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Why, given similar medical circumstances-high familial risk of breast cancer-will some women elect to join a trial of drugs designed to reduce that risk but others choose not to take part? The aim of this study was to identify measurable differences between women who elect to join a placebo-controlled, double-blind randomised trial of the drug tamoxifen and women who elect not to join. One hundred and six women attending a breast care clinic completed questionnaires covering demographic details, health locus of control, perception of risk and adequacy of medical communication. All were eligible for inclusion in the tamoxifen trial. Only half (n=53) of the sample elected to join, the other half (n=53) declined. Those who declined the trial were significantly more aware of lifestyle factors thought to influence the development of cancers-diet, exercise and oestrogen-prolonging activities (p<0.001), and they also appeared to find the information given by the hospital about tamoxifen harder to understand than did the group who had joined the trial (p=0.01). They could think of significantly fewer positive reasons for joining (p<0.001) and were significantly younger (p=0.001). Participants in both groups significantly overestimated the relative risks of breast cancer. The average estimation of risk for women aged 30 with a family history of breast cancer was 22 times higher than that given by their consultant. This gives rise to considerable concerns about the information underpinning informed consent. [ABSTRACT FROM AUTHOR]

Background: Tamoxifen preserves bone in postmenopausal women, but non-steroidal aromatase inhibitors accelerate bone loss and increase fracture risk. We aimed to study the effect on bone health in a subgroup of women included in the Intergroup Exemestane Study (IES), a large randomised trial that compared the switch to the steroidal aromatase inhibitor exemestane with continuation of tamoxifen in the adjuvant treatment of postmenopausal breast cancer. Methods: Results were analysed from 206 evaluable patients from the IES, in which postmenopausal women with histologically confirmed and completely resected unilateral breast cancer (that was oestrogen-receptor positive or of unknown status), who were disease-free after 2-3 years of treatment with tamoxifen were randomised to continue oral tamoxifen 20 mg/day or switch to oral exemestane 25 mg/day to complete a total of 5 years of adjuvant endocrine therapy. The primary endpoint was change in bone-mineral density (BMD) assessed by dual energy X-ray absorptiometry. Changes in biochemical markers of bone turnover were also analysed in this substudy, and the incidence of fractures in the entire study reported. The IES is registered on the Current Controlled Trials website . Findings: Within 6 months of switching to exemestane, BMD was lowered by 0.051 g/cm(3) (2.7%; 95% CI 2.0-3.4; p<0.0001) at the lumbar spine and 0.025 g/cm(3) (1.4%; 0.8-1.9; p<0.0001) at the hip compared with baseline. BMD decreases were only 1.0% (0.4-1.7; p=0.002) and 0.8% (0.3-1.4; p=0.003) in year 2 at the lumbar spine and hip, respectively. No patient with BMD in the normal range at trial entry developed osteoporosis. Bone resorption and formation markers increased at all time points in women receiving exemestane (p<0.001). With a median follow-up in all IES participants (n=4274) of 58 months, 162 (7%) and 115 (5%) patients in the exemestane and tamoxifen groups, respectively, had fractures (odds ratio 1.45 [1.13-1.87]; p=0.003). Interpretation: These results indicate that the increase in survival shown previously with the IES switch strategy is achieved at the expense of some detriment to skeletal health, so the risk-benefit ratio to women needs to be individually assessed. [ABSTRACT FROM AUTHOR]

Background: We report our early experience of a novel muscle-sparing breast (prepectoral) reconstruction technique using a pre-shaped Braxon® mesh (acellular dermal matrix) which completely wraps around the breast implant., Methods: All patients who underwent prepectoral implant-based breast reconstruction between April 2014 and September 2015 were included in the analysis. The dermal matrix Braxon® used is a pre-shaped matrix which forms a complete implant mesh wrap. The new breast created is placed over the chest wall without disturbing the pectoralis musculature., Results: A total of 51 (42 unilateral and 9 bilateral) muscle-sparing breast reconstructions were carried out. Complications included implant loss (n = 1; 1.7%) secondary to wound infection, seroma (n = 4; 6.7%), and superficial wound dehiscence (n = 1; 1.7%) which was re-sutured without further complication. The median follow-up period was 16.4 (range 8-25) months., Conclusion: The early experience appears highly satisfactory with good clinical outcome. The novel prepectoral implant-based breast reconstruction using the mesh wrap provides an effective alternative to the more traditional submuscular implant-based technique.

