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TREATMENT OF EARLY CANCER OF THE BREAST
1366
only of cancer of the oesophagus but also of cancers involving other outgrowths of the anterior foregut region (including the liver and pancreas). The hardness of the teeth and nails might also be important, and perhaps the incidence of cancers arising in the ducts related have records
to
DIABETES AND CŒLIAC DISEASE SIR,-I should like to reply to the letter of Professor
not
the cloacal region. Edinburgh 12.
HELEN RUSSELL.
Hooft and his colleagues (Nov. 29, p. 1192). They refer to confusion about the term " coeliac disease ". My definition is as follows: coeliac disease is a disease of the small intestine chiefly affecting its proximal portion, occurring in children. It is characterised by an abnormal small intestinal mucosa (usually flat) and associated with a permanent intolerance to
gluten. TREATMENT OF EARLY CANCER OF THE BREAST SiR,łThe type of axillary node sampling advocated by Dr. Hulbert (Dec. 6, p. 1259)-" to remove representative nodes for histological examination and to ablate all grossly enlarged nodes needs some qualification and elaboration. Nodes are only known to be representative where the composition of the whole group from which they are taken is known. If, for example, 2 or 3 lymph-nodes in an axillary clearance containing 20 or 30 nodes contain " metastases, what would constitute " representative nodes ? Certainly two lymph-nodes which contained metastases would not be representative. Again, where several lymphnodes contain metastases it may be that one node is not representative of tumour pattern or tumour-lymphoid tissue interrelationship-histological appearances which influence some clinicians in the management of mammary cancer.
There is an added practical difficulty, and that is of the detection at operation of small lymph-nodes (1-2 mm.), though it is a procedure which is relatively easy in the fixed specimen. At operation in a case where there is no clinical evidence of lymph-node enlargement, it is the larger, not necessarily the representative nodes, which are most likely to be removed by the surgeon. Thus the small nodes with their small deposits will remain undiscovered, and irradiation, which " has a good chance of destroying node-metastases under 3 cm. in diameter will not under these circumstances be utilised. These comments are, of course, only from the pathological viewpoint, and should not be interpreted as
favouring
any particular therapeutic Department of Histopathology, Royal Marsden Hospital,
procedure.
London S.W.3.
A. LEVENE.
DIABETES AND CANCER SIR,-Dr. Henderson’s hypothesis (Aug. 30, p. 469) that local concentrations of islet hormones affect the metabolism of the exocrine pancreas is certainly intriguing. A particularly interesting observation which might be relevant to this hypothesis is the apparently increased incidence of carcinoma of the exocrine pancreas in patients with diabetes mellitus. Many studies (briefly reviewed by Cohen 1) have revealed an increased incidence of pancreatic carcinoma in diabetics, although the overall incidence of cancer of all sites is apparently no greater than in the general population. Warren et al.2 cite a threefold greater frequency of cancer of the pancreas among diabetics. Cancer of the pancreas is apparently the only neoplasm manifesting a positive correlation with longstanding diabetes. This higher incidence may be related to alterations in the hormonal environment of the exocrine system of the pancreas. The effect of drugs which stimulate insulin secretion-probably at the cost of decreasing local concentration-on the incidence of pancreatic carcinoma will have to be carefully observed. Grant Hospital of Chicago, CHARLES K. TASHIMA. Chicago 60614. 1. 2.
Cohen, G. F. Lancet, 1965, ii, 267. Warren, S., Le Compte, P., Legg, M. Mellitus. Philadelphia, 1966.
The term " malabsorption syndrome" is used as a broader expression to embrace all forms of malabsorption in children, thus including coeliac disease, cystic fibrosis, &c. Both the children described by us 1,2differ from Professor Hooft’s patients in having completely flat small intestinal mucosa: and in having responded to a gluten-free diet. Thus, by our criteria, these children appear to have coeliac disease and diabetes mellitus, whereas Professor Hooft’s patients do not fulfil these criteria for coeliac disease and we would place them in the broader category of the malabsorption syndrome. Biopsy appearances similar to those described by Professor Hooft in his patients have been seen at the Royal Alexandra Hospital for Children3 in various disorders of the small intestine including post-gastroenteritis malabsorption, giardiasis, and stronglyoidiasis. Such partial villous atrophy appears to represent non-specific intestinal damage. A flat mucosa can occur in childhood in diseases other than coeliac disease,4,,, but in our experience of 63 biopsy specimens with flat mucosx, all except 1 child6 had coeliac disease according to our criteria. Royal Alexandra Hospital for Children, Camperdown, New South Wales, Australia.
