Increased levels of MMP-2 and MMP-9 proteins in ESCCs as compared to normal esophageal tissues suggest their association with esophageal tumorigenesis. Increased levels of these MMPs are observed in majority of dysplasias analyzed herein, indicating that these alterations may be early events in esophageal tumorigenesis. In-depth studies are warranted to determine their role in development and progression of esophageal cancer.

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Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement.

The preparation and spectroscopic character-

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SirWe were surprised to read the article by Mr Bradbeer recommending Tru-cut needle biopsy for out-patient diagnosis of breast cancer (Br J Surg 1985; 7 2 927-8). Fine needle aspiration cytology (FNAC) is easy, cheap, safe and equally (if not more) effective. FNAC, unlike Tru-cut needle biopsy, needs no assistance; no local anaesthesia is required as no skin incision is made. FNAC causes minor bruising only whereas Trucut needle biopsy can cause marked bruising and haematomas'. In 328 patients 99 per cent sensitivity and 95 per cent specificity has been reported'. Wollenberg et aL2 have reported 91.3 per cent overall diagnostic accuracy with FNAC, the predictive values of positive and negative diagnosis being 100 per cent and 89.6 per cent respectively. FNAC ensures collection of cellular material from throughout the mass owing to simultaneous in-and-out and radiating motion of the needle providing a fan-like sampling pattern3. Most of the false-negatives are due to sampling errors and false-positives occur only during the learning phase. Experienced and interested cytotechnologists and cytopathologists can lower the incidence of false-negatives and eliminate false-positives altogether. False-positives are, on the other hand, seen even with Trucut biopsy4 and frozen section biopsy5. FNAC should therefore be the initial diagnostic procedure for a breast lump. 1. 2.3. 4. 5.V. K. Kapoor Author's reply SirThe authors of the letter have slipped into the error ofcomparing FNAC with a Tru-cut biopsy needle used by hand. The point of my article is to draw attention to the fact that using a Tru-cut needle with the spring loaded 'Pistomat' eliminates the need for assistance, because a good specimen can be obtained with usually one pass of the needle. Bruising is uncommon and the pathologist has a greater chance of producing an accurate report than if the Tru-cut needle is used by hand.The method of reaching a diagnosis whether by FNAC or Tru-cut biopsy depends on the skill and experience of the operator and the pathologist, and this varies from one hospital to another. J. BradbeerMayday Hospital Thornton Heath Surrey CR4 7YE U K Solitary ulcer of rectum SirWe read with interest the recent article by R. J. Nicholls and J. N. L.Simson (Br J Surg 1986; 73: 2224) in which they reported the treatment of fourteen patients with the solitary rectal ulcer syndrome (SRUS) without overt rectal prolapse by anteroposterior rectopexy. Whilst we acknowledge their results with enthusiasm, we would like to stress the importance of a thorough search for complete rectal prolapse in this condition, since successful treatment can then follow with conventional abdominal rectopexy procedures. We routinely examine our patients after they have been straining in the squatting position and do not confine our observations to the left lateral position. Two of our cases illustrate this point.A 34-year-old man presented with the typical symptom complex of SRUS, subsequently proven on proctosigmoidoscopy and histology. On straining in the left lateral p...