Direct-contact B-scan sonomammography--an aid to X-ray mammography.

The addition of direct-contact B-scan ultrasound to X-ray mammography has resulted in a pre-operative sensitivity for carcinoma of ninety-seven per cent. There has also been a reduction in the number of biopsies for benign breast disease.

The hip joint in Paget's disease (Paget's "coxopathy").

Three hundred patients with Paget's disease around the hip joint are compared with 300 control patients who did not have Paget's disease. The incidence of joint degeneration in the two groups is similar at all ages, and there appears to be no predisposition to joint degeneration in patients who have Paget's disease. A feature of the hip joints is that in approximately half there is joint narrowing to less than 3 mm affecting a portion or the whole of the joint surface, which, together with the incidence of protrusio acetabuli, is probably a specific manifestation of the joint changes associated with Paget's disease.

Sonomammography in benign breast disease.

An assessment is made of direct-contact B-scan sonomammography in 480 patients with clinically benign breast disease, of whom 121 underwent biopsy. In eight patients, ultrasound was normal when histology showed diffuse benign disease, and in four patients, ultrasound gave a benign result when histology showed malignancy. In 25 patients, attenuating shadow led to biopsy for a false positive diagnosis of carcinoma. Ultrasound can be used to avert unnecessary biopsy either by excluding a focal mass or by revealing clinically unsuspected malignancy when X-ray mammography shows moderate or marked density in patients complaining of a breast lump or nodularity.

Paget's disease of the lumbar spine.

The frequency and extent of lumbar spondylosis is no greater in patients with Paget's disease (osteitis deformans) affecting the lumbar spine than in control groups, whether or not the disease is accompanied by deformity of vertebrae, and we have found no evidence that Paget's disease predisposes to our enhances lumbar spondylosis. The similarity of distribution of the Paget's disease and of degenerative spondylosis raises the possibility that bone stress may be an aetiological factor in the formation of Paget's disease of bone.

The clinical and radiological features of cholecystocolic fistulae.

The clinical and radiological features of seven patients presenting with cholecystocolic fistulae are reviewed. The majority of the patients were elderly (age range 43-85 years, mean 70.7 years) and there was a female preponderance (6:1). The condition usually has a benign clinical course. Diarrhoea was the most common presenting symptom and the typical clinical features of gallbladder disease were absent. Cholangitis occurred in only one patient. The time between onset of symptoms and diagnosis varied from 1 week to 2 years (mean 22 weeks). In only one patient was the diagnosis of biliary-intestinal fistula suspected on the basis of the plain abdominal radiograph (Case 5). A diagnosis of cholecystocolic fistula was established by barium enema (5 cases), endoscopic retrograde cholangiopancreatography (ERCP) (1 case) and diagnostic laparotomy (1 case). The only cause identified in this series was acute or chronic cholecystitis.

Breast size and prognosis in early breast cancer.

The influence of breast size on the prognosis of 196 patients with early breast cancer diagnosed in the period 1984-1985 was studied. Breast size was based on the volume from mammography. This method was validated against the volume of the mastectomy specimen determined by water displacement in 18 patients and found to be accurate (r = 0.93, P < 0.01). The median breast volume was 833.5 cm3 (interquartile range 522.8-1153.3 cm3). Breast size was significantly associated independently with age (Spearman's rank r = 0.24. P = 0.001), menstrual status (z = -4.81, P < 0.001), body weight (Spearman's rank r = 0.61, P < 0.001), T stage (z = -1.91, P = 0.05) but not N stage (z = -1.64, P = 0.10) or hormone receptor status (z = -0.80, P = 0.42). In an analysis of breast size and other known prognostic factors, based upon Cox's proportional hazards regression, N stage was the only significant factor for both breast cancer survival and disease-free survival. Even though women with larger tumours at presentation had larger breasts, breast size was not a significant prognostic factor in early breast cancer.

An evaluation of the preoperative diagnosis and management of cystosarcoma phyllodes.

Cystosarcoma phyllodes is a rare tumour of the breast which is notoriously difficult to diagnose accurately preoperatively. In this review we report the clinical, imaging and histopathological features of 20 patients who have presented in our Centre over a 10-year period.

Use of ultrasound localization to improve results of fine needle aspiration cytology of breast masses.

A prospective randomized controlled trial of 116 patients with breast masses was conducted to compare the accuracy of 'blind' aspiration cytology performed in the clinic with aspiration cytology using ultrasound localization. The unsatisfactory aspiration cytology rate was significantly reduced by ultrasound localization (P = 0.028). This was mainly due to an improvement in the unsatisfactory rate for tumours less than 3 cm in diameter (P = 0.036). The results were influenced by the number of needle manoeuvres performed, less than 10 needle manoeuvres being associated with a 54% unsatisfactory aspiration rate compared with 25% when greater than 10 manoeuvres were performed (P = less than 0.02). One experienced aspirator in the clinic had results comparable to those achieved with ultrasound localization. It is concluded that experience and technique are the most important factors in obtaining a satisfactory aspirate from breast masses. Routine ultrasound localization prior to aspiration confers some benefit. Consideration should be given to the use of the ultrasound-assisted technique following a previous unsatisfactory aspiration, particularly if the tumour is less than 3 cm in diameter.

X-ray and ultrasound localization of non-palpable breast lesions and difficulties in management.

Seventy-four patients who have had biopsy of a non-palpable breast lesion are reviewed. A double-dye localization technique was used in 88% while in 12% localization of the lesion was best achieved by ultrasound mammography. Biopsy was successful in 70 patients (95%) at the first attempt. The overall incidence of malignancy was 20%, being greater in asymptomatic patients (32%) than in patients with mastalagia (16%). Re-excision of the biopsy site in these patients showed residual cancer in 33%. It is suggested that both careful examination of the operative specimen and postoperative mammography may be necessary to ensure that the original lesion has been removed. Re-excision of the biopsy site appears to be necessary when the histology is malignant.

Impact of an extensive in situ component on the presence of residual disease in screen detected breast cancer.

This study investigates the histopathological characteristics of a consecutive series of 100 screen detected breast cancers in relation to residual disease. Tumour type, size, grade, resection margins and extent of primary or associated in situ disease were all assessed by one pathologist. Thirty-seven women underwent further surgery (wider excision or mastectomy) and the resected specimen was examined for residual in situ or invasive cancer. In total, 36 cancers had an extensive in situ component, of which 69% were predominantly intraduct carcinoma of comedo type. Of the 37 women who underwent further resection, 21 (57%) women had residual cancer. Of those with initial disease at the resection margin, 16/25 (64%) had residual disease. Five of 12 (42%) with disease close to (within 2-3 mm) but not at the margin had residual disease. Of those with an extensive in situ component, 18/25 (72%) had residual disease, whereas only 2/12 (17%) women with none or some in situ disease had residual cancer. In screen detected breast cancer, residual cancer was present in 72% of women with an extensive in situ component at initial surgery. These women comprise a group in which conservation surgery may be inappropriate if completeness of excision is considered a prerequisite for breast conserving surgery.

The use of ultrasound in benign breast disorders.

The role of ultrasonography in the diagnosis of benign conditions of the breast is presented. The images seen with common benign conditions are illustrated and diagnostic problems are discussed.