Emergency surgery: atavistic refuge of the general surgeon?

A prospective audit of emergency soft-tissue surgery for an eight-week period revealed that general surgical emergency operations were more than twice as common as those undertaken in other soft-tissue specialties. The audit reveals that emergency general surgery needs an increase in resources, an increase in available staff and an increase in the role of the consultant general surgeon on call. An alternative solution would be to admit soft-tissue emergencies by specialty and develop specialist emergency services.

Mammary hibernoma

Hibernomas are rare benign tumours of brown fat. We report the first account in the English literature of a mammary hibernoma, presenting in the post-lactational period.

The effect of danazol on discrete benign breast lumps

Surgical biopsy of benign breast lumps produces a significant surgical workload, morbidity and cost. A double-blind placebo-controlled trial of danazol 200 mg daily was carried out with the aim of reducing the size of solid discrete breast lumps, thereby avoiding surgical biopsy in benign cases. Twenty-two women with lumps diagnosed as benign by clinical examination, mammography and cytology were randomized to take danazol and 26 placebo. The patients were assessed monthly by two clinicians until surgical biopsy. Twenty patients in each treatment group were evaluated and five patients discontinued treatment (two on danazol, three on placebo) and three (all on placebo) were found to be malignant. There was no difference in the number of lumps which responded to treatment with danazol or placebo. There was a reduction in the number of lumps which subsequently developed in the breasts treated with danazol during the 12-month follow-up period, but this failed to achieve statistical significance. Danazol does not promote resolution of solid discrete benign breast lumps. Careful selection of women over 25 years for surgery with solid discrete breast lumps is required, utilizing a dedicated breast cytologist with a multidisciplinary approach, to avoid missing breast cancers.

Plasma fatty acid profiles in benign breast disorders

Breast pain (mastalgia) and macroscopic breast cysts present commonly. Mastalgia may be improved by dietary manipulation to reduce saturated fat or supplement essential fatty acid intake. Fatty acid profiles were measured in women with mastalgia and breast cysts, before and during treatment with evening primrose oil, a rich source of essential fatty acids. The fatty acid profiles of both groups of patients were abnormal, with increased proportions of saturated fatty acids and reduced proportions of essential fatty acids. Treatment with evening primrose oil improved the fatty acid profiles towards normal, but this was not necessarily associated with a clinical response.

Bioactive and immunoactive prolactin levels after TRH-stimulation in the sera of normal women

The availability of an improved microbioassay for lactogenic hormone measurement has enabled comparison of basal and dynamic prolactin bioactivity (BA) and immunoactivity (IRMA) in normal human serum. Serum from 16 normal females aged 22-74 years was assayed and revealed a mean BA/IRMA prolactin ratio of 1.6 for basal and 1.8 for peak TRH-stimulated levels. Basal prolactin levels in postmenopausal women measured by bioassay were lower than in premenopausal women showing a relative and absolute decrease in prolactin bioactivity with age, but there was no significant difference in dynamic levels. There was also no significant difference in BA or IRMA levels following the stress of venepuncture. These findings indicate that, as previously described for basal levels, there is a good correlation between dynamic prolactin bioactivity and immunoactivity in human serum.

Prolactin and total lactogenic hormone measured by microbioassay and immunoassay in breast cancer

Basal prolactin (PRL) and total lactogenic hormone (TLH) levels were measured using a new microbioassay (BA) and conventional immunoradiometric assay (IRMA) in patients with breast cancer and compared to an age-matched control group. No significant differences were found using the IRMA, but BA lactogenic levels were significantly elevated in breast cancer patients compared controls, leading to a markedly elevated BA/IRMA ratio for both PRL (2.7 vs 1.4, P less than 0.0001) and TLH (2.8 vs 1.4, P less than 0.0001) which was greatest for postmenopausal women. Using the mean +2 standard deviations as the upper limit of normal, there was no significant difference between breast cancer patients and controls for IRMA, but BA and BA/IRMA PRL levels were elevated in 42% and 61% of the patients, respectively. There was a weak negative correlation of BA and IRMA PRL with age for normals (r = -0.53 for both) but no correlation was evident for breast cancer patients (r = 0.06 and -0.13, respectively) implying a sustained absolute and relative bioactive hyperprolactinaemia at all ages. These results show increased lactogenic bioactivity in breast cancer and suggest that different forms of bioactive prolactin undetected by IRMA (or enhancing serum factors) are present in the sera of these patients.

