We report elastosis perforans serpiginosa (EPS) arising in three patients with Ehlers-Danlos syndrome, osteogenesis imperfecta and Down's syndrome. These cases illustrate some of the rare but well-recognized disease associations with EPS. The other causes of EPS are reviewed.

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We would recommend a full review of all histological specimens in patients with a diagnosis of temporal bone inflammatory pseudotumour or inflammatory myofibroblastic tumour. Consideration should be given to immunohistochemical analysis for anaplastic lymphoma kinase and immunoglobulin G4, with measurement of serum levels of the latter. Management of the condition is medical, with corticosteroids and immunosuppression, rather than surgical excision.

This case illustrates the rare association between hidradenitis suppurativa (HS) and Dowling-Degos disease (DDD). Furthermore the association of HS, DDD and multiple epidermal cysts has not to our knowledge been described before, but their coexistence in the same patient is likely to reflect the same follicular anomaly. It is possible that a single underlying defect of follicular proliferation may account for the coexistence of these conditions.

The significance of occult metastases in axillary lymph nodes in patients with carcinoma of the breast is controversial. Additional sections were cut from the axillary lymph nodes of 477 women with invasive carcinoma of the breast, in whom no metastases were seen on initial assessment of haematoxylin and eosin stained sections of the nodes. One section was stained with haematoxylin and eosin, and one using immunohistochemistry with two anti-epithelial antibodies (CAM5.2 and HMFG2). Occult metastases were found in 60 patients (13%). The median follow-up was 18.9 years with 153 breast cancer related deaths. There was no difference in survival between those with and those without occult metastases. Multivariate analysis, however, showed that survival was related to tumour size and histological grade. This node-negative group was compared with a second group of 202 patients who had one involved axillary node found on initial assessment of the haematoxylin and eosin sections; survival was worse in the patients in whom a nodal metastasis was found at the time of surgery. Survival was not related to the size of nodal metastases in the occult metastases and single node positive groups. Some previous studies have found a worse prognosis associated with occult metastases on univariate analysis, but the evidence that it is an independent prognostic factor on multivariate analysis is weak. We believe that the current evidence does not support the routine use of serial sections or immunohistochemistry for the detection of occult metastases in the management of lymph node negative patients, but that the traditional factors of histological grade and tumour size are useful. British Journal of Cancer (2002) Axillary lymph node stage has traditionally been regarded as the most powerful prognostic indicator in invasive carcinoma of the breast. Furthermore, the greater the number of axillary node metastases, the worse the prognosis. The fact that approximately 25% of patients without involvement of the axillary nodes subsequently developed distant metastases, however, has prompted the search for other prognostic factors. One approach has been to investigate the negative lymph nodes more thoroughly in an attempt to find metastases missed by conventional assessment.Detection of nodal metastases depends on a number of factors (Cserni, 2000). These include removal of sufficient tissue from the axilla of the patient (Reynolds et al, 1994), adequate dissection of the specimen (Cserni, 1998), the method of sampling the nodes for histological examination (Friedman et al, 1988), and the technique used to identify metastatic deposits within the histological section. In the past, it was standard practice to sample only readily palpable nodes and submit only half of each node for histology. One haematoxylin and eosin (H&E) stained section of each node was then examined microscopically. The value of axillary lymph node stage as a prognostic factor was based on studies using this methodology. Various methods for improving detection in surgical ...