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The Urethral Syndrome on 1 October 2021 by Guest BRITISH MEDICAL JOURNAL 3 SEPTEMBER 1977 593 reduce the death rate mortality in the next 10 years. Un- three patients out of the 90 with abnormal scans, presumably fortunately, combination cytotoxic chemotherapy is toxic, representing early metastatic disease. This time the conclusion and clinicians have, rightly, been reluctant to use it without was that: "It would appear that routine preoperative skeletal good evidence that the patient has metastases-or at least scintigraphy is a superfluous examination in patients clinically Br Med J: first published as 10.1136/bmj.2.6087.593 on 3 September 1977. Downloaded from evidence that the prognosis for their individual patient is suspected to have a breast cancer in stages T1,2 NO,la." sufficiently bad to warrant the discomfort, inconvenience, and What advice, therefore, can be given to the surgeon ? If he ill effects associated with the use of drugs.2 is practising in a hospital where bone scanning has not been The most reliable prognostic indicator is the presence of validated by a long follow-up of positive cases the strategy nodal metastases: when they are extensive they are a sign of adopted by the Cardiff group may represent the most realistic an almost invariable fatal outcome to the disease.3 More and economic approach.'3 They found that conventional recently Fisher and his colleagues4 have refined assessment of skeletal radiology carried out before mastectomy forstage 1 and the prognostic importance of node metastases by showing that 2 breast cancer produced very small returns. Use of both this when over four nodes are affected at the time of mastectomy technique and skeletal scintigraphy for every patient must be then the patient must be considered to have systemic disease. considered wasteful, and so they recommend initial skeletal Yet surgeons still dislike "statistical" assumptions of a poor scintigraphy for all patients, with radiology of the hot areas. prognosis; naturally they would prefer more direct evidence If the conventional x-ray films show obvious skeletal meta- of the presence of micrometastases. stases at the site of suspicion then this, of course, places the Post-mortem studies of patients dying within five years of patient in the stage 4 category. Those patients with hot mastectomy for carcinoma of the breast have shown that about spots on the scan but normal findings on radiology should not 70 have skeletal deposits) A search for this 70, e'arly in be denied the potential benefit of mastectomy pending the course of the disease might lead to more rational treatment. validation of the technique. In the meantime all centres would Unfortunately, the resolving power of skeletal radiology is be advised to continue to use axillary node sampling as the poor: at least half of a vertebra has to be destroyed by met- best-established prognostic test and to use this basis for astatic breast cancer before the lesion is apparent radiological- entering patients into trials of adjuvant chemotherapy. ly.fi Galasko's pioneer work with skeletal scintigraphy found IBaum, M, British Medical3Journal, 1976, 1, 439. that bone-seeking isotopes could show up skeletal metastases 2 British Breast Group, British Medical3Journal, 1976, 2, 861. two to three years before they become obvious with conven- 3 Syme, J, Principles of Surgery, 3rd edn. London, Bailliere, 1842. tional radiology.7 His original series showed that 2400 of 4Fisher, B, et al, Cancer, 1969, 24, 1071. 5 Sklaroff, D M, and Charkes, N D, Surgery, Gynecology and Obstetrics, women with apparently localised breast cancer had abnormal 1968, 127, 763. bone scans. These patients have now been followed up for 6 Edelstyn, G A, Gillespie, P J, and Grebbell, F S, Clinical Radiology, five years, during which all those with suspicious areas on the 1967, 18, 158. 7Galasko, C S B, British Journal of Surgery, 1969, 56, 757. scan developed evidence of metastatic spread.8 Since Galasko's 8 Galasko, C S B, British3Journal of Surgery, 1975, 62, 694. original work an enormous number of publications have Green, D, et al, Australian and New Zealand Journal of Surgery, 1973, 43, 251. largely confirmed his findings that women with apparently 10 Citrin, D L, et al, British Journal of Surgery, 1975, 62, 201. localised breast cancer may have abnormal scans. 1 Sauer, R, Hartweg, H, and Fridrich, R, Radiologia Clinica, 1975, 44, 350. 