Correspondence

Local excision of rectal tumours

Sir We read with interest your recent article by C . W. Mann (Br J Surg 1985; 72(Suppl.): S57-8), in which the importance of patient selection is stressed. It is stated that only tumours of favourable cytological differentiation (‘well’ or ‘average’ histological grade) are suitable for these local radical techniques.

It is important to draw attention to the fact that it is not possible to exclude accurately all poorly differentiated tumours pre-operatively based on the results of rectal biopsies. In a recent study’ we found that 70 per cent of poorly differentiated growths had been thought to be of only average grade when the rectal biopsy was examined. These findings were confirmed by Elliott et a/.’ who found that only 17 of 42 poorly differentiated tumours were correctly identified as being of unfavourable histological grade on rectal biopsy, a 60 per cent error.

The discovery of unfavourable histology after local excision may result in a medically unfit patient being subjected to further surgery.

lnaccuracy in the histological grading of rectal biopsies means that it cannot be certain that selection is completely correct when advocating local excision.

F. Smedley D. A. Macfarlane

St. Stephen‘., Hospital London SWlO 9TH U K

1.

2.

Smedley FH, Hoile R W, Macfarlane DA. Rectal biopsies: inaccuracy of histological grading in carcinoma of the rectum. J R Soc Med 1984; 78: 5646. Elliott MS, Todd IP, Nicholls RJ. Radical restorative surgery for poorly differentiated carcinoma of the mid-rectum. Br J Surg 1982; 6 9 273.

Author‘s reply

Sir We all recognize that when we operate on cases by a limited technique (such as local excision) we are very dependent on accurate histological grading. We also realize that tumours can vary in their grading from one part to another of their total bulk, and that occasional errors can occur. The better the quality of tissue submitted and the higher the degree of histopathological expertise available, so will the likelihood of grading error diminish. Only 20 per cent of rectal growths overall are poorly differentiated, so that even taking the possibility of a 60per cent error into account (which seems to be very high), this would mean only 12 per cent of patients at potential risk but because w r y & poorly differentiated growths possess the clinical characteristic of small size ( < 2 cm), mobility and absence ofdetectable nodes, this should reduce to only 1-2 per cent of cases at risk. Providing the clinician is aware of possible pathological pitfalls, I believe that local excision should remain an option for some rectal and anal cancers, and the reports in the literature confirm that such a process of selection is ethical.

Finally, I believe that, in the medically unfit patient, to opt for major radical surgery ‘de noiw’ in a case otherwise fulfilling all the strict criteria for a local excision would not be wise: if the growth was a Duke’s A tumour and the patient subsequently died of operative complications this would be a greater disaster than having to reconsider the possibility of further surgery in a few patients as a result of pathological reappraisal of the local excision specimen.

C. V. Mann

The London Hospital London E l I B B U K

Collagen metabolism in experimental colonic anastomoses

Sir Yesilkaya and his colleagues ( B r J Surg 1985; 72: 987) claim to have measured collagen metabolism and the hydroxyproline activity and content of anastomoses in the canine colon. In fact they did none of these: they measured the concentration of the amino acid in dried tissue samples and they found a wide scatter of values both in the normal colon and in colonic anastomoses. Nevertheless, they were able to show a difference between single layer and two layer anastomoses, the concentration of hydroxyproline being greater in the single layer anastomosis on the fifth and tenth postoperative days. Interestingly, an alternative method of analysis will produce an entirely different result. Using the normal value for hydroxyproline in the unwounded colon as a control for comparison with subsequent measurements in anastomoses in the same animal, one finds that ten days after surgery there is a 13 per cent increase in the colonic hydroxyproline concentration in animals given single layer anastomoses and a 21 per cent increase in those given two layer anastomoses.

The excellent clinical results of single layer anastomoses are well documented but I doubt that this experimental study enhances the case for single layer suture techniques.