Basal prolactin and total lactogenic hormone levels by microbioassay and immunoassay in normal human sera

The availability of an improved microbioassay for prolactin measurement has enabled comparison of lactogenic hormone bioactivity and immunoreactivity in normal human serum. Serum was studied from 61 normal females and 15 normal males. The correlation of both assays was very close for all subjects with a mean ratio of bioassay to immunoassay of 1.5 (range 0.8-2.0) for prolactin and 1.4 (range 0.5-1.9) for total lactogenic hormone. There was no significant variation in prolactin or total lactogenic hormone values by microbioassay or immunoassay with sexual or menstrual status. Postmenopausal prolactin levels were lower by both assays compared with premenopausal values with a relative and absolute decrease in prolactin bioactivity with age. These findings indicate that there is a good correlation between prolactin bioactivity and immunoactivity in human serum.

Traumatic rupture of the diaphragm: a difficult diagnosis

Rupture of the diaphragm occurs in approximately 5 per cent of cases of severe blunt trauma to the trunk, and the mortality may be as high as 50 per cent. The diagnosis is important because of the high incidence of associated organ damage and complications of a missed injury. Successful diagnosis requires a high index of suspicion but can be made from the chest radiograph in 90 per cent of cases if visceral herniation has occurred. We present three cases of rupture of the diaphragm which highlight the frequent occurrence of a delayed or missed diagnosis.

Mastalgia refractory to drug treatment

Management of the patient with mastalgia who fails to respond to first line therapy is a difficult problem and there is a group of patients who do not respond to any therapy. A group of 126 patients with mastalgia who failed to respond to first line therapy and completed further treatment options was studied. The response rate of those with cyclical mastalgia fell to 57 and 25 per cent for second and third line therapy respectively. Equivalent figures for non-cyclical mastalgia were 24 and 21 per cent. Danazol maintains a high response rate after the failure of other drugs, whereas the second line response to bromocriptine and evening primrose oil is poor. Unresponsive patients were matched to a group of patients who responded to first line therapy, and reproductive and historical factors were compared using the chi 2 test, but failed to identify which patients would respond to therapy.

Acute appendicitis secondary to metastatic carcinoma of the breast

A patient developing acute appendicitis and intestinal obstruction secondary to metastatic breast carcinoma is described. This rare occurrence may become more common with improved survival in cases of advanced breast malignancy. The intrinsic nature of malignant metastases in the appendix, with or without concurrent immunosuppressive chemotherapy, leads to a late presentation of appendicitis with a high incidence of perforation, associated with an increased mortality and morbidity. It is suggested that appendicectomy should be undertaken as a routine in patients with carcinoma of the breast when oophorectomy or laparotomy is to be performed.

A randomized trial of dietary intervention with essential fatty acids in patients with categorized cysts

Two hundred women with breast cysts proven by aspiration were entered into a randomized double-blind trial of Efamol (evening primrose oil) at a dose of 6 capsules daily or equivalent placebo dose for a year. Cysts were categorized by initial electrolyte composition, and follow-up continued for 1 year posttherapy. Recurrent cyst formation in the first year was slightly (but not significantly) lower in the Efamol group compared with the placebo-treated group. The Efamol treatment was well tolerated as the dropout rate was only 7% and equal in both the active and placebo groups. The initial electrolyte composition did not predict for cyst recurrence.

A randomised controlled trial of medroxyprogesterone acetate in mastalgia

A double-blind crossover study giving 20 mg/day of medroxyprogesterone acetate during the luteal phase was carried out in 26 women with cyclical mastalgia. Symptomatic response to this progestogen supplementation or placebo was assessed objectively by clinical examination and subjectively by linear analogue scales and breast pain charts. No significant relief of pain or tenderness was found on placebo or active treatment, irrespective of treatment order, and breast nodularity was similarly unaltered. No evidence of progesterone deficiency or prolactin abnormality was found. Side-effects were incurred in 11 patients (five on placebo, five on active treatment and one while on both) and were mostly vague premenstrual symptoms. We conclude that the therapeutic response of medroxyprogesterone acetate in cyclical mastalgia is no better than placebo and that progestogen supplementation can no longer be recommended for routine use in the management of breast pain.

Low-dose danazol for mastalgia

A low-dose danazol maintenance therapy (mean total dose 800 mg per month) was given during the luteal phase to 34 women with severe relapsing cyclical mastalgia. On conventional danazol dosage, all subjects had previously obtained a useful clinical response, but side effects occurred in 29 (85 per cent). Using this low-dose regimen, complete relief of symptoms was achieved in 15 women (44 per cent); the remainder obtained a substantial clinical improvement. Side effects were reduced to 12 per cent of women and were considered mild and tolerated by all patients. A low-dose regimen may be suitable for women with severe persistent cyclical mastalgia and minimises side effects that develop on conventional dosage.