Background: Implant-based breast reconstruction is becoming increasingly popular because of the widespread adoption of acellular dermal matrix (ADM), which allows surgeons to obtain good aesthetic results with fewer operations. To develop more conservative surgical techniques, a retrospective, three-centre, proof-of-concept study was performed to study the effectiveness of a new, immediate, muscle-sparing breast reconstruction technique using the patented Braxon ® ADM, which enables subcutaneous positioning of the breast implant without detaching the pectoralis major., Methods: Ethics committee of the study coordinating centre approved medical record review on 19 women who underwent muscle-sparing breast reconstruction between November 2012 and January 2014. The first 10 implants were performed using 0.9-mm-thick porcine ADM, with preservatives. In the subsequent 15 implants, the product was changed to 0.6-mm-thick porcine dry ADM, without preservatives., Results: Nineteen patients (25 implants) received six bilateral and 13 unilateral muscle-sparing breast reconstructions. For the first type of ADM used (0.9-mm-thick with preservatives), the rate of implant loss was 12% (n = 3) because of seroma (8%, n = 2) and infection (4%, n = 1). Minor complications, such as seroma (8%, n = 2), occurred when using the 0.6-mm-thick Braxon ® ADM and were treated by aspiration. Symmetrical and natural breasts with good shape, ptosis and softness to the touch were obtained. None of the patients reported experiencing pain., Conclusions: The preliminary results are encouraging from aesthetic and clinical viewpoints. Further studies are planned to evaluate long-term results., (© 2014 Royal Australasian College of Surgeons.)

Background: International guidelines, including NICE, recommend using the 21-gene Recurrence Score assay for guiding adjuvant treatment decisions in ER+, HER2-negative early breast cancer (BC). We investigated the impact of adding this assay to standard pathological tests on clinicians'/patients' treatment decisions and on patients' decisional conflict in the United Kingdom., Methods: In this prospective multicentre study, eligibility criteria included: ER+ HER2-negative BC (N0/Nmic for patients ⩽50 years; ⩽3 positive lymph nodes for patients >50 years) and being fit for chemotherapy. Physicians'/patients' treatment choices and patients' decisional conflict were recorded pre- and post testing., Results: The analysis included 137 patients. Overall, adjuvant treatment recommendations changed in 40.7% of patients, with the direction of the change consistent with the Recurrence Score results (net decrease in chemotherapy recommendation rate in low Recurrence Score patients and net increase in high Recurrence Score patients). Patients' choices were generally consistent with physicians' recommendations. Post-testing, patients' decisional conflict decreased significantly (P<0.0001). In the 67 patients meeting the NICE criteria for testing, the recommendation change rate was 49.3%., Conclusions: Recurrence Score testing significantly influenced treatment recommendations overall and in the subgroup of patients meeting the NICE criteria, suggesting that this test could substantially alter treatment patterns in the United Kingdom.

