Biomedical subjects
Publications and source records attributed to M J Greenall.
This paper reviews the development of excess breast tissue in the male. Gynaecomastia is a common problem and may have a physiological or pathological basis. It can be dealt with in most cases by reassurance or simple surgery.
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Two cases of soft tissue liposarcoma are presented occurring in a husband and wife. Their treatment is discussed and the possible infective or environmental causes of soft tissue sarcoma development are described.
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Lipid synthesis by freshly isolated human apocrine glands has been measured by the incorporation of [U-14C] acetate. Incorporation is linear over 6 h at 1010 +/- 282 pmol/mg wet weight/h (n = 11; mean +/- sem). The lipid classes, as percentages of the total lipid synthesized, were found by TLC to be cholesterol 12.3 +/- 2.0, mono-glycerides 7.5 +/- 1.5, 1,2 di-glycerides 3.0 +/- 0.9, 1,3 di-glycerides 3.5 +/- 0.5, tri-glycerides 28.4 +/- 1.8, free fatty acids 2.0 +/- 0.4, lysolecithin 15.4 +/- 3.9, sphingomyelin 9.9 +/- 4.3, phosphatidyl-choline 8.4 +/- 0.4, phosphatidyl-ethanolamine -inositol and -serine 1.8 +/- 0.1, phosphatidic acid and cardiolipin 3.3 +/- 0.5, and unidentified 3.3 +/- 0.5 (mean +/- sem, n = 5). Glands were maintained on permeable supports. After 10 d maintenance, electron microscopy showed that the cellular architecture had been preserved, that the ATP contents were the same as in freshly isolated glands, and that [U-14C] acetate incorporation was not significantly altered at 851 +/- 237 pmol/mg/h (n = 18). The addition of 3 microM testosterone had no effect on acetate incorporation at 844 +/- 231 pmol/mg/h (n = 18). The lipid classes and their proportions were similar to the values for fresh glands after 10 d maintenance both with and without testosterone.
Patients attending a breast clinic in two different periods were studied. In the first period fine needle aspiration cytology (FNAC) was not available and in the second it was used on all discrete solid breast lumps and reported immediately in the clinic. With the use of FNAC the overall surgical excision rate for discrete solid lumps was reduced from 83 per cent to 41 per cent and the excision rate in patients with benign disease was reduced from 74 per cent to 23 per cent (P less than 0.001). All patients with breast cancer in the second period had malignant cytology and no patient with benign or acellular cytology has been shown, after a minimum follow-up period of 18 months, to have breast cancer. Using FNAC with immediate reporting, the number of operations performed in patients with benign breast disease can be safely reduced.
One hundred and fifty one new patients attending a breast clinic over a 6 month period underwent fine needle aspiration cytology (FNAC), with immediate reporting of the smears in the clinic. Thirty nine smears (25.8%) were classified as unequivocally malignant, 10 (6.6%) as being suspicious of malignancy, 61 (40.3%) as benign and 41 (27.1%) were acellular. There were no false positive diagnoses and only one false negative cytological diagnosis of breast cancer [corrected]. Immediate reporting of results enabled the diagnosis to be discussed with the patient at the first attendance and allowed improved surgical management of both benign as well as malignant breast disease.
Of 83 patients with recurrent epidermoid cancer of the anus, 67 had tumors in the anal canal and 16 had tumors at the anal margin. Local pelvic or perineal recurrence after abdominoperineal resection of tumors in the canal had a poor prognosis. Median survival after combination chemotherapy and megavoltage irradiation was 14 months. With irradiation alone, median survival was 7 months, although nearly half of these patients had been treated with orthovoltage techniques. Untreated patients with visceral metastases had a median survival of 8 months, but no improvement in survival was seen after treatment with chemotherapy. In contrast, patients who had metastases in inguinal lymph nodes had a 55% 5-year survival rate after inguinal dissection. Patients with tumors at the anal margin did not have visceral metastases. This is an important difference between tumors arising in the canal and those arising at the anal margin. Local excision was satisfactory treatment for 90% of the patients who had local recurrence in the perianal skin; abdominoperineal resection was rarely required. Inguinal lymph node metastases from margin cancer are uncommon, but three of five such patients survived 5 years after groin dissection. A combination of 5-fluorouracil, mitomycin C, and radiation therapy was used for patients with pelvic recurrence after abdominoperineal resection of epidermoid cancer of the anal canal. In this study, there was no evaluation of the role of megavoltage irradiation alone at the recommended doses of 5500 to 6000 rad for these patients. Some patients with visceral metastases respond to combination chemotherapy, but median survival is not improved; evaluation of new chemotherapeutic regimens is required. Patients with canal tumors metastatic to inguinal nodes should be treated by groin dissection as their prognosis is relatively good. Local recurrence of tumors at the anal margin can be satisfactorily treated by further local excision; those patients with margin tumors metastatic to inguinal nodes require groin dissection.
Adriamycin is the only active single agent for patients with metastatic sarcoma; combination chemotherapy regimens that omit Adriamycin are ineffective in adults. Despite early success with CYVADIC, there have been recent doubts regarding its efficacy. No other chemotherapeutic combination has provided consistently better results than CYVADIC. As complete responses occur in less than 15 per cent of patients there is a need for further evaluation of new regimens. It is necessary to evaluate new regimens in prospective, randomized studies. Response criteria should be consistent and reproducible. Attenuation schedules and data relating to the total administered dosage should be provided. It would also be beneficial to analyze prognostic variables so that patients liable to an unfavorable outcome could be identified before commencement of treatment.
