D. J. T. Webster

Immediate reconstruction of the breast after mastectomy is it safe

The authors have reveiwed the results of their first 85 immediate reconstructive procedures following mastectomy for breast cancer. Acceptable cosmetic results were obtained in most patients with no mortality or life‐threatening morbidity. There were a number of problems related to the wounds and the prostheses, which decreased with increasing experience. There was a moderate increase in blood transfusion requirements, and a considerable increase in operating time. No detrimental effect on tumor behavior was observed when assessed as part of a case—control study. It is concluded that this approach is feasible and safe, and deserves further evaluation. Cancer 53:1416‐1419, 1984.

Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines

The recently published national guidelines to general practitioners for the referral of patients with breast problems were retrospectively applied to letters of all patients attending the Rapid Access Breast Clinic at the University Hospital of Wales. The patients have all had diagnostic investigations performed at the initial visit with a multidisciplinary review of results and provision of a management plan prior to the subsequent visit. Since its inception in May 1995 until the end of the year when the guidelines were published, 2332 new patients had been seen. Overall, 29% of patients with benign breast disease would not have been referred if the guidelines had been strictly followed. Of the 147 symptomatic carcinomas diagnosed from general practitioner referrals (6.3% of total referrals), no invasive cancers would have been missed. One patient with incidental detection of ductal carcinoma in situ (DCIS) in the asymptomatic contralateral breast would not have been referred. Referral for pain without a discrete lump constituted 63% of the patients with a benign diagnosis who fell outside the guidelines. The guidelines also include comprehensive algorithms for the initial management of benign breast symptoms that do not require immediate referral by the general practitioners. Our general practitioners were significantly better at referring patients over 50 years old but the proportion of appropriate referrals were not related to the number referred by each practice. The present guidelines adequately cover referral for the diagnosis of malignant breast disease to a specialist, and may reduce the benign workload of breast clinics.

Abdominal aortic aneurysm causing duodenal and ureteric obstruction

We report a unique case of an abdominal aortic aneurysm complicated by both duodenal and ureteric obstruction and review the literature on these conditions. Duodenal obstruction is a consequence of compression of the duodenum in its fixed retroperitoneal course between the aneurysmal aorta and the superior mesenteric artery. Treatment should be based on replacement of the aneurysm as gastrointestinal bypass alone does not resolve the risk of aneurysm rupture. Ureteric obstruction is related to encasement of the ureters in an inflammatory perianeurysmal fibrosis of unresolved etiology rather than secondary to aneurysm compression. Although urinary tract symptoms are often seen with aortic aneurysms, they tend to be nonspecific and are often overlooked. As many as 71% of patients with abdominal aortic aneurysms may have radiologic evidence of ureteric involvement. Although aneurysm replacement alone may resolve the perianeurysmal fibrosis with resultant relief of ureteric obstruction, most authors advise simultaneous ureterolysis. Aortic aneurysm should be considered as a possible cause of duodenal or ureteral obstruction in the elderly, especially in the presence of a pulsatile abdominal mass.

The effect of tamoxifen on plasma growth hormone and prolactin in postmenopausal women with advanced breast cancer

The effect of tamoxifen on serum levels of basal prolactin and basal and stimulated growth hormone was assessed in 10 women with advanced breast cancer prior to and after 1 and 8 weeks of treatment. Tamoxifen had no effect on basal levels of either hormone or on insulin-stimulated growth hormone. Two of 4 patients undergoing arginine provocation testing had a partial response to tamoxifen and both exhibited marked diminution of growth hormone stimulation which was not seen in the non-responders.