STERILISATION BY OVARIOTEXY SIR,-The technique for sterilisation by ovariotexy, described by Professor Wood and Mr. Leeton (Dec. 6, p. 1213), is both interesting and elegant. Clearly the demand for reversible surgical sterilisation of women presents a challenge to the techniques of gynaecology. As an anatomist with an interest in reproductive processes, I should like to comment on thereversal " aspect of the technique. The paper does not describe a case of proven reversal, but implies that potential reversibility is a feature which may be mentioned in the advice to the patient. I would draw your attention to recent work which suggests the importance to normal function of local feedback mechanisms between uterus and ovary.To my knowledge, no experiments have yet confirmed (or denied completely) that interference with the local blood-vascular or lymphatic pathways consistently produces lasting abnormalities of ovarian-uterine physiology in any mammal; but it is clear that in some cases such interference has produced effects.8 One may still retain an open mind as to the relevance of this in humans, but it is well to be aware of the problem. One wonders whether, with reversal in mind, it might be safer (if technically feasible), to bury the ovary without extensive mobilisation, and in particular without severing the round ligament of the ovary or separating the ovarian pedicle from the epoophoron. I realise that in ovariotexy the prime consideration should be reliable sterilisation, but would feel
happier if the surgeon bore in mind our ignorance
Walker-Smith, J. A., Grigor, W. Lancet, 1969, 1, 1021. Walker-Smith, J. A., Vines, R., Grigor, W. ibid. Sept. 20, 1969, p. 650. 3. Walker-Smith, J. A. Med. J. Aust. 1969, 1, 382. 4. Burke, V., Kerry, K. R., Anderson, C. M. Aust. pœdiat. J. 1965, 1,
1. 2.
147. 5. 6. 7.
A. The
J. A. WALKER-SMITH.
Pathology of Diabetes 8.
Stanfield, J. P., Hutt, M. S. R., Tunnicliffe, R. Lancet, 1965, ii, 519. Walker-Smith, J. A., Reye, R. D. K., Soutter, G. B., Kenrick, K. G. Archs. Dis. Childh. 1969, 44, 527. Moor, R. M., Rowson, L. E. A., Hay, M. F., Caldwell, B. V. J. Endocr. 1969, 43, 301. Bland, K. P., Donovan, B. T. ibid. p. 259.
only of cancer of the oesophagus but also of cancers involving other outgrowths of the anterior foregut region (including the liver and pancreas). The hardness of the teeth and nails might also be important, and perhaps the incidence of cancers arising in the ducts related have records
to
DIABETES AND CŒLIAC DISEASE SIR,-I should like to reply to the letter of Professor
not
the cloacal region. Edinburgh 12.
HELEN RUSSELL.
Hooft and his colleagues (Nov. 29, p. 1192). They refer to confusion about the term " coeliac disease ". My definition is as follows: coeliac disease is a disease of the small intestine chiefly affecting its proximal portion, occurring in children. It is characterised by an abnormal small intestinal mucosa (usually flat) and associated with a permanent intolerance to
gluten. TREATMENT OF EARLY CANCER OF THE BREAST SiR,łThe type of axillary node sampling advocated by Dr. Hulbert (Dec. 6, p. 1259)-" to remove representative nodes for histological examination and to ablate all grossly enlarged nodes needs some qualification and elaboration. Nodes are only known to be representative where the composition of the whole group from which they are taken is known. If, for example, 2 or 3 lymph-nodes in an axillary clearance containing 20 or 30 nodes contain " metastases, what would constitute " representative nodes ? Certainly two lymph-nodes which contained metastases would not be representative. Again, where several lymphnodes contain metastases it may be that one node is not representative of tumour pattern or tumour-lymphoid tissue interrelationship-histological appearances which influence some clinicians in the management of mammary cancer.
There is an added practical difficulty, and that is of the detection at operation of small lymph-nodes (1-2 mm.), though it is a procedure which is relatively easy in the fixed specimen. At operation in a case where there is no clinical evidence of lymph-node enlargement, it is the larger, not necessarily the representative nodes, which are most likely to be removed by the surgeon. Thus the small nodes with their small deposits will remain undiscovered, and irradiation, which " has a good chance of destroying node-metastases under 3 cm. in diameter will not under these circumstances be utilised. These comments are, of course, only from the pathological viewpoint, and should not be interpreted as
favouring
any particular therapeutic Department of Histopathology, Royal Marsden Hospital,
procedure.
London S.W.3.