T. T. lrvin

Department 01 Surgery Royal Deron arid Exeter Hospital Exerer E X 2 5D W U K

Chemodectomas of the neck

Sir I read with interest the article by Drs Mitchell and Clyne ( B r J Surg 1985; 72: 903-5). I reviewed 25 glomus jugulare tumours treated in a period from 1958 to 1976 in Newcastle upon Tyne and came to the conclusion that the response to radiotherapy was really rather limited and probably affected the supporting vascular tissue more than the tumour cells themselves. 1 would be interested to know how the authors of this article assessed regression of glomus jugulare tumours slightly because. arising as they d o from the jugular fossa. they are not always easily seen in the middle ear nor assessed on clinical examination of the neck.

A combined otological/neurosurgical approach to the tumour carries very little risk to the patient and ensures adequate assessment of the margins of the tumour prior to its removal.

D. East

Scurborough Hospitul Scurborough North Yorkshire YO12 6QL U K

Frozen section of Tru-cut biopsies versus cytology

Sir We read with interest the recent paper on outpatient diagnosis of breast carcinoma by frozen section examination of Tru-cut biopsies ( B r J Surg 1985; 72: 927-8). We note that inadequate biopsies were not submitted for frozen section. Before any conclusions can be drawn from this study, it is imperative to know how many Tru-cut biopsies were inadequate. This information should have been included in the original report.

We have data on 100 patients with breast cancer who had both fine needle aspiration (FNA) cytology and Tru-cut biopsy. Both procedures were performed by one individual (J.M.D.) with experience of both techniques and the results obtained are therefore considered optimal. The results (Tuhle I ) show FNA cytology is more accurate than Tru-cut

324 Br. J. Surg., Vol. 73, No. 4, April 1986

Correspondence

Angelchik prosthesis: a modification of surgical technique

Table 1 consecutiw breast curcinotnus

Comparison oj F N A c j~to logy and Tru-cut biopsy in 100

Diagnosis FNA cytology Tru-cut

Malignant 94 87 Suspicious 4 Benign 1 13 Acellular 1

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biopsy. It is also important to note that patients preferred FNA and that FNA had a lower incidence of complications'. The studies quoted by Mr Bradbeer showing Tru-cut biopsy to be more reliable than cytology were performed when FNA was in its infancy. More recent report much higher degrees of accuracy with FNA than have ever been obtained by Tru-cut.

In Oxford over the past year we have introduced immediate reporting of FNA cytology in our Breast Clinic as suggested by Duguid et d3 . Patients also have clinical examination and mammography (reported the same day). This has allowed us not only to diagnose definitively those patients with malignant disease but also to reduce dramatically the number of patients with benign disease undergoing biopsy. Unlike frozen section of Tru-cut biopsies we have had no false positives and with a trained aspirator the sensitivity of FNA cytology for malignancy has been 100 per cent. There were no inadequate samples. It is our view that FNA cytology is the outpatient method of choice for the diagnosis of breast lumps. We believe Tru-cut biopsy should be restricted to those centres where cytology is not available.

J. M. Dixon E. C. G. Lee

V. Crucioli John Rudclqje Hospitul OxJord O X 3 9DU U K

1. Dixon JM, Anderson TJ, Lamb J, Nixon SJ, Forrest APM. Fine needle aspiration cytology in relationship to clinical examination and mammography in the diagnosis of a solid breast mass. Br J Surg 1984; 71: 593-6. Dixon JM. Lamb J, Anderson TJ. Fine needle aspiration of the breast: the importance of the aspirator. Lancet 1983; ii: 564. Duguid HLD, Wood RAB, Irving AD, Preece PE, Cuschieri A. Needle aspiration of breast with immediate reporting of material. Br Med J 1979; 2: 185-7.

2.

3.

Author's reply

Sir In the course of this investigation (Br J Surg 1985; 7 2 927-8). six Tru-cut biopsies were found to be inadequate and not submitted for frozen section examination. The authors of the letter do not state whether the Tru-cut biopsy was taken in the routine manner by hand or whether a mechanical aid such as the 'Pistomat' was used.

I t is my contention that the use of the 'Pistomat' produces a much better biopsy than using the Tru-cut by hand and thus one can expect a higher degree of accuracy from the pathologist.

