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AIM: To determine the current practice in the UK National Health Service Breast Screening Programme for invasive diagnostic procedures and surgery in patients taking anticoagulant and antiplatelet medication. MATERIALS AND METHODS: Lead radiologists and surgeons at each breast screening service were surveyed to determine current practice. One hundred and five respondents provided information regarding their services, protocols, and willingness to proceed with combinations of procedures and anti-haemostatic medications. RESULTS: Between units there was wide variation in practice. Within 21 services providing more than one response, 10 (48%) disagreed on whether protocols existed. Decisions to perform biopsies were unrelated to professional group. The taking of a drug history was variable. Surgeons reported more adverse effects than radiologists [21 (48%) versus 12 (26%)], but no difference in self-assessment of knowledge. CONCLUSION: Both radiologists and surgeons have expressed uncertainty about their understanding of anticoagulant and antiplatelet treatment. This is reflected in a wide range of practice. Guidance regarding the management of these patients is suggested.

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AIM: To assess the impact of mammotome biopsy on preoperative diagnosis rate. METHODS: A prospective study was undertaken to examine the referral patterns, radiological abnormalities, sensitivity, specificity and outcome of the first 150 patients undergoing mammotome biopsy at our institution. Most of the referrals were from the NHS Breast Screening Programme (85/100). RESULTS: The commonest radiological abnormality was microcalcification (87%). The accuracy of this biopsy technique for the target lesion was over 99%. Post-biopsy, 11 patients needed to proceed to a diagnostic surgical biopsy (7%). Forty-two malignancies were identified at final histology; 41 were diagnosed preoperatively. The positive predictive of mammotome biopsy was 98% for the present study. The present results for mammotome biopsy with regard to predicting invasion were: sensitivity 71.4% (10/14); specificity 100% (0/0); positive predictive value 100% (10/10); and negative predictive value 87% (27/31). CONCLUSION: Prone mammotome biopsy has proven to be highly accurate, considerably improving the preoperative diagnosis within our unit, and obviating the majority of diagnostic excision biopsies.

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Accidental injury to the female breast can cause symptoms and signs which may mimic carcinoma and can also be painful or disfiguring. Nine women who sustained injury to the breast are presented, illustrating some of the manifestations of traumatic injury to the female breast, the majority of which are attributable to fat necrosis. A brief discussion of the clinical and imaging features of fat necrosis is included. These cases reinforce the importance of triple assessment in any woman presenting with a breast lump, even with a clear history of trauma.

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Invasive lobular breast carcinoma accounts for approximately 15% of all breast cancers and is difficult to detect using conventional breast imaging techniques. We report a comparison between clinical, ultrasound scan (USS), mammographic and magnetic resonance imaging (MRI) of 22 patients with invasive lobular breast carcinomas. Actual tumour size was ascertained by histopathology. MRI detected 21 of the 22 invasive lobular cancers whilst mammography and USS detected 16 and 20 respectively. 19 tumours were clinically palpable. MRI was more accurate at assessing tumour size than USS and clinical examination, both of which underestimated tumour size.

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Sentinel lymph node biopsy for invasive breast cancer is a new technique that has been shown to be accurate in staging the axilla. Patients with a positive sentinel node will potentially need a second operation to clear the axilla. A reliable technique for assessing lymph nodes intraoperatively could potentially avoid this second procedure. This study aimed to assess the accuracy of peroperative imprint cytology of axillary lymph nodes in patients with invasive breast carcinoma. A total of 157 nodes were studied. One-hundred and nineteen nodes were both negative on imprint cytology and paraffin section. Thirty-eight nodes were positive on imprint cytology. Of these, 37 were positive on histology. Imprint cytology is a rapid technique that is inexpensive and has been shown to be reliable in this and other studies. It may prove to be of value in patients undergoing sentinel lymph-node biopsy for breast carcinoma.

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Specimen scrape cytology (SSC) and tumour bed biopsy (TBB) were used to assess adequacy of wide local excision of breast cancer. Thirty-nine (49%) of 80 cases were SSC positive and 18 (23%) TBB positive. When the main specimen contained ductal carcinoma in situ (DCIS) 21 (66%) of 32 cases were SSC positive compared to 18 (38%) of 48 when DCIS was absent (chi 2 = 9.17, P < 0.01). TBB results were not affected by the presence of DCIS. These findings may reflect the multifocal nature of breast cancer and especially DCIS. It is postulated that positive specimen cytology could be a better indicator of inadequate local surgical treatment than involved tumour bed biopsies or positive margins judged by conventional histology.

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Intact surgical gloves provide an efficient barrier against the HIV and Hepatitis B viruses but glove perforations are common, particularly during mass closure of laparotomy wounds. Attempts to develop gloves immune to perforation have failed. A series of 100 consecutive laparotomy wounds were randomised to mass closure by either the 'hand in' technique currently favoured by many surgeons, or a 'no touch' technique manipulating the wound edges with instruments only. The two groups were similar with regard to grade of surgeon and assistant, proportion of routine and emergency cases, and proportion of clean or dirty cases. The wound lengths in each group were similar, and the time taken to close the abdominal wall was similar in both groups. Although a similar number of perforated gloves occurred in each group while the operative procedure was being performed ('hand in', 9 of 50 vs 'no touch', 12 of 50; P = 0.62); a significantly reduced number of glove perforations occurred in the 'no touch' group during wound closure ('hand in', 16 of 50 vs 'no touch', 3 of 50, P = 0.0017). No touch closure of the abdominal wall may provide protection to surgeons against blood-borne viruses such as HIV and hepatitis B.