A. LEVENE.
DIABETES AND CANCER SIR,-Dr. Henderson’s hypothesis (Aug. 30, p. 469) that local concentrations of islet hormones affect the metabolism of the exocrine pancreas is certainly intriguing. A particularly interesting observation which might be relevant to this hypothesis is the apparently increased incidence of carcinoma of the exocrine pancreas in patients with diabetes mellitus. Many studies (briefly reviewed by Cohen 1) have revealed an increased incidence of pancreatic carcinoma in diabetics, although the overall incidence of cancer of all sites is apparently no greater than in the general population. Warren et al.2 cite a threefold greater frequency of cancer of the pancreas among diabetics. Cancer of the pancreas is apparently the only neoplasm manifesting a positive correlation with longstanding diabetes. This higher incidence may be related to alterations in the hormonal environment of the exocrine system of the pancreas. The effect of drugs which stimulate insulin secretion-probably at the cost of decreasing local concentration-on the incidence of pancreatic carcinoma will have to be carefully observed. Grant Hospital of Chicago, CHARLES K. TASHIMA. Chicago 60614. 1. 2.
Cohen, G. F. Lancet, 1965, ii, 267. Warren, S., Le Compte, P., Legg, M. Mellitus. Philadelphia, 1966.
The term " malabsorption syndrome" is used as a broader expression to embrace all forms of malabsorption in children, thus including coeliac disease, cystic fibrosis, &c. Both the children described by us 1,2differ from Professor Hooft’s patients in having completely flat small intestinal mucosa: and in having responded to a gluten-free diet. Thus, by our criteria, these children appear to have coeliac disease and diabetes mellitus, whereas Professor Hooft’s patients do not fulfil these criteria for coeliac disease and we would place them in the broader category of the malabsorption syndrome. Biopsy appearances similar to those described by Professor Hooft in his patients have been seen at the Royal Alexandra Hospital for Children3 in various disorders of the small intestine including post-gastroenteritis malabsorption, giardiasis, and stronglyoidiasis. Such partial villous atrophy appears to represent non-specific intestinal damage. A flat mucosa can occur in childhood in diseases other than coeliac disease,4,,, but in our experience of 63 biopsy specimens with flat mucosx, all except 1 child6 had coeliac disease according to our criteria. Royal Alexandra Hospital for Children, Camperdown, New South Wales, Australia.
STERILISATION BY OVARIOTEXY SIR,-The technique for sterilisation by ovariotexy, described by Professor Wood and Mr. Leeton (Dec. 6, p. 1213), is both interesting and elegant. Clearly the demand for reversible surgical sterilisation of women presents a challenge to the techniques of gynaecology. As an anatomist with an interest in reproductive processes, I should like to comment on thereversal " aspect of the technique. The paper does not describe a case of proven reversal, but implies that potential reversibility is a feature which may be mentioned in the advice to the patient. I would draw your attention to recent work which suggests the importance to normal function of local feedback mechanisms between uterus and ovary.To my knowledge, no experiments have yet confirmed (or denied completely) that interference with the local blood-vascular or lymphatic pathways consistently produces lasting abnormalities of ovarian-uterine physiology in any mammal; but it is clear that in some cases such interference has produced effects.8 One may still retain an open mind as to the relevance of this in humans, but it is well to be aware of the problem. One wonders whether, with reversal in mind, it might be safer (if technically feasible), to bury the ovary without extensive mobilisation, and in particular without severing the round ligament of the ovary or separating the ovarian pedicle from the epoophoron. I realise that in ovariotexy the prime consideration should be reliable sterilisation, but would feel
happier if the surgeon bore in mind our ignorance
Walker-Smith, J. A., Grigor, W. Lancet, 1969, 1, 1021. Walker-Smith, J. A., Vines, R., Grigor, W. ibid. Sept. 20, 1969, p. 650. 3. Walker-Smith, J. A. Med. J. Aust. 1969, 1, 382. 4. Burke, V., Kerry, K. R., Anderson, C. M. Aust. pœdiat. J. 1965, 1,
1. 2.
147. 5. 6. 7.
A. The
J. A. WALKER-SMITH.
Pathology of Diabetes 8.
Stanfield, J. P., Hutt, M. S. R., Tunnicliffe, R. Lancet, 1965, ii, 519. Walker-Smith, J. A., Reye, R. D. K., Soutter, G. B., Kenrick, K. G. Archs. Dis. Childh. 1969, 44, 527. Moor, R. M., Rowson, L. E. A., Hay, M. F., Caldwell, B. V. J. Endocr. 1969, 43, 301. Bland, K. P., Donovan, B. T. ibid. p. 259.