12 Charkes, N D, et al, Journal of the American Medical Association, 1975, So should a positive bone scan influence the management 233, 516. of the woman with "early" breast cancer? Galasko used 13 Roberts, J G, et al, Lancet, 1976, 1, 237. http://www.bmj.com/ fluorine-18 as his bone-seeking isotope, recorded the y emission 14 Campbell, D J, Banks, A J, and Oates, G D, British Journal of Surgery, 1976, 63, 811. on a gamma camera, developed his own criteria for reporting, 15 Butzelaar, R M J M, et al, European J7ournal of Cancer, 1977, 13, 19. and has one of the few series that has been validated by a five- year follow-up. Most other authors have used other isotopes with different scanning techniques and different criteria for reporting, and most have yet to validate their results. Further- more, it is difficult to judge whether the extent of the local disease in the patients examined is comparable in all series. The urethral syndrome on 1 October 2021 by guest. Protected copyright. Nevertheless, a Birmingham group has recently added strong support to Galasko's experience.'4 They found 1800 positive Rational treatment for women with the syndrome of recurrent bone scans in women with stage I carcinoma of the breast and dysuria, frequency, urgency, and a feeling of incomplete 41%,o positives in those with stage II growths. At a follow-up bladderemptying depends on differentiating between those who at 18 months 860 of the patients with positive scans had have relapsing or recurrent bacteriuria and those who have developed signs of disseminated disease compared with not. Much confusion has been caused by labelling all patients, only 11%O of those with negative scans. The group concluded irrespective of age and the results of bacteriological studies, that bone scans provided an excellent prognostic index at a as suffering from bacterial cystitis. Too often patients suffering patient's initial assessment. from this syndrome are given systemic antibiotics on the Hence it could be argued that clinicians having access to assumption that they have bladder bacteriuria when their the scanning service in Birmingham would be well advised to primary condition would appear to be a local irritative urethral advocate systemic treatment for patients with positive scans. or bladder lesion. It is therefore essential that a midstream Nevertheless, an entirely opposing point of view is provided specimen of urine should be taken as soon as the symptoms in the European_7Jurnal of Cancer15 with a series of 90 patients begin and before treatment is started. with carcinoma of the breast staged with stage 1 or 2 tumours The natural history of lower urinary tract infection varies and stage 0 or la nodes. There were seven positive scans in in different age groups. In prepubertal girls, for example, this group, and two of these abnormalities could be accounted symptoms rarely arise in the absence of bacteria, and docu- for by non-malignant conditions. Two further patients with mented urinary infection can usually be controlled by appro- "hot" areas in the vertebrae had bone biopsies which failed priate antibiotic treatment. Rarely surgery may be necessary to confirm the presence of metastatic disease; that left only to correct severe degrees of ureteric reflux. Two prospective 594 BRITISH MEDICAL JOURNAL 3 SEPTEMBER 1977 trials of treatment of proved urinary tract infection in this 2 Kaplan, G W, Sammons, T A, and King, L R, Journal of Urology, 1973, 100, 917. age group' 2 have failed to show any benefit from either 3 Asscher, A W, British Medical Journal, 1977, 1, 1332. 4 Rees, D L P, et al, British of Urology, 1975, 47, 853. urethral dilatation or internal urethrotomy. Journal Br Med J: first published as 10.1136/bmj.2.6087.593 on 3 September 1977. Downloaded from In adults control of bacterial infection by appropriate advice 5 Rees, D L P, and Farhoumand, N, British Journal of Urology, 1977, in press. on fluid loading, frequent voiding, and attention to vulval Farrar, D J, Alan Green, N, and Handley Ashken, M, British Journal of hygiene together with appropriate antibiotic treatment will Urology, 1973, 45, 610. Splatt, A J, and Weedon, D, British Journal of Urology, 1977, 49, 173. alleviate symptoms in most women with bacteriuria. In a 8 Richardson, F H, and Stonington, 0 G, Surgical Clinics of North America, very few cases of persistent urinary tract infection surgery 1969, vol 49, 1201. may be necessary to deal with infective calculi or functionless 9 Shand, D G, et al, British Journal of Urology, 1968, 40, 196. pyelonephritic kidneys. In the abacteriuric group it is important to try to identify the cause of the syndrome. A third of the patients will show evidence of bladder instability on cystometry,4 and anti- cholinergic drugs such as propantheline, emepromium Screening children for visual bromide, or flavoxate hydrochloride may be effective. In the postmenopausal patient with senile vaginitis and urethritis defects symptoms may be relieved by a course of local or systemic oestrogens. The elimination of vaginal infections, careful instruction in personal hygiene, the maintenance of a good Nowhere are the opportunities for preventive medicine better fluid intake, frequent and complete bladder emptying, and than in the treatment of amblyopia, whether it be associated voiding after sexual intercourse have all been shown to be with a squint (strabismic amblyopia) or with unequal refractive beneficial.
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