log transformed to normalize the data and presented as geometric mean (95 per cent confidence interval).Conclusion: DNA damage was found to be significantly higher in mononuclear cells of breast cancer patients compared to benign breast disease control patients. Breast cancer patients tended to have lower red cell folate and higher plasma homocysteine concentrations, but these differences were not significant. A mechanistic role for low folate status in the aetiology of breast cancer is under further investigation.
British Journal of Surgery 01/2009; 89(S1):52 - 52. · 4.61 Impact Factor
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ABSTRACT: BackgroundA 29-year-old man was admitted with a 7-day history of progressive non-specific abdominal pain that progressed to small bowel
obstruction following ingestion of a 20-pence coin 4-months previously. Colonoscopic retrieval was unsuccessful. A subsequent
laparotomy revealed a chronically inflamed thickened terminal ileum with mesenteric fat encroachment necessitating a right
hemicolectomy. Histopathological analysis confirmed Crohn’s disease with impaction of the 20-pence coin in a distal terminal
ileum stricture near the ileo-caecal valve.
Learning pointGastrointestinal foreign body retention should alert the clinician to the presence of an undiagnosed bowel abnormality. Furthermore,
failed endoscopic retrieval should be considered as a marker for potential underlying gastrointestinal pathology and a requirement
for operative intervention.
ConclusionThis case describes a rare presentation of Crohn’s disease and highlights the need to consider underlying gastrointestinal
pathology in patients presenting with a deteriorating clinical condition in the presence of an incidental foreign body.
Irish Journal of Medical Science 11/2008; 177(4):401-403. · 0.58 Impact Factor
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ABSTRACT: Breast conserving surgery (BCS) is increasingly offered to suitable patients diagnosed with early stage breast cancer. Occasionally the pathological margins on specimens following BCS are positive. The objective of this study is to assess the proportion of patients within our unit who required completion mastectomy after BCS and to determine if predictive factors could be identified to assist the breast surgeon identifying those patients at risk of positive margins following BCS.
All patients diagnosed with breast cancer between 2001 and 2005 were reviewed. Patients undergoing BCS had their histopathological specimens examined for any evidence of residual tumour at the margins of the resected specimen. These patients then proceeded to completion mastectomy if these margins were positive for residual tumour. Multinominal logistic regression was then performed on clinico-pathological factors for each of these patients to determine if predictive factors existed for determination of residual disease in the mastectomy specimen following BCS.
Logistic regression demonstrated that size of the initial tumour was the only significant predictor for the presence of completion mastectomy residual carcinoma (CMRC) (p=0.014) and that tumours with an initial size > 2.5 cm were 15 times more likely to have a CMRC than tumours < 1.5 cm. This prediction model based on the initial tumour size had an 89.5% specificity and 52.2% sensitivity. The odds ratio for CMRC based on histological tumour type for each additional 1cm increase in size of the initial tumour was 2.82 for ductal carcinoma in situ, 2.60 for infiltrating ductal carcinoma and 2.26 for other tumours.
This study demonstrates that residual disease in total mastectomy specimens following BCS increases significantly with increasing original tumour size. With current data, surgeons can inform patients of the risks of residual cancer associated with BCS with a view to increase the rate of primary mastectomies in those patients with presenting tumours greater than 2.5 cm.
The Breast 04/2008; 17(2):199-204. · 2.49 Impact Factor
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ABSTRACT: Fine needle aspiration (FNA) is an important adjuvant to the diagnosis of a palpable lesion which often permits the complete assessment of patients. The main objective of this study was to determine the clinical benefit of a dedicated FNA service at a tertiary referral Head and Neck Clinic and to assess if such a service is cost effective.
All patients attending the Head and Neck Clinic during 2004 were prospectively assessed in this study. Patient records were analysed regarding investigative modalities including FNA, the subsequent cytology result and the requirement for further histopathological investigations. A cost analysis for all investigative procedures was performed.
A total of 135 patients (36 males) had FNAs performed during the study period. The median age was 51.5 years (range 17-92). Patients presented with lesions of lymph nodes (n = 46), thyroid (n = 41), salivary, parotid or submandibular glands (n = 22) and other cutaneous or cystic lesions (n = 26). Cytological grading results were; C1 = 26, C2 = 93, C3 = 8, C4 = 2 and C5 = 6. Patients with lesions C3 or above normally proceeded to further investigations. The overall cost of the FNA per episode in the out-patient clinic was pound114 per episode compared to day case open biopsy per patient of pound333 and an in-patient stay per patient was pound2371. FNA provided sufficient pathological diagnosis to avoid day case surgery in 57 patients (42.2%), and inpatient surgery in 65 patients (48.1%) resulting in a total saving of pound158 372 in 2004.
This study demonstrates the clinical benefit and cost-effectiveness of FNA services in a dedicated Head and Neck clinic.