Background: Well-designed randomised clinical trials (RCTs) provide the best evidence to inform decision-making and should be the default option for evaluating surgical procedures. Such trials can be challenging, and surgeons' preferences may influence whether trials are initiated and successfully conducted and their results accepted. Preferences are particularly problematic when surgeons' views play a key role in procedure selection and patient eligibility. The bases of such preferences have rarely been explored. Our aim in this qualitative study was to investigate surgeons' preferences regarding the feasibility of surgical RCTs and their understanding of study design issues using breast reconstruction surgery as a case study., Methods: Semistructured qualitative interviews were undertaken with a purposive sample of 35 professionals practicing at 15 centres across the United Kingdom. Interviews were transcribed verbatim and analysed thematically using constant comparative techniques. Sampling, data collection and analysis were conducted concurrently and iteratively until data saturation was achieved., Results: Surgeons often struggle with the concept of equipoise. We found that if surgeons did not feel 'in equipoise', they did not accept randomisation as a method of treatment allocation. The underlying reasons for limited equipoise were limited appreciation of the methodological weaknesses of data derived from nonrandomised studies and little understanding of pragmatic trial design. Their belief in the value of RCTs for generating high-quality data to change or inform practice was not widely held., Conclusion: There is a need to help surgeons understand evidence, equipoise and bias. Current National Institute of Health Research/Medical Research Council investment into education and infrastructure for RCTs, combined with strong leadership, may begin to address these issues or more specific interventions may be required.

We report the case of a 44 year old lady with bilateral cosmetic silicone breast implants who had previously undergone a change of her right implant following extracapsular rupture. She presented 4 years later with a new lump in her right breast and underwent subcutaneous mastectomy for a grade 3 invasive ductal carcinoma. Sentinel lymph node biopsy demonstrated axillary silicone lymphadenopathy but nil evidence of metastatic disease. We present this as the first described case of successful sentinel lymph node biopsy in the context of prior augmentation mammaplasty and ipsilateral implant rupture with silicone lymphadenopathy., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Gynaecomastia is the most common benign condition of the male breast and accounts for up to 80% of male breast referrals. We sought to identify any changes in the number of patients referred with the condition and assess its impact on clinical practice., Methods: Patients were identified from two prospectively maintained databases. Diagnosis of gynaecomastia was based on clinical findings, ultrasound scan (USS) assessment and/or histology., Results: There was a significant increase in the number of men referred to a specialist unit and diagnosed with gynaecomastia. Gynaecomastia was more prevalent in the under twenties age group. Core biopsy (CB) became the histological investigation of choice for men with unilateral disease and there was no change in the percentage of men undergoing surgery., Conclusion: Most men are looking for reassurance that their condition is benign and that no intervention is required. Thus it is important to offer these men psychological support as part of their treatment., (Copyright © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: Breast reconstruction after mastectomy for cancer requires accurate evaluation to inform evidence-based participatory decision making, but the standards of outcome reporting after breast reconstruction have not previously been considered., Methods: We used extensive searches to identify articles reporting surgical outcomes of breast reconstruction. We extracted data using published criteria for complication reporting modified to reflect reconstructive practice. Study designs included randomized controlled trials, cohort studies, and case series. The Cochrane Risk of Bias tool was used to critically appraise all study designs. Other criteria used to assess the studies were selection and funding bias, statistical power calculations, and institutional review board approval. Wilcoxon signed rank tests were used to compare the breadth and frequency of study outcomes, and χ² tests were used to compare the number of studies in each group reporting each of the published criteria. All statistical tests were two-sided., Results: Surgical complications following breast reconstruction in 42,146 women were evaluated in 134 studies. These included 11 (8.2%) randomized trials, 74 (55.2%) cohort studies, and 49 (36.6%) case series. Fifty-three percent of studies demonstrated a disparity between methods and results in the numbers of complications reported. Complications were defined by 87 (64.9%) studies and graded by 78 (58.2%). Details such as the duration of follow-up and risk factors for adverse outcomes were omitted from 47 (35.1%) and 58 (43.3%) studies, respectively. Overall, the studies defined fewer than 20% of the complications they reported, and the definitions were largely inconsistent., Conclusions: The results of this systematic review suggest that outcome reporting in breast reconstruction is inconsistent and lacks methodological rigor. The development of a standardized core outcome set is recommended to improve outcome reporting in breast reconstruction.