Management of breast pain and nodularity

The management of mastalgia consists of classification into its various patterns: reassurance, drug therapy for severe cases, and, rarely, surgery. Differentiation into cyclical and noncyclical patterns on a simple pain chart is useful for objective assessment of pain severity and for selection of appropriate drug therapy and subsequent monitoring of response. About 85% of new patients will be satisfied with adequate reassurance, but some 15% will have persistent pain and warrant medical treatment. Only a small number of drugs have been adequately tested in controlled trails and have been demonstrated to be more effective than placebo; these are bromocriptine, danazol, evening primrose oil, and tamoxifen. No ideal agent exists and the choice of drug will depend on efficacy, side effects, and cost. Noncyclical pain has a lower response rate compared to cyclical mastalgia, but differentiation of a subgroup with chest wall pain leads to an overall 90% response to treatment by local infiltration with steroid and lignocaine. Newer agents such as LHRH agonists are currently undergoing evaluation in double-blind controlled trials against placebo. The management of nodularity is based on the clinical differentiation of the normal spectrum of physiological change within the breast (ANDI), requiring simple reassurance, from a true dominant breast nodule that will require excision biopsy to exclude malignancy. When pain and lumpiness coexist, some reduction in overall nodularity (with the use of agents given for mastalgia) may occur.

Non-cyclical mastalgia: an improved classification and treatment

A prospective study of 72 patients with non-cyclical breast pain was carried out. Non-cyclical breast pain was subdivided into true non-cyclical mastalgia (35 patients) and musculoskeletal pain (37 patients), the latter including Tietze's syndrome and other causes of chest wall pain. Mean age at presentation was significantly greater in the musculoskeletal group (39.3 versus 33.9 years) with a shorter mean duration of pain (14.7 versus 35.4 months) compared with the non-cyclical mastalgia group. True non-cyclical mastalgia was commonly bilateral and located within the upper outer quadrant of the breast, whereas musculoskeletal pain was almost always along the lateral chest wall or costochondral junctions and unilateral in 92 per cent of cases. Breast nodularity was present in 54 per cent of patients with non-cyclical mastalgia, but in only four cases (11 per cent) in the musculoskeletal group. Nine of 14 patients (64 per cent) with non-cyclical mastalgia obtained a good clinical response to drug therapy (over half responding to danazol alone); 19 underwent spontaneous remission, but there was a prolonged mean time to pain resolution of 27 months. In the musculoskeletal group 33 of 34 patients (97 per cent) had a good response to steroid and local anaesthetic injection; three resolved spontaneously without treatment, with a mean time to pain resolution of 17 months. This study indicates that differentiation of musculoskeletal pain from non-cyclical mastalgia may lead to more effective treatment with some prediction of the overall prognosis.

Maintenance therapy of cyclical mastalgia using low-dose danazol

In an open study, low-dose danazol (mean total dose 700 mg/month) was given during the luteal phase to 20 women with severe relapsing cyclical mastalgia. All subjects had previously obtained a useful clinical response on conventional dosage of danazol, but side effects occurred in 13 (65%). On the low-dose regimen, complete relief of symptoms was attained by 11 women (55%) and the remainder achieved a substantial clinical improvement; no side effects were reported. A low-dose regimen may be suitable for women with chronic relapsing cyclical mastalgia or those who develop side effects on conventional dosage.

The management of mastalgia in the UK

Mastalgia is a common breast symptom which, when severe and persistent, warrants medical therapy. Current and future treatments are reviewed.

A new microbioassay for the measurement of lactogenic hormones in human serum

The standard Nb2 assay for biologically active prolactin has been modified to allow a rapid convenient microbioassay without loss of specificity or accuracy. Lactogenic hormones specifically stimulate the replication of Nb2 node rat lymphoma cells in suspension culture and form the basis of a currently available bioassay to measure prolactin and growth hormone in human serum. A new microbioassay was developed using microtest plates enabling a large number of samples to be assayed simultaneously whilst maintaining the overall sensitivity of the bioassay for lactogenic hormones. Growth of the Nb2 node lymphoma cells, measured by a light scattering technique using optical density on a spectrophotometer, was shown to be closely correlated with the cell number determined on a Coulter counter. Addition of excess anti-human prolactin and anti-human growth hormone completely inhibited the growth stimulatory effects of both human prolactin and human growth hormone. This new microbioassay (BA) and conventional radioimmunoassay (RIA) were used to measure lactogenic hormones in 48 normal subjects. There was a close correlation between the results of both assays for each hormone studied in the control sera. The mean basal BA/RIA ratio was 1.5 (range 0.8-2.0) for prolactin, 0.7 (range 0-4.5) for growth hormone and 1.3 (range 0.5-1.9) for total lactogenic activity.