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Objective: To investigate the incidence of scalp metastases in high-risk breast cancer patients in order to assess whether caution is warranted with scalp cooling during adjuvant therapy., Design: Observational study., Methods: The incidence of scalp metastases and the disease course were studied in 885 very well evaluated high-risk breast cancer patients. These patients, who had at least four positive axillary lymph nodes, were treated in a randomised study with either classical chemotherapy, or the same chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (the so-called N4+ study)., Results: After a median follow up of 110 months, 403 of the 885 patients (46%) had relapsed or developed metastases. 25 patients (3%) had developed skin metastasis; 4 of these patients (0.5%) had developed hairy scalp metastasis. The scalp metastases always occurred at the same time as or later than metastases elsewhere., Conclusion: Scalp metastases occur with a very low frequency and not as the first sign of metastatic disease. It is therefore unlikely that scalp cooling (to prevent baldness) decreases the local working of chemotherapy to such an extent that the risk of scalp metastases increases.

In two female patients aged 44 and 86 years, a chronic lymphocytosis was observed caused by a proliferation of large granular lymphocytes (LGL). The first one had been successfully treated for Hodgkin lymphoma long before, the second had diabetes mellitus type 2. Immunophenotyping showed the proliferating lymphocytes to be natural killer (NK) cells. In contrast to the proliferation of B- and T-lymphocytes, data on the prognosis and treatment of NK-lymphocytosis are very scarce. A literature search revealed three major clinical entities in which LGL proliferate: at one end of the spectrum we see the very aggressive NK-LGL leukaemia, at the other, NK-lymphocytosis, a benign chronic disorder, in between is the relatively indolent chronic T-LGL leukaemia. Both patients suffered from chronic NK-lymphocytosis with a favourable course; there were no further symptoms 4 and 2 years, respectively, after the diagnosis. In cases of prolonged lymphocytosis of unknown origin, immunophenotyping of the lymphocytes is essential. Only in this way can one arrive at the proper diagnosis and reach conclusions as to the prognosis and the possible methods of treatment.

Mammary carcinoma was diagnosed in two women aged 31 and 38 years after they had been subjected to mantle irradiation for Hodgkin's disease at the ages of 17 and 20 years, respectively. Breast amputation was performed in one case, lumpectomy in the other; the subsequent courses were uncomplicated. During follow-up there was no sign of recurrence. Lifelong follow-up by specialists of women irradiated for Hodgkin's disease should be considered; monthly self-examination of the breasts should be advised and mammography should be carried out annually as from 10 years after thoracic or axillary irradiation. It is especially women treated before their 20th year of life who run a relatively high risk.

A man aged 57 years with a chronic megakaryocytic granulocytic myelosis, treated with an intermittent low-dose busulfan schedule, developed intrahepatic cholestasis. We advise to do liver biopsy, if possible, to differentiate between busulfan hepatotoxicity and leukaemic activity. In the former case, it may be necessary to stop busulfan.