The adjuvant use of aromatase inhibitors in breast cancer is associated with adverse effects on bone health. We previously reported a decline in bone mineral density (BMD) following the switch from tamoxifen to exemestane in the Intergroup Exemestane Study (IES). Here we report effects of endocrine treatment withdrawal on BMD, bone turnover markers (BTM) and fracture rates. 4,724 patients took part in IES, and 206 patients were included in a bone sub-study. BMD and BTM were assessed pre-randomization, during and after the end of treatment (EOT). To evaluate treatment withdrawal effects, 12- and 24-month post EOT BMD results are available for 122 and 126 patients, respectively. Similar patient numbers had BTM measured post EOT. Following treatment withdrawal, the differences in BMD observed between the two endocrine strategies were partially reversed. At 24 months from EOT, spine BMD increased by 1.53% (95%CI 0.63-2.43; p = 0.001) after stopping exemestane and fell by 1.93% (95%CI -2.91 to 0.95; p = 0.0002) following tamoxifen withdrawal. A similar pattern of changes was observed at the hip. At 2 years post EOT, BMD changes from baseline were similar with both treatment strategies. Corresponding inverse changes in BTM were seen, with an increase following tamoxifen withdrawal and a reduction after exemestane. A higher number of fractures occurred during exemestane treatment, but fracture rates were similar after treatment withdrawal. With the switch strategy used in IES, the on treatment adverse bone effects of exemestane are reversed. Ongoing monitoring of BMD is therefore not routinely required.

Background: Immediate breast reconstruction may result in superior cosmetic outcomes as a result of the preservation of the skin envelope. The impact of implant use and radiotherapy (RT) on the cosmetic outcome of latissimus dorsi (LD) breast reconstruction, however, has never been prospectively evaluated with adequate long-term follow-up., Methods: Women undergoing immediate LD breast reconstruction from January 2000 to February 2007 underwent photographic assessment and clinical evaluation for breast retraction analysis (BRA) at 3, 6 and 12 months postoperatively and on the anniversary of their surgery. The resulting photographs were subject to panel cosmetic assessment. A patient-reported cosmetic outcome questionnaire and the body image scale (BIS) were administered to each woman at a single time point to coincide with the anniversary of their surgery. Multilevel linear regression modelling was used to analyse the results., Results: Seventy-three women underwent 53 implant-assisted LD breast reconstructions and 20 autologous procedures with a mean follow-up of 2.71 years. The incidence of radiotherapy in this cohort was 43%. RT over time adversely influenced overall cosmetic outcome as assessed by the panel (P = 0.0002), and BRA (P = 0.033), both of which were significantly worse in the implant-assisted group (P = 0.020). Patient reporting of overall cosmetic outcome and BIS, however, did not differ significantly between the LD groups or following RT., Conclusion: Radiotherapy may adversely affect the cosmetic outcome of latissimus dorsi breast reconstruction, particularly if an implant is used, but this is not universal. Patient assessment of their cosmetic outcome may, however, differ significantly from the clinician's view.

Objective: To investigate the long term impact of the two week wait rule for breast cancer on referral patterns, cancer diagnoses, and waiting times., Design: Prospective cohort study., Setting: A specialist breast clinic in a teaching hospital in Bristol., Participants: All patients referred to breast clinic from primary care between 1999 and 2005., Main Outcome Measures: Number, route, and outcome of referrals from primary care and waiting times for urgent and routine appointments., Results: The annual number of referrals increased by 9% over the seven years from 3499 in 1999 to 3821 in 2005. Routine referrals decreased by 24% (from 1748 to 1331), but two week wait referrals increased by 42% (from 1751 to 2490) during this time. The percentage of patients diagnosed with cancer in the two week wait group decreased from 12.8% (224/1751) in 1999 to 7.7% (191/2490) in 2005 (P<0.001), while the number of cancers detected in the "routine" group increased from 2.5% (43/1748) to 5.3% (70/1331) (P<0.001) over the same period. About 27% (70/261) of people with cancer are currently referred in the non-urgent group. Waiting times for routine referrals have increased with time., Conclusion: The two week wait rule for breast cancer is failing patients. The number of cancers detected in the two week wait population is decreasing, and an unacceptable proportion is now being referred via the routine route. If breast cancer services are to be improved, the two week wait rule should be reviewed urgently.

