558. Letters and Comment. In addition, the 'mighty mouse' can tax the cytologist by undergoing infarction. Also suffer spontaneous intraductal ...
558
Letters and Comment
In addition, the 'mighty mouse' can tax the cytologist by undergoing infarction. Also suffer spontaneous intraductal haemorrhage-almost a minor apoplexyproducing both a bloody FNAC and nipple discharge. Truly a treacherous, perplexing and yet beguiling benignancy. A J WEBB ChM FRCS FIAC Consultant Surgeon Bristol Royal Infirmary
References 1 Wilkinson S, Forrest APM. Fibroadenoma of the breast. Br J Surg 1985; 72: 838-40. 2 Hughes LE, Mansell RE, Webster DJT. Benign Disorders and Diseases of the Breast. London: Bailliere Tindall, 1989: 190-92. 3 Cardozo PL. Atlas of Clinical Cytology. London: William Heinemann Medical Books, 1979: 492-3. 4 Linsk JA, Franzen S, eds. Clinical Aspiration Cytology. London, St Louis: JB Lippincott Company, 1983: 11216. S Cornillot M, Verhaege M, Cappelaere P, Clay A. Place de la cytologie par ponction dans le diagnostic des tumeurs du sein, 2,267 examens cytologiques. Lille Med 1971; 16: 1027-32.
Transecting the rectum: the 'clean cut' approach De Boyce et al. (Annals, May 1996, vol 78, p191) are to be congratulated for bringing to the attention of your readers the clean cut approach to dividing the rectum during anterior resection. It is not necessary, however, for surgeons to look to the hospital medical physics department to provide a custom-made knife. One should look no further than the Beaver knife (Fig. 1) used by gynaecologists for cone biopsies, which has been my standard method for the past 15 years for achieving clean cuts during bowel resection. It has the added advantage of a cutting blade on both sides for right- or left-handed surgeons! B F RIBEIRO FRCS Consultant Surgeon Basildon Hospital Basildon
Aetiology and management of hypertrophic scars and keloids We read with interest the article by O'Sullivan et al. (Annals, May 1996, vol 78, p168). As dermatologists, we frequently manage patients with hypertrophic scars and keloids, and find intralesional triamcinolone (5-20 mg/ml) to be a simple and effective treatment for most small lesions. However, injections are painful (confirmed by personal experience) and repeated treatment may not be tolerated, especially by children. Silicone gel sheets are not available on NHS prescription, and patients may be unable to afford this product at a price of approximately £20-25 per 13 cm2 sheet. We have found use of a very potent topical corticosteroid (eg clobetasone dipropionate) under a hydrocolloid dressing occlusion to be an effective and well-tolerated alternative. The dressings are comfortable and need only be changed once or twice weekly. We find this regimen to be more effective than commercially available steroid-impregnated tape. Occlusion enhances the cutaneous penetration of potent topical steroids, and lesions may flatten considerably within a few weeks. Hydrocolloid dressings have been demonstrated to be superior to plastic semi-occlusion in occlusive corticosteroid therapy of psoriasis (1). As with intralesional steroid therapy, care needs to be taken to monitor for lesional and perilesional atrophy. SARAH H WAKELIN MRCP Senior Registrar in Dermatology PAULINE MARREN MRCPI Consultant Dermatologist
Department of Dermatology Amersham Hospital, Amersham, Bucks Reference 1 van de Kerkhof PC, Chang A, van der Walle HB et al. Weekly treatment of psoriasis with a hydrocolloid dressing in combination with triamcinolone acetonide. A controlled comparative study. Acta Derm Venereol 1994; 74: 143-6.
Figure 1 A survey of the management of breast cancer in England and Wales (Annals, May 1996, vol 78, p197) With more than one in 12 women likely to develop cancer of the breast in the UK each year it is worrying that there is still no generally agreed and uniform management of the condition. This is particularly so as regards the diagnosis of breast cancer and in management of the axilla. While the authors quote 15% of surgeons as not using fine needle aspiration cytology (FNAC), this figure is really a reflection of those who replied. Only 395 surgeons out of a possible 853 use FNAC. This means that large numbers of patients may not be in receipt of ideal management-diagnosis involving palpation, FNAC, and mammography/ultrasonography. Additionally, while there is continuing debate regarding the best management of the axilla, there seems to be little doubt that the axillary lymph node status vis-a-vis cancer is about the best available prognostic factor that also helps to determine subsequent treatment. Again, the figures given for no axillary management may be higher than those that actually pertain in practice because of the 40% non-response rate to the questionnaire. On the basis of the foregoing there can be little disagreement with the authors' conclusion that the best management of cancer ofthe breast is by surgeons who have the expertise, the necessary volume of patients, and the
