Correspondence

Severe haemo r r hag ic corn pl icat ion following needle or open biopsy of a breast mass: suspect angiosarcoma

Sir Angiosarcoma is considered to be an exceedingly rare form of breast malignancy, which occurs in younger women and is associated with a poor prognosis',2. We wish to draw attention to an unusual feature of this tumour, namely a severe local bleeding tendency following biopsy.

A 43-year-old woman presented with a rapidly growing mass in the right breast. Clinically the tumour was assessed as a TINOM, carcinoma. She was sent for fine needle aspiration ( F N A ) biopsy which was interpreted as suspected malignant cells. Following the procedure the patient developed a large haematoma, measuring 5 x 6 cm, which obscured the original mass. During 2 weeks of local treatment the haematoma did not reduce in size. Definitive treatment of the suspected carcinoma (in the form of lumpectomy with frozen section and axillary dissection) was therefore delayed. Instead, it was decided to perform an open incisional biopsy and evacuate the haematoma. During the procedure there was diffuse bleeding from the biopsy site and haemostasis was extremely difficult to achieve. A suction drain removed almost 500 ml during the first day after operation. A full coagulation profile was examined and appeared normal. The biopsy specimen revealed a diagnosis of a grade 1-11 angiosarcoma of the breast. Simple uneventful mastectomy was performed 1 week later and the patient referred for chemotherapy.

During 10 years of clinical experience in a busy teaching hospital we have not previously encountered the formation ofa large haematoma following FNA of a breast mass, nor have we seen severe bleeding after an incisional breast biopsy. Thus, we believe that haemorrhagic complications constitute a specific feature of this vascular tumour. T o the best of our knowledge, this aspect has not been previously described in the relevant l i t e ra t~re ' -~ .

We conclude that the unexpected development of haematoma or haemorrhage after needle or open breast biopsy should alert the clinician to the possible diagnosis of angiosarcoma of the breast.

A. Assalia M. Schein

Department of Surgery B Rambam Medical Centre Haifa Israel

I . Rainwater LM, Martin JK, Gaffey TA, Van Heerden JA. Angiosarcoma of the breast. Arch Surg 1986; 121: 669-72.

2. Merino MJ, Berman M, Carter D . Angiosarcoma of the breast. Am J Surg Pathol 1983; 7: 53-60.

3. Chen KT, Kirkegaard DD, Bocian JJ. Angiosarcoma of the breast. Cancer 1980; 46: 371-86.

4. Gulesserian HP, Lawton RL. Angiosarcoma of the breast. Cancer 1969; 24: 1021-6.

Use of a resorbable mesh graft to obtain haemostasis from the cut surface of the liver after hepatic resection

Sir We are writing with regard to the article by Pr&tre et a / . on resorbable mesh grafts used to obtain haemostasis after liver resection (Br J Sury 1991; 78: 361-2). This alluded to the major role of suture and electrocautery to obtain haemostasis on the cut surface of the liver. The use of a resorbable Vicryl (Ethicon) mesh as a tamponade has been previously described and a clinical need for such material is apparent'. The authors used microcrystalline collagen powder between the mesh and the raw surface to obtain haemostasis. This utilizes the known effects of collagen on the intrinsic clotting mechanisms and platelet adherence. It is likely that the collagen, rather than the mesh alone, was responsible for haemostasis. Recently we reported the use of a composite collagen-Vicryl mesh for the repair of the cut surface of the kidney in three patients who had undergone partial nephrectomy'. This new material, constructed from Vicryl mesh with layered collagen film

on each surface, achieved haemostasis and prevented urinary leakage. Previous in v i m studies3 had shown the composite mesh to elicit little inflammatory response and to be resorbed in 90 days. This mesh is currently available for clinical use only in France. It offers advantages over Vicryl mesh alone in that it has inherent haemostatic properties, requiring no additional collagen powder, and is more likely to restrict biliary leakage than a porous Vicryl mesh alone.

R. N. Meddings R. Scott

Department of Urology Glasgow Royal Infirmary Glasgow G31 2ER UK

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2.

3.

Brunet C, Fairisse J, Guillamont P e f a / . Ruptures hepatique - envellopment par treilles resorbable. Presse Med 1986; 15: 104 1 - 3, Scott R, Gorham SD, Aitcheson M et al. First clinical report of a new biodegradable membrane for use in urological surgery. Br J Urol 1991; 68: 421-4. Mohammed R, Monsour MJ, Gorman S D et al. The use of a biodegradable collagen/Vicryl composite membrane to repair partial nephrectomy in rabbits. Urol Res 1987; 15: 239-42.

Pancreatic tissue and ductal pressures in chronic pancreatitis

Sir We read with interest the recent paper by Jalleh et al. (Br J Surg 1991; 78: 1235-7). This study confirmed previous work in humans and in animal models. While we accept that there are different ways of measuring tissue pressure, we believe that the method employed by the authors is not truly representative of tissue pressure. The values measured appear to be too high and, in theory, at these pressures all parenchymal blood flow would cease. The values quoted must represent resistance of the tissues to a saline infusion rather than tissue pressure.

We have studied pancreatic tissue pressure using a direct puncture needle technique with a low pressure transducer. We showed that in normal cats basal pancreatic tissue pressure was negative and on stimulating secretion there was virtually no change in its value. Cats with obstructive chronic pancreatitis had a greater basal pancreatic tissue pressure which increased further after secretory stimulation. This increase was abolished by decompression of the main pancreatic duct. These pressures suggested to us that the chronically inflamed pancreas was involved in a compartment syndrome. We then measured pancreatic blood flow'.' and showed in chronic pancreatitis that the basal blood flow was lower than in the normal pancreas. Secretory stimulation which increased blood flow in the normal pancreas caused a significant decrease in chronic pancreatitis. Decompression of the main pancreatic duct was associated with an improvement in basal blood flow, and the normal increase in blood flow on secretory stimulation was restored. We consider that these results showed that the chronically inflamed pancreas was involved in a compartment syndrome. This might provide an explanation for the intractable pain of chronic pancreatitis, the efficacy of ductal decompression and the phenomenon of disease progression.

N. D. Karanjia A. L. Widdison

H. A. Reber

3 Village Close Weybridge Surrey KT13 9HF U K

1. Karanjia ND, Widdison AL, Leung FW, Lutrin FJ, Reber HA. Pancreatic blood flow in chronic pancreatitis: the effect of decompression of the main pancreatic duct. Pancreas 1990; 5 : 713. Karanjia ND, Widdison A, Leung F, Lutrin FJ, Chang YB, Reber HA. Blood flow alterations in chronic pancreatitis: effects of secretory stimulation. Gastroenterology 1990; 98: A221.

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Br. J. Surg., Vol. 79, No. 5, May 1992 469