The National Breast Screening Programme had dramatically impacted surgical practice. Up to 50% of all newly diagnosed cancers are now impalpable creating increased demand for image-guided localisation. Wire-guided localisation (WGL) is the current gold standard, but USS-guided localisation by radiologists is a well-documented and effective technique. Increasing numbers of surgeons are proficient in using ultrasound and may be as accurate as radiologists in localising lesions intra-operatively. Of 68 patients with screen-detected impalpable lesions referred to one surgeon in our unit between January 2005 and February 2006, 32 had mass lesions, which were well seen on ultrasound and underwent intra-operative USS-guided localisation performed by a surgeon. All lesions were correctly identified and 87.5% (n=28) were fully excised. Those lesions not fully excised were lobular cancers. Intra-operative sonographic localisation performed by surgeons is an accurate and effective technique. It may produce less patient anxiety and discomfort than WGL and allow more effective and efficient use of resources and theatre time.

Nipple tattooing is a safe and effective technique for restoration of the nipple-areola complex following breast reconstruction and has a positive impact on patient well-being and body image. This procedure is usually performed by a surgeon, but following appropriate training, a nurse-led nipple tattooing service was established in our unit in December 2005. All 14 patients who had undergone nipple tattooing over a 6 month period were contacted by telephone and questioned about their cosmetic results and satisfaction with the service. Hundred percent of patients were 'satisfied' with their tattoo and all patients rated the nurse-led service as 'excellent'. It was estimated that 20h of consultant time was saved. Our study demonstrates that a nurse-led service is associated with both excellent cosmetic outcomes and high levels of patient satisfaction. It also results in a significant saving of consultant time allowing more effective use of clinic and theatre resources.

Aim: To describe our experience in the use of ultrasound guided mammotome in the diagnosis and management of single duct nipple discharge., Methods: Patients for whom surgical excision of the single duct had been advised for single duct nipple discharge were offered ultrasound guided mammotome excision of the duct as an alternative to surgical excision. The procedure was performed in the breast clinic by a surgeon or a breast clinician who had interventional ultrasound skills., Results: Seventy-seven patients had 81 procedures. Follow-up at a mean time of 16 months revealed resolution of the presenting problematic discharge in 95% of patients. Nipple discharge recurred in four patients. Two patients had microdochectomy and two had a repeat mammotome for recurrence of symptoms. Complications were mild and infrequent., Conclusion: Ultrasound guided mammotome excision is a new tool in the work up and management of single duct nipple discharge. It can be performed under local anaesthetic by a surgeon/breast clinician or radiologist with interventional ultrasound skills. It has the potential to replace surgical excision (microdochectomy) as a treatment for nipple discharge.

Aim: To evaluate the role of ultrasound guided mammotome biopsy of the ducts beneath the nipple areola complex (NAC), as a new technique in detecting the occult involvement of the NAC in breast cancer patients prior to nipple preserving subcutaneous mastectomy., Method: A prospective study where 33 women requesting nipple preserving mastectomy for invasive or in situ disease were offered the procedure to determine if leaving the nipple was safe. A 5 mm skin incision was made after infiltration with local anaesthetic and the 11G mammotome needle was positioned beneath the nipple under ultrasound guidance which was turned through 360 degrees as the biopsies were taken. The procedures were performed by trained non-radiologists., Results: Thirty-three women had 36 procedures. Seven out of the 36 had a positive mammotome biopsy. Twenty-three patients had 26 NAC preserving mastectomies with immediate reconstruction. Three had bilateral procedures. Ten patients had NAC sacrificed. The histopathology of the mastectomy specimen correlated 100% with the mammotome biopsy., Conclusion: Preoperative ultrasound guided mammotome biopsy of the ducts beneath the NAC is a safe, reliable and accurate technique and is evolving as an oncologically safe procedure. The large mammotome needle can be visualized easily under high resolution, near field high frequency scanners and this increases the accuracy of the biopsy. It can replace the traditional frozen section and be used as an alternate. It can be performed safely by an appropriately trained non-radiologist (surgeon/breast clinician).

