Biomedical subjects
J J Tate
Publications and source records attributed to J J Tate.
Faecal occult blood testing in symptomatic patients: comparison of three tests.
This study examines three faecal occult blood tests, Haemoccult, Fecatwin and E-Z Detect, each with different sensitivities, to determine which is best suited for use in symptomatic patients--both for the detection of cancer and of non-malignant mucosal disease of the large bowel. A test was completed by 1025 patients before double-contrast barium enema and the performance of each test was determined from the result of this investigation. The study was completed by 969 patients. There were 49 patients with colorectal cancer, 92 patients with a cancer or a polyp greater than 5 mm, and 130 with some mucosal abnormality. The test most sensitive for blood, Fecatwin, detected 14 of 15 (93 per cent) cancers and 29 (69 per cent) of 42 patients with mucosal disease (including inflammatory bowel disease) but gave three times as many false positive results as the Haemoccult test, which is less sensitive for blood. The chance of a patient with a positive Haemoccult result having mucosal disease on barium enema was 24 of 47 patients (51 per cent) (two-thirds of these having colorectal cancer). A negative Haemoccult result, however, was unreliable and should not influence patient management. A test less sensitive for blood than Haemoccult was found to be of little value in symptomatic patients.
Through the colonoscope--a radiologist's view.
A series of 1578 consecutive colonoscopies performed by radiologists in training is reviewed, with specific reference to patients with colorectal neoplasms. The contribution of the radiologist to the practice of colonoscopy is discussed. This input to the colonoscopy service of a hospital carries several benefits, including the following: a link is established between radiologists and gastroenterologists which improves the standard of both barium enema and colonoscopic examinations; informed discussion is made possible about the suitability of a barium enema lesion for endoscopic removal; the endoscoping radiologist acquires an impartial view of each examination and is able to choose the more appropriate investigation; direct visualisation of the colonic mucosa and its abnormalities may facilitate the interpretation of barium radiographs and enhance the quality of the radiological training that can be offered. In our experience, participation in a weekly colonoscopy session has had no adverse effect on the routine work of the radiology department.
Cytology of colorectal adenomas.
A study of the cytological appearances of benign and malignant colorectal adenomatous polyps is reported. The aim of the study was to characterize the cytological features of adenomatous polyps and predict the likelihood of malignancy using cytology. A five grade classification of colorectal cytology has been developed and the characteristic appearances of cells from adenomatous polyps are described. The reproducibility of cytological diagnosis based on this classification has been tested in 120 smears from normal mucosa and adenomatous polyps (including polyp cancers). Correlation with histology was achieved in 88% and correlation of the cytological diagnosis between two observers was achieved in 84%. We conclude that cytology can be used reliably as an adjunct to histology in the assessment of malignancy of adenomatous polyps.
Radiological evidence for the polyp/cancer sequence in the colon.
Three cases of frank malignancy developing in pre-existing colonic polyps are presented. Although this sequence of events is well recognised, it is rarely demonstrated radiologically. The cases illustrate the importance of identifying and appropriately treating polypoid colonic lesions.
Breast carcinoma metastatic to the gallbladder.
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Evaluation of a 'DIY' test for the detection of colorectal cancer.
A new type of faecal occult blood test, EZ-Detect, has been evaluated in 404 patients presenting with symptoms suggestive of colorectal disease. The test avoids handling of stools and gives a result which patients can read themselves--factors which may increase patient compliance. In comparison with the Haemoccult test, EZ-Detect has the same sensitivity for blood in laboratory conditions. In clinical use 98% of patients expressed a preference for EZ-Detect but it detected significantly fewer patients with cancer than did Haemoccult (P = less than 0.05). In its present form, this type of test would be unsuitable for population screening for colorectal cancer even if improved compliance is achieved.
After surgery for breast cancer: which mode of surveillance?
Five hundred and ten women attending a specialized breast clinic for follow-up after surgery of early breast cancer (Stage I and II) have been studied. Recurrence was found most often (58%) in symptomatic women who returned to the clinic earlier than planned. Only 3% of asymptomatic patients had recurrent disease. It is concluded that counselling in symptoms of recurrent breast cancer would allow more efficient follow-up.
Ultrasound detection of axillary lymph node metastases in breast cancer.
