COMPUTERISED TOMOGRAPHY IN METASTATIC BREAST CANCER

193 antibodies using the agglutination and immobilisation tests than Morgan et al. found (table n). Positives were present in all media, but in 11 couples where a cervical factor was present agglutinating antibodies were found only in 1 male serum and 2 males had immobilising antibodies in the seminal plasma. There was no inter-test or inter-media correlation of positives. The significant differences between these two sets of data from the same laboratory require explanation. Similarity between the results on my patients and those reported by Morgan et al., where a cervical factor is present, is confined to samples from the male. In my series, few men attending the male clinic were sampled, most samples being obtained by personal request after the infertile wife had attended the female clinic. It may be that the higher frequency of antibodies found by Morgan et al. was due to sampling from a different clinical population with the inclusion of many more samples from the male fertility clinic. Not only might this explain the differences in antibody frequency but also it suggests that if anti-sperm antibodies, as detected by agglutination and immobilisation tests, have any part to play in infertility they are of much greater significance in the male. Until better, more specific methods for detecting anti-sperm antibodies are developed for the infertile couple, it would perhaps be more profitable to concentrate detection and treatment on the male partner.

COMPUTERISED TOMOGRAPHY IN METASTATIC BREAST CANCER

SIR,-Much lip service has been given to the importance of the internal mammary or parasternal lymph-nodes in breast cancer. However, although the anatomical details have been well recorded’ little has been published on the clinical presentation of recurrence at this site. Investigations to demonstrate metastases in the parasternal area are often time-consuming and seldom productive, so the following case of clinical evidence of internal mammary recurrence investigated by computerised tomography may be of interest.

Department of Obstetrics and Gynæcology,

Trinity College Unit, Rotunda Hospital,

ROBERT F. HARRISON

Dublin, Ireland

Fig. 1—Cut through first interspace showing right parasternal mass (looking towards head).

BRONCHIAL ASTHMA DUE TO ALLERGY TO PANCREATIC EXTRACT that sidebut you do not respiratory-tract allergy in parents and others who administer these extracts to children with cystic fibrosis. The following case (to be more fully reported elsewhere’) illustrates this hazard. A woman aged 32 had two sons, aged 4tand 2 years, both with cystic fibrosis. She had a history of typical mild seasonal hayfever, but after the birth of her first child, who was found to have cystic fibrosis, the hayfever symptoms persisted outside the grass-pollen season. When the second child was born, also with cystic fibrosis, severe bronchial asthma developed. Careful inquiry revealed that her asthmatic attacks related to handling of pancreatic extract. Pancreatin (’Pancrex V’) had been prescribed in capsule form, and the mother opened the capsules and sprinkled the powder on to the children’s meals. On each occasion, severe nasal congestion developed followed by chest wheezing lasting up to an hour. Chest X-ray was normal. White blood-cells 10 800/[jd (8% eosinophils). Skin-prick test with pancreatin gave a 4+ immediate positive reaction. Serum precipitin test to pancreatin was positive. Pulmonary-function tests confirmed reversible airway obstruction but there was no reduction of gas-transfer factor. Inhalation challenge test to pancreatin produced typical symptoms within the first half hour, followed by a second milder phase of symptoms after 5-6 h. The hazard to parents handling pancreatic extract applies only when they are feeding their very young children. Older children can swallow tablets and capsules whole. Pharmacists, and nurses administering pancreatic extract to small children with cystic fibrosis, are also potentially at risk. Children with cystic fibrosis often have a tendency to chest wheeziness, and further investigation of the possible role of pancreatic extract in the causation of this symptom may be re-

SIR,-You

are correct

effects of pancreatic mention the risk of

(July 9,

p.

73)

to state

extracts are uncommon,

’

Fig. 2-Cut through 2nd interspace showing parasternal lymph node.

similar

enlarged

A 29-year-old woman was referred from another department in 1972 after left local mastectomy for grade m, stage 2 scirrhous carcinoma of the breast in 1971. She received postoperative radiotherapy. In 1974, when she was 4tmonths pregnant, a carcinoma of the right breast was diagnosed in the medial upper quadrant and a simple mastectomy was performed, which again showed scirrhous carcinoma grade in. Because she was pregnant no postoperative radiotherapy was given, and she remained well until early in 1977 when a parasternal mass was found in the 4th right intercostal space. Within a few weeks a similar mass developed in the 2nd space. An E.M.I. scan of the affected segments clearly demonstrated the extent of the involvement (figs 1 and 2). The efficacy and simplicity of this investigation will have considerable significance to the future assessment of breast cancer.

,

warding. Redhill General

Hospital,

ALEX SAKULA

Redhill, Surrey 1.

Sakula,

A. Br.

J.

Dis. Chest

(in

the

press).

I thank Dr Harold Eckert and the services of the Western Provident Association department of computerised tomography, Bristol Radiotherapy Centre for the E.M.I. scans.

Department of Radiotherapy, Royal Berkshire Hospital, Reading, Berkshire RG1 5AN 1.

J. S. BUNTING

McDonald, J. J., Haagensen, C. D., Stout, A. P. Surgery, 1953, 34, 521.