The significance of new densities and microcalcification in the second round of breast screening.

AIM: To assess the nature of new densities and microcalcifications in the second round of breast screening. MATERIALS AND METHODS: A total of 34 634 women were screened at our unit in the second round of the United Kingdom National Health Service Breast Screening Programme. Of those attending for the second time, 302 were recalled for further work-up of 311 new lesions. The lesions were divided into masses, microcalcifications, asymmetric densities and architectural distortions. Masses were classified according to margin and density, and microcalcifications according to morphology and distribution. RESULTS: Among women attending for the second time, the cancer detection rate was 0.45% (89 cancers). One hundred and eighty-eight new masses were identified: 53 well-defined (two malignant), 67 partially defined (six malignant), 54 ill-defined (18 malignant), and 14 spiculate (14 malignant). Well-defined masses were usually cysts, especially in women on hormone replacement therapy. Of 97 new microcalcifications, 71 were pleomorphic (28 malignant), 12 linear (one malignant), and 14 punctate (none malignant). Twenty-five new asymmetric densities were identified (five malignant). One of two architectural distortions was malignant. Malignancy was found in 21% of new masses, 30% of new microcalcification and 20% of asymmetric densities. CONCLUSION: Carcinoma was found in 24% of all new mammographic abnormalities appearing in a 3-year screening period. Spiculate and ill-defined masses, clustered pleomorphic microcalcification, and new asymmetric densities should be regarded with particular suspicion. The use of fine needle aspiration cytology in combination with imaging assessment may help to reduce the number of benign excisional biopsies for new mammographic lesions.

Retrograde embolization and causes of failure in the primary treatment of varicocele.

OBJECTIVE: To assess retrograde embolization for the treatment of varicocele and to examine the causes of surgical and radiological treatment failure. PATIENTS AND METHODS: Of 154 patients with clinical varicocele associated with subfertility or symptoms who were treated, 100 underwent surgical high ligation, retrograde embolization under fluoroscopic control was attempted in 84 and 30 had both forms of treatment. Venographic findings were defined in those patients for whom embolization proved impossible and in those in whom prior high ligation had failed. Among subfertile patients, 64 had semen analyses before and at least 3 months after the procedure available for comparison. Those patients undergoing both radiological and surgical procedures were sent questionnaires to evaluate their experience. RESULTS: Retrograde embolization was technically successful in 68 (81%) of the 84 patients. Two early failures were associated with venous spasm provoked by technical inexperience, while difficulties in the remainder were caused by anomalous venous anatomy. In patients who had recurrent varicocele after previous ligation, venography showed incomplete ligation of collateral channels; 14 of 18 patients were successfully re-treated by embolization. The sperm concentration improved significantly in 83% of patients undergoing embolization and in 63% of those surgically ligated. Patients who underwent both procedures expressed a strong preference for embolization. CONCLUSION: In centres where there is a skilled interventional radiologist, embolization is an effective alternative to surgical ligation of varicocele. Carried out under local anaesthesia as an out-patient procedure, it is cost-effective, associated with minimal morbidity and most patients are able to return to normal daily activities immediately.

Use of image enhancement during lithotripsy.

Renal excursion during breathing is inevitable and is a cause of poor localization during extracorporeal shock-wave lithotripsy (SWL), which in theory might lead to poor treatment results. Eighty-one patients underwent lithotripsy treatment with and without the use of an image enhancement system designed for use with the Dornier MPL9000 lithotripter. This device contains a memory incorporated into a separate differential grayscale monitor, which allows the stone image to be stored. Shockwave release is enabled only when this image corresponds to the real-time image on the lithotripter ultrasound monitor. No improvement in success rates was found using this system, although upper-pole stones appeared to be fragmented more successfully. Overall, the results were favorable in both groups after a single treatment. Further work is needed to establish whether image enhancement is capable of improving the success rates and reducing the side effects of lithotripsy by better targeting.

Choosing the correct pain relief for extracorporeal lithotripsy.

