Search

Although quality assurance guidelines for surgeons have been issued and adopted for use in population-based breast screening programs in Australia, similar guidelines are unavailable for women referred with symptomatic breast problems.Six hundred and ninety-six women who attended the Royal Adelaide Hospital Women's Health Centre between February and November 1998 for investigation and management of a new breast-related complaint were prospectively evaluated. Investigation strategies and outcomes of the initial consultation were determined and the results compared with the performance quality standards for symptomatic breast disease according to the British Association of Surgical Oncology (BASO) Breast Surgeons' Group.A breast lump was the presenting symptom in 45%, while breast pain was present in 26%. Ninety per cent of women referred with breast symptoms were given a definitive benign or malignant diagnosis at the initial clinic visit. Although the median time delay between the date of general practitioner referral and breast clinic appointments for all patients wasor =7 days, the time delay for 'urgent' cases was not met according to BASO performance indicators. All other Royal Adelaide Hospital Breast Clinic audit data were within the range suggested by BASO performance indicators for new consultations in a symptomatic breast assessment clinic.A multidisciplinary breast clinic in a public hospital setting is able to provide clinical services to symptomatic women, with the majority of patients obtaining a confident diagnosis at the first presentation. Performance indicators for symptomatic breast disease are useful in identifying inadequacies at the clerical or clinical level which, following the implementation of subsequent changes, may lead to improvement in patient outcomes.

CD1a molecules are expressed on dendritic cells (DC) during certain maturational phases coincident with the functions of antigen capture and processing. During these phases, CD1a is anchored to the cytoplasmic membrane through its cytoplasmic domain and the antigenic binding domain is projected from the cell surface. Membrane bound HLA Class I and II molecules are also expressed at relatively high levels on DC, but it is not known whether there is any interdependence between CD1 expression and that of the classical histocompatability molecules. Recent information concerning the structure, function and likely role of CD1 in presentation of hydrophobic lipid and carbohydrate antigens to the immune system is detailed. The potential relevance of the lipid presenting functions of CD1 molecules for the detection and recognition of tumour glycolipid antigens is hypothesised and discussed. CD1 a tumour infiltrating putative dendritic cells are discussed in terms of their density, separation, culture and possible function in breast cancers in the light of recent findings.

Identification of dendritic cells (DC) in human tissues has been technically problematic due to the lack of truly specific immunohistochemical markers for DC's. Human dendritic cells express CD1a glycoprotein at certain points in their life cycle. CD1a positive cells are present in many human tumours and have been associated with improved survival. However, little information exists concerning the separation of DC from human tumours. The current study reports that human breast carcinomas have low densities of CD1a positive cells with dendritic morphology, and details are shown of a technique for successful separation of these cells from tumour tissues.

Tumor-infiltrating lymphocytes (TIL) are found in most human infiltrating ductal breast carcinomas. In studies of other tumors, TIL were capable of activation by IL-2, both in vitro and in vivo, to produce selective tumor cytolysis. Specific TIL-mediated tumor cytolysis in human breast tumors has recently been reported. The large numbers of TIL within human breast cancers imply that an immune response is occurring, since many of these cells express HLA class II as a late activation marker. However, the degree of early activation of the native TIL in breast tumors has not been fully investigated. Early activation markers CD69, CD43, and CD38 together with the IL-2R (CD25) and IL-2 cytokine were examined using mAbs and tissue section immunohistology. In situ hybridization was used to detect IL-2 mRNA (IL-2 mRNA) in parallel with immunohistochemical localization of IL-2. The results revealed the expression of CD69, CD43, and CD38, but markedly low CD25 (IL-2R) and IL-2 protein expression by the TIL. This strongly indicates that the TIL are an activated population of T cells that shows a deficiency in IL-2 protein and IL-2R expression despite adequate levels of IL-2 mRNA. The mechanism for apparent inhibition of IL-2 production and IL-2R expression in the presence of IL-2 mRNA is currently unclear; however, this may explain the relative anergic state of native TIL.

To assess the degree to which limb-sparing surgery is implemented in patients with soft-tissue sarcoma, and its outcome.A detailed review of 40 patients who were all tertiary referrals to one surgeon, and general review of all 215 patients with sarcoma treated in South Australia between 1986 and 1992.Conservation of the limb by wide resection or marginal resection of soft tissue, combined when necessary with radiotherapy. Amputation was used when limb conservation failed or was not possible.Median survival time after treatment.Limb-sparing treatment was successful in 37 of the group of 40 patients. Thirty-two patients received adjuvant radiotherapy, and 19 received chemotherapy. Median survival time was 35 months. Review of all 215 patients with sarcoma revealed a higher initial amputation rate and a lower use of combined treatment methods than in our series. Twenty-six patients (65%) were initially incorrectly diagnosed before referral, resulting in a median delay in treatment of 16 weeks.The concept of limb-sparing surgery is well established, but is not yet as widely practised for limb sarcomas as it could be. Delay in diagnosis is a significant problem.