In the Oxford series, 13 out of the 100 Tru-cut biopsies of patients with carcinoma of the breast were reported as benign, whereas in the Croydon series only 8 out of the 170 patients who had a Tru-cut biopsy reported as benign were found later to be malignant. When the present series was commenced, we did not have the services of a cytologist. We now have a cytologist in the hospital and carry out fine needle aspiration and Tru-cut biopsies on the same patient to assess their relative value. The result of our first 200 biopsies will be reported in due course. I t is my experience that, when the 'Pistomat' is used, patients experience more pain from a fine needle aspiration than Tru-cut biopsy.

The main lesson from our publication and from the Oxford workers is that it is now possible and desirable to inform the patient of the diagnosis of breast cancer as soon as possible.

The method of reaching the diagnosis whether by fine needle aspiration or Tru-cut biopsy depends on the skill and experience of the operator and the pathologist, and this must vary from one hospital to another.

Mayday Hospitul Thornton Heath Surrey C R 4 7YE U K

J. Bradbeer

Sir We read with interest the paper by D. L. Morris et al. (Br J Surg 1985; 7 2 1017-20) describing the use of the Angelchik prosthesis in 27 cases. It is interesting that in three of the cases failure of the prosthesis was attributed to its rotation. In our series of 35 cases' we have not seen this particular complication; however we have had three cases of intragastric erosion of the prosthesis. It was felt that the knot in the Dacron tape and the liga clip may act as a focal point for the initial migration. Therefore we now tether the knot away from the stomach by suturing it anteriorly to the diaphragm with linen. Since adopting this technique, we have had no further problems with erosion. This modification of Angelchik's procedure for insertion of his prosthesis* may also prevent the rotation noted by Morris et a / . We would advocate the adoption of this technique.

A. L. Blower J. F. Clegg

Leighton Hospitul Leiyhton Crewe U K

1. Blower AL. Clegg JF. The Angelchik prosthesis and its complications. Ann R Coll Surg Edinb (in press).

2. Angelchik JP, Cohen R. A new surgical procedure for treatment of gastro-oesophageal reflux and hiatal hernia. Surg Gynecol Obstet 1979; 148. 2 4 6 8 .

Oxygen tension

Sir In their paper'oxygen tension on the skin of thegaiter area of limbs with venous disease' (Br J Surg 1985; 72: 644-7) Clyne et al. describe TcpO, measurements in the legs in three groups of patients. 1 believe the criteria for defining group one 'clinically apparent superficial varicose veins and no skin changes' are not adequately stated. If Group 1 patients indeed had only uncomplicated superficial varicose veins, then the PPG postexercise recovery time should have been either within normal limits signifying that the varicosities had competent valves or, if primarily shortened, the PPG recovery time should have been normalized by the application of the inflated cuff. As defined by the PPG recovery time, Group 1 patients had moderately severe deep vein reflux based on a reduced PPG recovery time not affected by the application of the cuff. I have reviewed the authors' Reference 6 and believe this confirms my opinion.

A. Singer

1 J Gilchrest Road Greut Neck New York 11021 U S A

Testicular torsion does not cause autoimmunization in man

Sir We read with interest the article by Fraser et al. (Br J Surg 1985; 72: 237-8. In this study, a retrospective analysis of 47 patients, who had previously sufTered testicular torsion, showed evidence of autoimmune reactivity against spermatazoa in three cases. The results are similar to previously reported series'. The authors also tested 11 acute torsion cases of torsion at 1 month and 3-6 months post-torsion, presumably to see if a transient rise in antibody levels might be detected, which theoretically might cause permanent testicular injury and explain the incidence of post-torsion subfertility. In no acute case was antibody detected. In their discussion the authors discounted previous animal studies involving small numbers of rats which produced positive evidence of autoimmunization and mentioned the possibility that both testes might be abnormal in testicular torsion.

We have performed experiments in 70 rats using an experimental model of torsion previously described and reported an incidence of

Br. J. Surg., Vol. 73, No. 4, April 1986 325