Cytopathology 02/2008; 20(2):81-6. · 1.59 Impact Factor
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ABSTRACT: A novel glycoprotein, pMQ1, is positively correlated with increasing histological grade in malignant astrocytomas. Cerebral metastases from breast cancer have also been found to contain pMQ1-positive cells. This study aimed to determine the role of pMQ1 in primary breast cancer.
Breast cancer specimens were analysed for pMQ1 by immunohistochemistry. The expression of pMQ1 was correlated with conventional prognostic indicators. Kaplan-Meier analyses were performed to compare clinical outcome between pMQ1-positive and pMQ1-negative tumours.
pMQ1 was expressed in most of the breast cancer specimens. The surrounding normal tissue margins and benign breast tissues always lacked pMQ1 expression. A significant positive correlation was observed between pMQ1 expression and histological grade, the presence of lymphovascular invasion and Nottingham Prognostic Index. Cancers that were pMQ1 positive were significantly more likely to develop a local recurrence.
pMQ1 appears to be a tumour-associated protein. The positive correlation of pMQ1 with histological grade, presence of lymphovascular invasion and Nottingham Prognostic Index suggests that it confers an adverse prognosis.
British Journal of Surgery 04/2006; 93(3):309-14. · 4.61 Impact Factor
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ABSTRACT: To determine the final histological and clinical diagnosis of patients with granulomatous lymphadenitis on fine needle aspiration cytology (FNAC).
A retrospective cohort study was carried out over a five year period in a tertiary referral hospital. FNAC of 22 patients with granulomatous lymphadenitis was reviewed and correlated with the final histological diagnosis and clinical outcome.
Fourteen cases (64%) underwent surgical biopsy for histological assessment. A definitive diagnosis on FNAC with ancillary investigations was achieved in 82% (18 out of 22) of the cases: four Hodgkin's lymphoma, two non-Hodgkin's lymphoma (NHL), five tuberculosis (TB), two toxoplasmosis, one sarcoidosis and four benign reactive changes.
A significant number of cases of FNAC diagnosed granulomatous lymphadenitis have an identifiable underlying cause. Patients with reactive cytological changes, who clinically appear benign, can avoid unnecessary surgery.
The Ulster medical journal 02/2006; 75(1):59-64.
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ABSTRACT: Folate is required for DNA synthesis, repair and methylation. Low folate status has been implicated in carcinogenesis, possibly as a result of higher rate of genetic damage. The aim of this study is to compare folate status and levels of DNA damage between breast cancer and benign breast disease control patients. Fasting blood samples from 64 histologically confirmed untreated breast cancer patients (mean age 57 years) and 30 benign breast disease control patients (mean age 51 years) were obtained. Red cell folate (RCF) and plasma homocysteine were measured. Mononuclear cells (MNC) were isolated for genetic damage analysis using the basic alkaline comet assay. Results are expressed as tail moment. Data were log transformed as appropriate before analysis for normalisation purposes. The geometric mean (95% confidence interval) of RCF (ng ml(-1)) in breast cancer patients was 339.07 (333.3-404.6) vs 379.5 (335.8-505.2) in control patients (P = 0.24). Corresponding plasma homocysteine concentrations (micromol l(-1)) were 11.9 (10.6-16.4) vs 10.1 (9.3-11.9) (P = 0.073), respectively. The mean tail moment (s.d.) of DNA damage in MNC of breast cancer patients detected by the basic comet assay was 1.4 (0.66) vs -0.17 (0.79) in controls (P < 0.0001, t-test), the modified comet assay 'endonuclease III (Endo III)' was 1.7 (0.70) vs 0.86 (0.81) (P < 0.0001, t-test), and the modified comet assay 'formamidopyrimidine glycosylase (FPG)' was 1.6 (0.62) vs 0.99 (0.94) (P < 0.0001, t-test). There was a significant negative correlation between RCF levels and DNA damage detected by modified comet assay 'FPG' (Pearson Correlation Coefficient r2 = -0.26, P = 0.02) and DNA damage was found to be significantly higher in MNC of breast cancer patients compared to benign breast disease control patients. Breast cancer patients tended to have lower RCF levels and higher levels of plasma homocysteine, but these differences were not significant. The study provides preliminary evidence that reduced folate status may be implicated in the aetiology of breast cancer perhaps by increasing the in vivo level of genetic instability.
British Journal of Cancer 04/2005; 92(8):1524-30. · 5.04 Impact Factor
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ABSTRACT: Complete axillary clearance is recommended as part of the treatment in selected patients with invasive breast cancer. There are a number of potential technical difficulties in performing level III axillary clearance including: the deep and high position of level II and III nodes, their close proximity to the axillary vein, the difficulty in adjusting the operating light to illuminate the different levels of the axilla and the need for at least one assistant to perform the procedure.