A multicenter, prospective study ( = 103) examined the psychological implications of women's decisions for or against breast reconstruction. Recognized measures of anxiety, depression, body image, and quality of life were completed before the operation, and 6 and 12 months later. A reduction in psychological distress over the year following the operation was evident in each surgical group (mastectomy alone or immediate or delayed reconstruction), indicating that reconstructive surgery can offer psychological benefits to some women; however, others report improved psychological functioning without this surgical procedure. In contrast to existing retrospective research, the prospective design enabled the process of adjustment during the first year after the operation to be examined. The results indicate that breast reconstruction is not a universal panacea for the emotional and psychological consequences of mastectomy. Women still reported feeling conscious of altered body image 1 year postoperatively, regardless of whether or not they had elected breast reconstruction. Health professionals should be careful of assuming that breast reconstruction necessarily confers psychological benefits compared with mastectomy alone.

Aim and Method: The aim of this questionnaire study was to identify knowledge of breast and colorectal cancer symptoms among 100 patients attending one-stop breast clinics and rectal bleeding clinics and to determine the source of the information., Results: Seventy-five breast clinic (mean age 46 years, all female) and 78 colorectal clinic patients (mean age 59 years, 51% male) responded. Knowledge of breast was significantly greater than bowel cancer in both groups (P<0.0001, McNemar's chi(2)). There was no difference in knowledge of symptoms of breast cancer or bowel cancer between patients attending either clinic. There was a positive association between cancer knowledge, family history and female gender but no association with age. Knowledge of Bowel Cancer Awareness Week was positively associated with colorectal cancer knowledge., Conclusion: Knowledge of colorectal cancer is much less than breast cancer in clinic attenders. Seventy-five per cent of women attending breast clinic could name a breast cancer symptom whereas only 37% of patients attending colorectal clinic could name a bowel cancer symptom. These findings have implications when considering patients' anxiety, expectations of a cancer diagnosis and breaking bad news.

A prospective audit of seroma formation following breast-conserving surgery for carcinoma with axillary dissection was carried out. Ninety-seven consecutive patients were studied. The post-operative formation of fluid within the axilla (seroma) was recorded on a computerised data collection system. From August 1998 to December 1998, no drain or other axillary restriction was used. The seroma rate in 27 of these patients who had at least seven nodes in the axillary sample was 14/27 (52%). From December 1998 to June 1999, an additional suture was inserted between the axillary skin and the chest wall (buttress suture). This was designed to obliterate the axillary space after dissection. There were 37 patients with seven or more nodes in the axillary dissection in this study and of these, nine patients developed a seroma (24%) (P=0.007). The use of the buttress suture reduces the seroma rate following axillary dissection without axillary drainage.

Expression of the pS2 protein in breast carcinoma is a useful guide to prognosis and response to tamoxifen. We have investigated pS2 protein expression in both the primary tumour and lymph node metastases (LNM) using a computer-assisted image analysis system. In a consecutive series of 208 patients undergoing surgical excision of primary breast cancer with axillary clearance, 89 patients were found to have involved lymph nodes. We found a highly significant correlation between pS2 expression in primary tumours and their LNM when 5% was taken as the cut-off for positive staining (Fischer Exact, P < 0.0001). There was also a highly significant correlation between the proportion of positive staining between the local metastases and primary tumours (Spearman's rank order correlation = 0.87; P < 0.0001). We conclude that the pS2 status of LNM can be accurately predicted from the pS2 status of the primary tumour. As such, appropriate adjuvant therapy for primary breast cancer, or second line therapy for disseminated disease can be selected on the pS2 status of the primary tumour alone.