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This paper describes a case of recurrent aorto-duodenal fistula treated successfully by re-sitting the duodenum in an ante-colic position. Secondary aorto-duodenal fistula affects less than 1% of patients who have received a prosthetic abdominal aortic graft. However following correction of such a fistula the incidence of recurrent fistulation or aortic stump blow-out is reported as high as 47%. we describe an alternative approach to management of this difficult problem.

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Using a specially designed incubation chamber, differential synthesis and the response to added arachidonic acid (25 mM) and L-alpha-phosphatidylcholine (LAP; 2 mM) was quantified in gallbladders from male and female dogs. Prostaglandin I2 (PGI2) was the predominant prostanoid synthesized, and tissues from females produced much more PGI2 under basal conditions than did gallbladders harvested from male dogs. Addition of arachidonic acid stimulated PGI2 synthesis by almost 100 per cent. Arachidonate-stimulated mucosal and serosal production of PGI2 were (mean(s.e.m.] comparable, 343(178) and 375(89) pg/cm2/min, respectively. Gallbladders from female animals synthesized significantly more PGI2 than did tissue from males. Indomethacin inhibited PGI2 synthesis in a dose-response manner; at 7 x 10(-5) M, prostanoid synthesis was inhibited by greater than 80 per cent. Arachidonic acid did not stimulate prostaglandin E2 (PGE2) production by gallbladder tissue. LAP similarly stimulated PGI2 biosynthesis, but in contrast to the effect of arachidonic acid, the effect was significantly greater in the serosa than the mucosa, 355(107) and 213(59) pg/cm2/min, respectively. LAP also stimulated PGE2 biosynthesis by the canine gallbladder in a pattern very similar to that of PGI2. Based on the differences in response to the two agents added, we conclude that arachidonic acid and L-alpha-phosphatidylcholine stimulate prostaglandin biosynthesis via independent pathways. We advocate the use of the incubation chamber for the assessment of prostanoid biosynthesis by the gallbladder in vitro.

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To investigate whether female sex hormones and pregnancy induce increased gallbladder synthesis of prostaglandin I2 (PGI2) and prostaglandin E (PGE), we used an in vitro incubation chamber to quantitate the effects of progesterone, estrogen, pregnancy, and pregnancy plus a 2%-cholesterol diet on mucosal and serosal PGI2 and PGE production by the rabbit gallbladder. Neither the female sex hormones nor pregnancy alone caused a significant increase in PGI2 or PGE synthesis. The gallbladders of cholesterol-fed, pregnant rabbits demonstrated significant increases only in serosal synthesis of PGI2. This increased production was equivalent to that noted for gallbladders from nonpregnant rabbits fed a high-cholesterol diet. There were no increases in mucosal synthesis of PGE or of PGI2. Thus, neither elevated levels of progesterone or estrogen nor pregnancy is directly responsible for the increased PGI2 activity in the female gallbladder; conversely, this effect seems to be mediated by the increased biliary concentrations of cholesterol.

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A pancreatic pleural effusion is an uncommon presenting feature of pancreatic malignancy. A case is described where such an effusion was associated with an oncocytic carcinoma of the pancreas, a tumour which itself has been reported on only one previous occasion.

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Eleven rabbits (five female, six male) were fed a high (2%) cholesterol diet for 2 weeks. Twelve control rabbits (six female, six male) were fed standard rabbit chow. As expected, the cholesterol feeding raised serum and bile cholesterol concentrations and increased the lithogenic indexes. The gallbladders were harvested, and the mucosa and serosa were separately exposed to arachidonic acid in an in vitro incubation chamber at 37 degrees C. Cholesterol feeding stimulated the rates of synthesis of PGI2, but this effect was limited to the serosa (and not the mucosa) of gallbladders from female (but not male) animals. In contrast, cholesterol did not induce any changes in PGE biosynthesis.

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Gastric emptying was studied in two groups of 10 patients who underwent elective cholecystectomy. The groups were comparable for age, weight and duration of operation. Gastric emptying was measured with a radioisotopic technique using Tc99m-DTPA (diethylene triamine pentaacetic acid) before, and 24 h after, surgery. Analgesia was provided by intrathecal morphine 0.8 mg alone (group A) or by i.m. papaveretum 10 mg, administered as required, plus one additional dose 1 h before the postoperative measurement (group B). Control gastric emptying rates were not significantly different in the two groups (mean +/- SD: A = 76.6 +/- 23.0 ml; B = 81.8 +/- 16.3 ml in 30 min). After surgery, gastric emptying was significantly greater in group A (42.9 +/- 35.6 ml) than in group B (11.0 +/- 27.9 ml) (P less than 0.05).

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