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The presence of bilateral invasive breast cancer places the patient in a state of double jeopardy. At Memorial Sloan-Kettering Cancer Center, the overall 10-year recurrence rate for unilateral Stage I breast cancer was 16%, whereas the recurrence rate for simultaneous, bilateral Stage I breast carcinoma was 29%: almost twice as high. The average 10-year survival of all patients with negative axillary nodes was 57%. In this retrospective analysis of 403 patients with bilateral primary operable breast cancer treated at Memorial Sloan-Kettering Cancer Center, significant differences were noted in the disease-free survival between patients with bilateral noninvasive cancer, bilateral invasive cancer, and the combination of invasive and in situ cancers. Bilateral intraductal cancer and lobular carcinoma in situ offered an excellent prognosis. The combination of preinvasive cancer on one side and infiltrating carcinoma on the other had the next best survival. The in situ lesion, when treated by mastectomy, did not alter the patients' life expectancy from that of the general population with unilateral breast cancer, thus indicating that surgeons should strive to detect breast cancer in its preinvasive form. The 5- and 10-year relapse-free survival of patients with bilateral invasive disease, regardless of axillary nodal status and tumor size, was 60% and 51%, respectively, for patients with a bilateral presentation and 54% and 38%, respectively, for carcinomas presenting metachronously. More important in determining prognosis, however, was the number of axillary nodes involved and the level of involvement. Invasion of bilateral axillary nodes at all levels predicted a poor prognosis. Because of this shortened survival, systemic adjuvant therapy should be considered for patients with bilateral invasive disease. The most common preinvasive breast cancer was lobular carcinoma in situ and the most frequently invasive tumor was infiltrating duct cancer. Since a contralateral breast cancer at the time of definitive treatment of the first side does not always present as a mass or with positive mammography, a random biopsy of the second breast is recommended. This should be done in the upper, outer quadrant and should include the subareolar area. With prompt adequate treatment, it is expected that survival from bilateral breast cancer should improve.
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The results of elective gastrectomy and vagotomy with drainage for benign gastric ulcer are described in terms of operative mortality, recurrent ulceration, overall clinical results, and risk of malignancy. Although it has a slightly lower operative morbidity and mortality, the results of vagotomy with drainage are not sufficiently superior to abandon gastrectomy. Highly selective vagotomy, without drainage, provides good overall clinical results but has a high associated incidence of recurrent ulceration. Neither gastrectomy nor vagotomy with drainage have a distinct advantage in patients with combined gastroduodenal or prepyloric ulceration.
Epidermoid cancer of the anal margin should be distinguished from that in the canal because of its different clinical and pathologic characteristics, the suitability of local excision for its treatment, and its better overall prognosis. In addition, margin cancer rarely metastasises to visceral sites. Forty-eight patients with epidermoid cancer of the anal margin were reviewed. Two refused treatment, 4 had palliative therapy for advanced, inoperable disease, 31 had local excision, and 11 were treated by abdominoperineal resection. Local excision provided satisfactory results with a corrected 5 year survival of 88 percent, although locoregional recurrence developed in 46 percent of these patients during follow-up. A second local excision or inguinal lymphadenectomy provided good results in the patients with recurrence. Abdominoperineal resection did not provide better overall survival figures.
Epidermoid carcinoma of the anal canal should be differentiated from that of the anal margin because of the different clinical presentations, pathologic characteristics, treatments and prognosis. The traditional treatment for carcinoma of the canal, abdominoperineal resection, produced a 55 per cent absolute five year survival rate but at the expense of permanent colostomy. Initial treatment with 5-fluorouracil and mitomycin C combined with external beam radiation therapy reduced the size of the tumor in 72 per cent of the patients and, with subsequent local excision or abdominoperineal resection, resulted in a 78 per cent survival rate in five years. The long term results from combined treatment are better than abdominoperineal resection alone with preservation of anal function in 45 per cent of the patients.
One hundred patients undergoing appendicectomy through a right iliac fossa incision were randomized to receive normal saline or 500 mg metronidazole as an intravenous infusion during the operation. One patient in the saline group developed an erythematous rash. There were 13 wound infections (as defined by the discharge of pus), 12 (out of 51) in the saline group and 1 (out of 49) in the metronidazole group. Bacteroides spp. were frequently cultured from the lumen of removed appendices and from pus obtained from infected wounds. This work supports the value of metronidazole but suggests that a single-dose regimen is adequate for prophylaxis.
Two hundred and thirty consecutive patients undergoing laparotomy were randomly allocated to one of three single-dose intra-incisional prophylactic regimens: clindamycin, clindamycin plus cephaloridine, and cephaloridine alone. Wounds were classified on a bacteriological basis into four groups: clean, potentially contaminated, lightly contaminated and heavily contaminated. The first two of these groups had a low incidence of wound sepsis (6.6%), the third an incidence of 19.7% and the last of 53.1%. In the latter two groups clindamycin was a significantly less effective prophylactic than cephaloridine, and the combination of the two antibiotics was no more efficacious than cephaloridine alone. The high in vitro activity of cindamycin against Bacteroides species was not mirrored in vivo.
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