Laparoscopic cholecystectomy is the surgical treatment of choice for symptomatic gallstones. Nonsteroidal antiinflammatory drugs offer effective analgesia, avoiding the central side effects of opiate drugs. To assess intramuscular diclofenac sodium (Voltarol; Ciba-Geigy) after laparoscopic cholecystectomy, 55 consecutive patients (41 female; 14 male; mean age: 50 years) were randomised to receive either diclofenac or placebo in double-blind fashion. Six patients were withdrawn from study (three conversions to open cholecystectomy; three incomplete documentation). Pain scores were assessed at 4, 24, and 48 h using a linear analogue scale; opiate consumption and time to first oral fluid and food were recorded. In 26 patients receiving diclofenac, median scores at 4 h were 1.6 (range 0-7.6) as compared with 4.1 (range 0-7.6) in 23 control patients (p = 0.05, 95% confidence limits 3.2, 0; Mann-Whitney U test). Nausea scores, return to diet, and time to discharge did not differ significantly between the groups. Intramuscular diclofenac significantly reduces early postoperative pain after laparoscopic cholecystectomy and is worthy of consideration if the procedure were ever undertaken as day case surgery.

Fine-needle aspirates from 52 breast cancers in 50 patients over 70 years of age were immunocytochemically stained for pS2 protein. All patients were treated with tamoxifen 40 mg/day and followed up at intervals of 2 months. The size of the tumour was serially assessed with calipers and portable ultrasonography. Change in tumour size was confirmed mammographically. Clinical monitoring was performed bind of the pS2 status. Twenty-five tumours were pS2 positive, of which 23 showed a significant response; ten went into complete remission (mean time to complete remission 6.8 (range 2-14) months) and 13 demonstrated partial remission (mean follow-up 8.9 (range 6-19) months). Two tumours remained static. Twenty-seven tumours were pS2 negative and none of these responded to tamoxifen; six remained static (mean follow-up 11.5 (range 6-14) months) and 21 progressed (mean time to progression 7.0 (range 3-14) months) (P < 0.001). Immunocytochemical assessment of fine-needle aspirates from elderly women with breast cancer accurately predicts a worthwhile response to tamoxifen.

Inflammatory arterial disease is often insidious and associated with a substantial morbidity and mortality. Early recognition is vital. Patients with arteritis (n = 106) were studied and divided into five groups. Two of these were subgroups of giant cell arteritis classified by site into either cranial arteritis (66), or upper limb arteritis (7). Three other groups were identified; chronic periaortitis (with or without inflammatory aortic aneurysm) (7), polyarteritis nodosa (14), and small vessel arteritis (12). Clinicians are not sufficiently aware of arteritis and its many atypical presentations. Delay in management is associated with a significant morbidity and mortality. In this district serving 200,000 people at least one patient per month is seriously at risk from the disease. Improved outlook depends on early recognition of the clinical syndromes and rapid appropriate treatment.

pS2 protein is a cysteine-rich polypeptide, of unknown function, the expression of which is induced in the human cancer cell line MCF-7 by oestrogen. The availability of a murine monoclonal antibody to human pS2 protein has prompted us to evaluate its expression in 47 cases of primary breast carcinoma. Using a double indirect immunoperoxidase technique, we compared the expression of pS2 protein in fine needle aspiration (FNA) cytology smears with that in formalin-fixed, paraffin-embedded sections from subsequently excised tumours from the same patients. We also compared the expression of pS2 protein and oestrogen receptor (ER) status using immunocytochemical assay (ER-ICA) in formalin-fixed, paraffin-embedded sections from 22 primary breast carcinomas. We found the application of immunocytochemistry in the assessment of pS2 protein expression in FNA cytology to be a reliable and cost-effective technique, having a sensitivity of 84% and a specificity of 100%. There was also a good correlation between the expression of pS2 protein and ER status.

Fifty-seven patients who presented to the Royal Surrey County Hospital, Guildford, with critical upper limb ischaemia between 1980 and 1989 were studied. Only 13 patients had emboli, while 23 presented with arteritis, seven involving large vessels and 16 with small vessel disease. Other causes included nine patients with trauma, six with atherosclerosis (of whom five were women), and four with vascular complications of thoracic outlet obstruction. Single examples of ischaemia due to radiation fibrosis and disseminated intravascular coagulation were also seen. Critical ischaemia of the upper limb remains an uncommon yet challenging problem. The review demonstrates that total limb arteriography should be performed in all patients, except the minority who present with direct arterial trauma or classical emboli.