To evaluate a new axillary clearance retractor, which is designed to overcome the technical difficulties in axillary clearance.
The retractor was used for level III axillary clearance in 30 patients with invasive breast cancer either as part of total mastectomy (16 patients) or breast conservation surgery (14 patients). The retractor is table-based and provides simultaneous illumination to all levels of the axilla via light bundles. It has a long L-shaped component to retract the pectoral muscles and a self-retaining component to retract the skin edges. Assistants were not required in all patients. The details of the retractor and technique is described and literature reviewed.
The mean age of patients was 54 years (range 46-83) and the mean tumour size was 24.9 mm (range 11-70). The mean number of total lymph nodes removed was 19.4 nodes (range 11-50). The mean number of lymph nodes identified in level III dissection was 2.4 nodes (range 0-8). Six patients developed axillary seroma, which was treated by aspiration.
The axillary clearance retractor can be used with ease and without complications. It helps to overcome the technical difficulties in this operation.
The Breast 05/2004; 13(2):133-8. · 2.49 Impact Factor
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ABSTRACT: The management and outcome of 131 women with infiltrating lobular carcinoma treated in the Belfast City Hospital between October 1987 and February 1999 were reviewed. Two patients had primary hormonal treatment and were excluded from the statistical analysis, and 129 patients were followed up. Fifty-four patients (41%) had initial breast conservation surgery, which was followed by re-excision of margins in eight patients (14.8%) and completion total mastectomy in 26 patients (48.1%). The breast conservation surgery group, 28 patients (21.7%), was compared with the total mastectomy group, 101 patients (78.2%), after a median follow-up period of 90 months (range 24-160 months). The overall survival was 68.7%. Survival analysis was performed using Kaplan-Meier and Cox regression which showed that lymph node involvement and tumour grade were the only variables affecting survival (P<0.0001, and 0.01, respectively). The type of surgery performed did not affect survival (P=0.42). The total number of patients who developed local recurrence was 17 patients (13.1%, 12 patients in the breast conservation surgery group and five patients in the total mastectomy group, P<0.0001). Kaplan-Meier analysis of local recurrence showed that the type of surgery (P<0.0001), patient age (P=0.02), tumour grade (P=0.002), adjuvant radiotherapy (P=0.013), chemotherapy (P=0.031) and hormonal treatment (P=0.003) significantly affected local recurrence. Cox regression analysis showed that the only factor significantly affecting local recurrence was the type of surgery performed (P=0.02). Patients who underwent mastectomy had less local recurrence than those who had breast conservation surgery. Local recurrence after breast conservation surgery is high, even with clear surgical margins and post-operative radiotherapy. The authors believe that total mastectomy for infiltrating lobular carcinoma is a safer option to control local disease, especially in younger patients and those with high-grade tumours. Overall survival is not affected by the type of surgical treatment. Local recurrence can be a late event and a long-term follow-up is recommended.
The Breast 02/2003; 12(1):23-35. · 2.49 Impact Factor
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ABSTRACT: Aims: pMQ1 is a tumour-associated glycoprotein with characteristics suggestive of an adhesion molecule. The level of pMQ1 expression had been positively correlated with increasing histological grade in astrocytomas. pMQ1 was also found to be expressed in metastatic breast cancer in the brain. The aim of this study was to determine the correlation between the level of pMQ1 expression and known prognostic indicators in breast cancer.Method: Breast cancer (n = 228) were examined for pMQ1 expression, p53 and Ki-67 by the immunohistochemical method. The expression of pMQ1 was compared with known prognostic indicators (age, tumour size, histological grade, lymph node status, lymphovascular invasion, oestrogen receptor status, p53, Ki-67, Nottingham prognostic index and TNM-UICC staging) using a bivariate correlation analysis.Results: pMQ1 was expressed in 60 per cent (137/228) of the breast cancers. The normal surrounding tissue margins were negative for pMQ1 expression, and benign breast diseases always lacked pMQ1 expression. A significant positive correlation was observed between pMQ1 expression and the tumours' histological grade (P ≤ 0.00005), and lymphovascular invasion (P = 0.018). pMQ1 was inversely correlated with oestrogen receptor status (P = 0.001). However, no correlation exists between pMQ1 and age, tumour size and lymph node status. pMQ1 was significantly correlated with Nottingham prognostic index (P = 0.008) but not with TNM-UICC staging.Conclusion: pMQ1 has a positive correlation with tumour histological grade, lymphovascular invasion and Nottingham prognostic index, and inverse correlation with oestrogen receptor status. Therefore, pMQ1 may have prognostic importance in identifying biologically aggressive breast tumours.
British Journal of Surgery 12/1996; 89:73-74. · 4.61 Impact Factor