OBJECTIVES: To determine the best choice of analgesic for patients undergoing lithotripsy, and to attempt to identify factors which might predict which patients are most likely to find the procedure painful. PATIENTS AND METHODS: Sixty patients with stones in the pelvicalyceal system of the kidney were randomized prospectively to undergo lithotripsy with the Dornier MPL9000 lithotripter (Dormier Medical Systems, Marietta, GA, USA) after receiving either diclofenac 100 mg per rectum (n = 30) or pethidine 50 mg intravenously (n = 30) for analgesia. The patients completed a detailed questionnaire prior to treatment, and the level of pain perceived during lithotripsy was monitored using visual analogue scales (VASs). Arterial oxygen saturation (SaO2) was monitored before analgesia was given, throughout the treatment and for 30 min after cessation of treatment. RESULTS: The VASs were available for 56 patients and the results of pulse oximetry for 51 patients. Although a higher kilovoltage was recorded in the group who received pethidine this difference was not significant. Patients who received diclofenac or pethidine alone, showed a non-significant fall of SaO2 30 minutes after the end of treatment, although the largest fall in SaO2 observed with pethidine was 10%. Patients who received diclofenac and pethidine similarly showed a non-significant fall in SaO2. Four patients received intravenous benzodiazepines in addition to pethidine, and in this group there was a dramatic fall in SaO2 which persisted more than 30 min after the end of treatment (P < 0.0027). Diclofenac provided effective analgesia for most of the patients who underwent lithotripsy. Overall 11 patients (18%) required additional analgesia. Diclofenac or pethidine alone, in the doses used in this study, did not cause a significant drop in SaO2 during ESWL. The only response found to be of value in predicting a painful experience was fear of the dentist. CONCLUSIONS: This study shows that modern lithotripsy, in addition to being safe and effective, can be performed as an out-patient procedure using simple non-opiate analgesics. The need for stronger analgesia and/or sedation should be tailored to the needs of the individual patient, although it remains difficult to predict which patients will require such measures.

Does lithotripsy cause hearing loss?

OBJECTIVE: To determine whether lithotripsy with the Dornier MPL9000 has any significant effect on the hearing of either patients or operators, as determined by pure tone audiometry. PATIENTS AND METHODS: Twenty patients had audiometry prior to a single exposure to lithotripsy and one hour after treatment. Staff were monitored on a 3 monthly basis. RESULTS: No evidence was found to suggest that single or repeated exposure to the noise emitted by this Dornier lithotripter was associated with any hearing loss. CONCLUSIONS: These results suggest that the risk to the hearing of patients exposed to lithotripter noise is negligible. Cochlear damage resulting from excessive noise depends on both the intensity of the sound and the duration of exposure. The acoustic properties of the building housing the machine may also be important and can significantly influence the intensity of the sound at the ear. At marginal levels it may be years before the deficit reaches a level that can be detected by subjective audiometry. In addition, susceptibility to noise induced hearing loss is difficult to predict. Although these results suggest that there is minimal risk to the hearing of staff members exposed to lithotripter noise, the authors recommend that staff exposed to repeated lithotripter noise over long periods undergo regular audiometric assessment (including a preemployment baseline assessment) to identify evidence of noise induced auditory trauma, and that protective equipment be worn by staff members to reduce the possibility of long-term damage.

Comparison of duplex ultrasonography and venography in the diagnosis of deep venous thrombosis.

Sixty-five patients with suspected deep venous thrombosis (DVT) in 68 limbs were entered consecutively into a study to compare venography with duplex ultrasonography scanning. Both tests were performed on 64 limbs, venography being contraindicated in four. Overall, duplex scanning correctly identified 86 per cent of DVTs diagnosed on venography and correctly excluded 80 per cent with negative venograms. Nearly all errors arose in the diagnosis of calf DVT. In the femoral vein duplex scanning had a specificity of 100 per cent and a sensitivity of 95 per cent. In addition, duplex scanning provided data on the limb not undergoing venography. Of 55 limbs that underwent bilateral duplex scanning, five had thrombus in the femoropopliteal segment and a negative contralateral venogram. In addition, three Baker's cysts were diagnosed. Duplex scanning can be used in patients in whom venography is contraindicated and may also provide information about the contralateral limb. We regard femoropopliteal duplex scanning as sufficiently accurate that treatment can be initiated on the basis of the scan. Duplex scanning should replace venography as the standard method of diagnosing femoropopliteal DVT; radiographic studies should now be required only when the scan result is in doubt.

The pre-operative assessment of advanced gastric cancer by computed tomography.

Forty-five patients with proven gastric adenocarcinoma underwent pre-operative abdominal computed tomography (CT). The radiological findings of tumour spread were prospectively compared with the surgical findings obtained at laparotomy. CT evidence of involvement of three organs, together with the presence of a large gastric tumour mass, correlated with the inability to resect the tumour in this series.