TREATMENT OF EARLY CANCER OF THE BREAST

TREATMENT OF EARLY CANCER OF THE BREAST

1259 WHITE-CELL AND PLATELET COUNTS* IN 20 PATIENTS BEFORE, DURING, AND AFTER TREATMENT WITH INTRA-ARTERIAL METHOTREXATE AND 8-HOURLY INJECTIONS OF CI...

157KB Sizes 3 Downloads 95 Views

1259 WHITE-CELL AND PLATELET COUNTS* IN 20 PATIENTS BEFORE, DURING, AND AFTER TREATMENT WITH INTRA-ARTERIAL METHOTREXATE AND 8-HOURLY INJECTIONS OF CITROVORUM FACTOR

proportion of cases.1 What are we to answer such a patient if she asks why this was not done at the time of the first operation ? The much-quoted Manchester trial did prove that postoperative irradiation suppresses the appearance or in the irradiated parts. Similar conclusions drawn by other observers.23 The risk of local recurrence is proportional to the size of the primary tumour and to the degree of axillary-node inolvement.4 Irradiation has a good chance of destroying node-metastases under 3 cm. in diameter,5 and it is more effective in preventing axillary recurrences in combination with formal axillary dissection than without it.In the treatment of early carcinoma of the breast it is, therefore, logical to explore the axilla in every case, to remove representative nodes for histological examination, and to ablate all grossly enlarged nodes. Postoperative irradiation can then be applied or withheld

recurrences were

accordingly. *

Platelet-counts were made visually after dilution of capillary blood in 1% ammonium-oxalate solution. This procedure causes loss of some platelets at the capillary site,’ and some are also unpredictably lysed by the diluent.1’ The true platelet-counts were therefore probably higher than those shown.

continued for a few days after the methotrexate infusions had been discontinued. Using monkeys,3 it was shown that methotrexate in saline, or saline alone, did not cause any such increase in platelet-counts, but that citrovorum factor alone, or citrovorum factor with methotrexate, did cause such an increase. We concluded that the platelet-counts were affected by citrovorum-factor injections, and were thus of no value in the control of this type of methotrexate therapy. We did give citrovorum factor to a few patients with idiopathic thrombocytopenia in the hope of inducing thrombocytosis, but this was not successful. Department of Pathology, Frenchay Hospital, Bristol.

R. D. EASTHAM E. H. MORGAN.

TREATMENT OF EARLY CANCER OF THE BREAST SIR,-Your leading article of Nov. 29 (p. 1175) advises participation in clinical trials in order to find the best treatment method from amongst the different ones now in use, all of which yield very similar survival-rates. In the choice of method we must, however, consider important factors apart from the survival-rate. Patients in the different treatment-groups with indistinguishable survivalrates do not fare equally well when we consider their peace of mind, which depends to a large extent on freedom from further trouble in the pectoral region, the axilla, and the neck. In the follow-up after wedge-excision of the tumour from the breast plus irradiation, one experiences difficulties in the interpretation of thickenings and lumps which are often felt in the heavily irradiated breast or axilla. These difficulties lead to frequent consultations and, possibly, to surgical exploration with all the attendant anxieties on the part of the patient and her relatives. Wedge-excision also carries a high risk of recurrence in the remainder of the breast, which then means the loss of the very organ the preservation of which was promised to the patient (as she will claim). In these circumstances the average patient will firmly believe that the initial treatment was a failure and that her case is a particularly bad one. Mastectomy without surgical or radiological treatment of the axillary nodes entails a " watch policy " which, even in a group of patients with primary tumours of only 2-7cm. average size, has led to delayed axillary dissection in a 1. 2.

3.

Borchgrevink, C. F. Acta med. scand. 1960, 168, 157. Eastham, R. D., Morgan, E. H. J. med. Lab. Technol. 1967, 24, 315. Hayes, D. M., Spurr, C. L., Deskins, W. B. Blood, 1961, 18, 797.

Participation in clinical trials is justified if all available information, as well as personal experience, leaves one choose between one method and another. For I am not taking part in any clinical experiment on oatients with early breast cancer which subjects randomly selected patients to incomplete removal of the breast, or to postoperative irradiation without proof of spread to the axillary nodes, or which omits postoperative irradiation when such proof has been obtained.

nothing that

to

reason

Department of Radiotherapy, Mary’s Hospital, London W.2.

St.

M. HULBERT.

LONG-ACTING ANTICONVULSANTS SIR,-In modern clinical psychiatry most schizophrenics are discharged from the mental hospital as soon as they become relatively symptom-free, usually after a few weeks of inpatient care. The maintenance and rehabilitation of these often chronically handicapped patients in the community has been much easier since the introduction of the long-acting phenothiazines, such as fluphenazine enanthate (’ Prolixin Enanthate Moditen ’) and fluphenazine decanoate (’ Modecate In our practice we often treat schizophrenics (or other severely disturbed patients) with convulsive disorders, and epileptic patients who have developed schizophrenia-like psychoses.’ In the hospital, with supervised phenothiazine and anticonvulsant treatment, many of these patients are manageable and improve. When discharged, however, they are unreliable, and tend to stop taking the anticonvulsant drugs regularly. Thus seizures develop, which result in deterioration and readmission to hospital. We feel that these patients would benefit from an anticonvulsant with a more prolonged action which could be administered intramuscularly. There are numerous anticonvulsants on the market at present, but we do not know of any with a prolonged action. We have also been unable to find any pharmacological or clinical study on long-acting anticonvulsants. It seems to us that such a medication would be especially useful in advancing the treatment of convulsive disorders in the mentallv ill. PAUL E. YARDEN LANE GLASSMAN BARBARA PIZARRO Bronx State Hospital, PRISCILLA GRANTHAM. Bronx, New York 10461. 1. Crile, G., Jr. Ann. Surg. 1968, 108, 330. 2. Robbins, G. F., Lucas, J. C., Fracchia, A. A., Farrow, J. H., Chu, F. C. H. Surgery Gynec Obstet. 1966, 122, 979. 3. Fletcher, G. H., Montague, E. D., White, E. C. Cancer, N.Y.

1968, 21, 791. Zimmerman, K. W., Montague, E. D., Fletcher, G. H. ibid. 1966, 19, 67. 5. Guttman, R. J. Am. J. Roentg. 1966, 96, 560. 6. Devitt, J. E., Beattie, W. G. Ann. Surg. 1964, 160, 71. 7. Slater, E., Beard, A. W. Br. J. Psychiat. 1963, 109, 95. 4.