Conservative treatment of minimal breast cancer.
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Biomedical subjects
Publications and source records attributed to F Fontaine.
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At the conclusion of this study based on 327 cases of breast cancer T1, T2 T3 (less than 7 cm) No, N1, Mo Pev O, treated by mastectomy and axillary dissection without previous treatment, it appears that the microscopic dissemination to the nipple has a pejorative prognosis value. The 5 years is 84 p. 100 when there is no nipple dissemination, 74 p. 100 when there is an intraductal nipple dissemination, and 57 p. 100 when there is lymphatic or interstitial nipple dissemination. These differences have a statistical value. This value does not seem connected with other pathological prognosis factors: tumors size, Bloom histopronostic grading, and the number of nodes invaded. The intra-mammary spread without nipple involvment has no prognostical value.
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Two groups of patients with folic acid responsive neurological and psychiatric disorders are reported. The first group (7 patients) had well-established acquired folate deficiency due either to defective absorption (4 cases with atrophy of jejunal mucosa) or to a deficient diet (3 cases). One patient had a subacute combined degeneration of the spinal cord while others were depressed and had weight loss, permanent muscular and intellectual fatigue, restless legs syndrome, depressed ankle jerks, diminution of the sense of vibration in the knees and a stocking-type tactile hypoesthesia. The second group (9 patients) comprised idiopathic cases of folic acid deficiency. Their main subjective complaints were chronic fatigability and familial restless legs syndrome. The neurological findings were similar to those of the patients with acquired disorders. Neuropsychological testing procedures revealed an abnormal intellectual functioning in all 16 patients. Abnormal patterns of radionuclide cisternograms and computerized transaxial tomography (CTT) were found in 11 patients. After 6-12 months of folic acid therapy a striking improvement regarding their intellectual functioning was noticed: the IQ, Kohs Block Design and Category tests were significantly improved. The correlation of neuropsychological findings with CTT and radionuclide cisternograms led to the conclusion that chronic folate deficiency could induce cerebral atrophy.
At the conclusion of this study based on a careful histological analysis of 454 mastectomy specimens carried out at the Institut Gustave-Roussy between 1966 and 1971 it appears that 39 per cent of tumours which are neither central nor deep to the nipple have microscopic foci outside the main focus of tumour of which 24 per cent are at the level of the single nipple. The importance of these extensions is bound up with the size and histological type of the adenocarcinoma: pure intraduct and infiltrating lobular forms are accompanied frequently by microscopic intramammary foci at a distance (89% and 72%) the opposite of findings in the case of well differentiated and medullary forms. On the other hand no connection between the Scarff and Bloom grading is apparent except where the nipple only is involved. Finally there is a strong relationship between intramammary dissemination and regional lymph node metastases.
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Some of the complications which occur after classical treatment of breast cancer can best be treated by use of the omental flap described by Kiricuta. These include radionecrosis of the chest wall, skin defects occuring after radical mastectomy combined with maximal irradiation, and local recurrence taking place after classical treatment. The results from the Gustave-Roussy Institute, which include experience with twenty omental flaps performed in breast cancer patients, confirm the exceptional qualities of this flap, especially reconstructing defects in irradiated tissue.
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The affinity of new urinary 18-hydroxy-steroid (Cp x) for mineralocorticoid receptors was estimated. When rat kidney slices were incubated with 2 x 10(-9) M 3H-aldosterone, Cp x (2 x 10(-5) M) was able to compete with aldosterone for the mineralocorticoid cytosol receptors. Cp x had low but significant affinity for mineralocorticoid receptor sites. This affinity was less than that obtained with 18-OH-progesterone. Moreover, in the adrenalectomized rats, the injection of Cp x induced a decrease of urinary Na+/K+ ratio which seems comparable to that obtained with 18-OH-progesterone.
At the Symposium in Teheran two aspects of radiotherapy in mammary cancer came up for discussion: post-operative radiotherapy and the possibilities of conservative treatment, combining tumorectomy ("lumpectomy", "tylectomy ") for stage 1 cases. The place of post-operative irradiation was discussed in relationship to the appearance of local recurrences, metastases and the survival rates available from published data (therapeutic trials and retrospective studies) and in relationship with a population of 206 cases treated at the Gustave Roussy Institute between 1963 and 1966. The possible relationship between post-operative irradiation and immunity were mentioned. With identical wide surgical excision the essential role of post-operative irradiation consists of diminishing in a significant fashion the level of local recurrences. With more restricted surgery of the simple mastectomy type one asks whether irradiation could not replace radical node dissections. It should be reserved for the bad N+ cases. A retrospective study of 44 cases coded T1 NO/N1 MO/PevO treated by tumorectomy and cobalt 60 was compared with 44 matching cases which differed only in their local treatment which consisted of wide surgical excision. The survival actuarial rate at 8 years is 88.6% for the more conservatively treated group compared with 73% for the radical group. In order to provide a quite impartial result a WHO therapeutic trial was begun in 1972.
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The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.