The increasing demand for fully trained vascular surgeons in the UK has highlighted the need for urgent review of that training. Such a review must examine the number of trainees required and the number and role of teaching centres. Vascular surgical training should only take place where an integrated approach, including experience in interventional radiology and intensive care, is available. The relationship of vascular to general surgery must now be defined with training needs in mind if we are to provide an appropriate service within the next decade.

Historical review shows that the treatment of popliteal aneurysm has developed by trial and error and there is disagreement about the proper management of the symptomless patient. In 1981 a policy of conservative management for asymptomatic popliteal aneurysm was adopted in this unit. Since that time we have also managed nine patients with thrombosed popliteal aneurysms by arteriography and low-dose intra-arterial streptokinase. Six patients treated within 72 h of occlusion achieved significant (70-100 per cent) lysis, but streptokinase was ineffective in those treated 10 or more days after the thrombosis. Of the six patients with significant lysis, three were treated by elective reconstruction and two by anticoagulation. One patient who had significant lysis died. Vascular patency of all five successfully treated limbs was maintained and no limb loss occurred in those who presented late and failed to achieve significant lysis. These results reinforce the view that thrombolysis is the treatment of choice for thrombosed popliteal aneurysms. The low complication rate for asymptomatic popliteal aneurysms and the advent of safe, effective thrombolysis indicate that operation for symptomless popliteal aneurysm is no longer required.

The extent of tumour growth beyond the muscularis propria (mesorectal spread) was measured in specimens from 167 consecutive patients with rectal cancer. The 5-year survival was significantly greater in patients with slight mesorectal spread (4 mm or less) than in those with more extensive mesorectal spread (55% [95% confidence interval 42-66%] vs 25% [13-38%]). The prognostic value for survival of mesorectal spread was independent of the presence of lymphnode metastases. There were also significant differences in survival between patients with slight and extensive mesorectal spread among patients with Dukes' stage B tumours (66% [41-82%] vs 37% [14-60%]) and those with Dukes' stage C tumours (30% [12-52%] vs 18% [6-34%]). Thus mesorectal spread of rectal cancer is an important determinant of survival, and its accurate measurement may serve to subdivide Dukes' B and C cases. In this study tumour involvement of the lateral resection margin was not a useful predictor of local recurrence, but it did correlate with poor prognosis.

Lymph node metastases are an important determinant of prognosis following surgery for colorectal cancer. A xylene alcohol clearance technique has been employed in Guildford to facilitate the identification of lymph nodes in the mesorectum of rectal cancer specimens. The numbers of lymph nodes and lymph node metastases were compared with seven other centres and St. Mark's Hospital, where clearance techniques were not employed in patients undergoing a randomized trial of pre-operative radiotherapy for rectal cancer. The total number of lymph nodes identified per patient in the mesorectum of patients at Guildford (mean = 23.1 +/- 1.18) was significantly higher when compared with patients at St. Mark's Hospital alone (mean = 13.1 +/- 0.86) and the seven combined "non-cleared' centres (mean = 10.5 +/- 0.6) (P less than 0.001). The number of lymph node metastases per patient was significantly higher in the Guildford series (mean = 3.21 +/- 0.58) when compared with the seven combined centres (mean = 1.9 +/- 0.3) (P less than 0.05). The numbers of lymph node metastases found in the lowest part of the specimen close to the levator ani were significantly higher in the Guildford patients (mean = 1.2 +/- 0.4) compared with St. Mark's Hospital (mean = 0.13 +/- 0.1) and the seven combined 'non-cleared' centres (mean = 0.56 +/- 0.1). This clearance technique identified not only a greater number of lymph nodes but also more metastases within those nodes, particularly in the supralevator area of the mesorectum.