Presence or absence of lymph node metastases is the most accurate prognostic indicator in breast cancer. Clinical examination is unreliable in detecting involved nodes. Preoperative ultrasound scan of the axilla has been performed in 140 consecutive women with breast cancer. The sensitivity for involved nodes was 66% which was significantly higher than clinical examination (42%) (P = less than 0.01). However ultrasound gave more false positives than clinical examination and thus no overall improvement in prognostic information was achieved.
Pre-operative or postoperative colonic examination for synchronous lesions in colorectal cancer.
A review of 130 consecutive large bowel examinations at which a cancer of the colon or rectum was diagnosed has been undertaken. Of 50 patients examined by colonoscopy, the whole colon was seen in only 21 (42 per cent) and almost half of these had a tumour in the caecum or ascending colon. In most cases, an incomplete examination was the result of narrowing of the lumen by the tumour preventing passage of the endoscope. Of 80 patients examined by double contrast barium enema, the entire length of the colon was visualized in 83 per cent but the quality of the examination was sufficient to confidently exclude synchronous neoplastic lesions in only 51 per cent. The incidence of synchronous cancer in this series was within the expected range, although two such cancers were not detected until laparotomy, but the incidence of synchronous adenomas was two-thirds of the expected number in colonoscopy patients and one-third in those examined by barium enema. It is concluded that, in patients with known colorectal cancer, preoperative investigation is unreliable for the detection of all synchronous neoplasia and that patients should have postoperative colonoscopy.
Open access colonoscopy for suspected colonic neoplasia.
An open access endoscopy service for direct referral of patients suspected to have colonic neoplasia has been analysed. In the first year of the service 137 patients were referred by 52 general practitioners. The most common reason for referral was rectal bleeding (58%). Colonoscopy was done without outpatient consultation or barium enema examination in 130 patients: there were no complications. The diagnostic yield was 57%: 34 patients (25%) had neoplasia (cancer 14, adenoma 20), which was higher than the yield of neoplasia in patients referred for open access double contrast barium enema during the same period. Only nine patients (7%) needed further investigation because colonoscopy was incomplete and 21 (16%) were treated by polypectomy at the diagnostic colonoscopy.
The practical management of Fournier's gangrene.
Effective early treatment of this serious condition is necessary to prevent death. Urgent exploration by the most experienced surgeon available should include wide excision of all necrotic or dubious tissue, and adequate drainage of deep fascial planes. Deep and apparently healthy tissues must be exposed and the surgeon must be prepared to proceed to laparotomy, and even diverting colostomy and/or suprapubic cystotomy when necessary. Cross matched blood must be available, and we have found hydrogen peroxide irrigation useful. Pus, tissues, and blood samples for bacteriological culture and sensitivity should always be sent, but broad spectrum antibiotics should be started without delay to prevent systemic complications. In addition to the urgent initial surgery, repeated daily examination of all wounds is necessary, usually under general anaesthesia to allow full inspection, further débridement, irrigation and change of dressings, until the infective process is halted. This is a serious condition with a high mortality which we believe may be reduced by early diagnosis and appropriate aggressive surgery.
X-ray and ultrasound localization of non-palpable breast lesions and difficulties in management.
Seventy-four patients who have had biopsy of a non-palpable breast lesion are reviewed. A double-dye localization technique was used in 88% while in 12% localization of the lesion was best achieved by ultrasound mammography. Biopsy was successful in 70 patients (95%) at the first attempt. The overall incidence of malignancy was 20%, being greater in asymptomatic patients (32%) than in patients with mastalagia (16%). Re-excision of the biopsy site in these patients showed residual cancer in 33%. It is suggested that both careful examination of the operative specimen and postoperative mammography may be necessary to ensure that the original lesion has been removed. Re-excision of the biopsy site appears to be necessary when the histology is malignant.
The changing trend in prostatectomy in a district general hospital.
The results of 600 prostatectomies performed at Kingston Hospital are reviewed with particular reference to morbidity and mortality. The indication for surgery was prostatism in 61% of patients and retention in 34.5%. Transurethral resection (TUR) was performed in 65.5% of the operations. The mean postoperative stay for TUR was 6 days but for open operation 10 days. The overall complication rate including urinary tract infections was 14.8%, with an overall mortality of 1.3%. The results show the trends and improvement in service achieved since an earlier report of 600 cases published in 1979.