A single-centre experience of chemoradiotherapy for rectal cancer: is there potential for nonoperative management?

AIM: The aim of the study was to assess the outcome of patients who received chemoradiotherapy (CRT) for locally advanced rectal cancer, specifically those with complete clinical response (CCR) and who were then managed nonoperatively with a 'Watch and Wait' follow-up protocol. METHOD: A retrospective study was carried out of patients undergoing preoperative CRT for rectal cancer, conducted in a district general hospital managing rectal cancer through the multidisciplinary team process. RESULTS: Forty-nine patients received preoperative CRT over a 5-year period (2004-2009). Twelve (24%) were considered potentially to have had a complete response on MRI. Of these, six subsequently had clinical evidence of residual disease, leading to surgery (mean time to surgery, 24 weeks; range, 12-36 weeks). The remaining six had CCR, avoiding surgery (mean follow up, 26 months; range, 12-45 months), with all six patients disease free to date. A further six patients had complete pathological response (CPR) following surgery after comprehensive histopathological assessment of the specimen. CONCLUSION: In this consecutive series of patients with locally advanced rectal cancer treated with CRT, 12% demonstrated a CCR and have been actively managed conservatively, thereby avoiding surgery. With further improvements in diagnostic assessment of response to CRT, this figure may rise.

Multicentre study of prepectoral breast reconstruction using acellular dermal matrix.

BACKGROUND: Single-stage reconstruction is used widely after mastectomy. Prepectoral implant placement is a relatively new technique. This multicentre audit examined surgical outcomes following prepectoral reconstruction using acellular dermal matrix (ADM). METHODS: All patients who had a mastectomy with prepectoral breast reconstruction and ADM in the participating centres between January 2015 and December 2017 were included. Demographic and treatment details, and short- and long-term operative outcomes were recorded. Factors affecting complications and implant loss were analysed: age, BMI, smoking status, diabetes, vascular disease, laterality of surgery, previous ipsilateral breast surgery or radiotherapy, indication for surgery (invasive versus in situ carcinoma, or risk reduction), type of mastectomy, axillary clearance, breast volume, implant volume, and neoadjuvant and adjuvant chemotherapy. RESULTS: A total of 406 reconstructions were performed across 18 centres. Median follow-up was 9·65 months. Median hospital stay was 1 day. The 90-day unplanned readmission rate was 15·7 per cent, and the return-to-theatre rate 16·7 per cent. Some 15·3 per cent of patients had a major complication, with a 90-day implant loss rate of 4·9 per cent. A further six patients had delayed implant loss. In multivariable analysis, no factor was significantly associated with complications or implant loss. CONCLUSION: Prepectoral breast reconstruction with ADM has satisfactory surgical outcomes. The duration of follow-up needs to be extended to examine outcomes in patients who received adjuvant radiotherapy.

ANTECEDENTES: La reconstrucción en un tiempo es una técnica muy utilizada tras la mastectomía. La colocación de un implante prepectoral es una técnica relativamente novedosa. Esta auditoría multicéntrica analizó los resultados quirúrgicos después de la reconstrucción prepectoral utilizando una matriz dérmica acelular (acellular dermal matrix, ADM). MÉTODOS: Se incluyeron todas las pacientes en las que se efectuó una reconstrucción mamaria prepectoral y ADM tras la mastectomía en los centros participantes desde enero de 2015 hasta diciembre de 2017. Se analizaron los datos demográficos, detalles del tratamiento y los resultados operatorios a corto y a largo plazo. Se evaluaron los factores relacionados con las complicaciones y la pérdida del implante, incluyendo la edad, el índice de masa corporal, el tabaquismo, la diabetes, la enfermedad vascular, la lateralidad de la cirugía, la cirugía mamaria ipsilateral previa o la radioterapia previa, la indicación de cirugía (carcinoma invasivo versus carcinoma in situ o reducción del riesgo), el tipo de mastectomía, el vaciamiento axilar, el volumen mamario, el volumen del implante y la quimioterapia neoadyuvante y adyuvante. RESULTADOS: Se incluyeron 406 reconstrucciones efectuadas en 18 centros. La mediana de seguimiento fue de 9,65 meses. La mediana de la estancia hospitalaria fue de un día. La tasa de reingreso no planificado a los 90 días fue de 15,74% y la tasa de reoperaciones fue del 16,66%. Alrededor del 15% de las pacientes presentaron una complicación mayor, con una tasa de pérdida de implante del 4,93% a los 90 días. En otras 6 pacientes se retiró el implante con posterioridad. En el análisis multivariable no se identificó ningún factor que se asociara significativamente con la tasa de complicaciones o la pérdida del implante. CONCLUSIÓN: La reconstrucción mamaria prepectoral con ADM tiene resultados quirúrgicos satisfactorios. Se debe ampliar el periodo de seguimiento para analizar los resultados en pacientes tratadas con radioterapia adyuvante.

Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated?

Pheochromocytoma is rare in pregnancy, with an estimated incidence of 0.007%. Diagnosis is difficult owing to the variety of presentations and nonspecific symptoms. Nevertheless, unsuspected disease accounts for a significant proportion of morbidity and mortality. Currently, there appears to be no consensus on management with regard to the need for and timing of medical vs. surgical management. In this case report, we describe two patients who underwent different modes of treatment based on careful consideration of disease-related and nondisease-related factors. We emphasise that good outcomes can be achieved through individualized management within the context of a multidisciplinary team, involving close collaboration among physicians, surgeons, obstetricians, and anesthetists. We also illustrate the importance of genetic testing in all patients with pheochromocytoma in pregnancy, especially with the emergence of new predisposing genes (succinate dehydrogenase B and D) and the recognition that germline mutations in these and more established genes (VHL and RET) account for over a quarter of all apparently sporadic cases.

Mothers of Africa--an anaesthesia charity.

An anaesthetic charity 'Mothers of Africa' has been established as a link between the academic departments of anaesthesia in Togo and Benin and the University Hospital of Wales. Visits by UK consultant anaesthetists have identified a number of clinical areas where collaborative working in both classroom and theatre has the potential to improve outcomes in maternal mortality and morbidity.

A subdural abscess and infected blood patch complicating regional analgesia for labour.

We report two very unusual cases of infection complicating labour analgesia. The first case was a sub-dural abscess presenting with deep-seated backache seven days after combined spinal-epidural analgesia for labour. The second was a painful lumbar swelling and septicaemia that presented three days after a blood patch for a post dural puncture headache. Because of their complicated and unusual presentation, the diagnosis and management of both were initially delayed.

Computed tomography-pathologic assessment of laser-induced necrosis in rat liver.

RATIONALE AND OBJECTIVES: Interstitial laser photocoagulation (ILP) causes localized tissue necrosis. This study was performed to determine 1) whether the changes seen on computed tomography (CT) correspond to the necrosis pathologically, and 2) which CT technique best shows the necrosis. METHODS: Eighteen Wistar rats had ILP to their liver using a neodymium yttrium aluminum garnet [Nd:YAG] laser. Radio-opaque markers attached to the liver defined an imaging plane. Precontrast "dynamic" and delayed CT scans were performed. The size of necrosis was measured on CT, and macroscopically after resecting the liver. Computed tomography density numbers were measured from the necrotic area and normal liver for each CT technique. RESULTS: There was a good correlation between the necrosis size on CT and pathologically (P < .001). Maximum lesion-to-liver contrast was obtained on "dynamic" CT scans. CONCLUSIONS: The extent of tissue density changes on CT in rat liver after ILP match the extent of necrosis seen pathologically. The best CT technique use assessed for evaluating laser-induced liver necrosis is dynamic contrast-enhanced scanning.

Intraoperative axillary lymph node assessment in breast cancer.

Bedside assessment of axillary lymph node metastases in breast cancer is notoriously inaccurate. The aim of this study was to assess the accuracy of the clinical assessment of the presence of axillary node metastases in patients with breast cancer, both at the bedside and intraoperatively. Intraoperative assessment was significantly more accurate than bedside assessment, having an accuracy of 86%, compared with 66% of bedside clinical assessment. As axillary lymph node involvement is an important prognostic factor in breast cancer, this technique which has a high specificity and far higher sensitivity than bedside clinical assessment and may have a valuable role to play in planning management.

Pre-cervical soft tissues: a cautionary note.

Visualization of pre-cervical soft tissue swelling on a lateral radiograph is an important indicator of possible bony injury in the context of cervical spine trauma. We report a case where apparent swelling was in fact an artefact due to an inappropriately placed endotracheal tube. We recommend review of the position of endotracheal tubes when interpreting pre-cervical soft tissue swelling.

Why should diagnostic benign breast biopsies weight less than twenty grams?

To reduce the cosmetic deformity resulting from diagnostic biopsies, current breast screening guidelines recommend that 80% of biopsy specimens that subsequently prove to be benign should weigh less than 20 g. The relationship between specimen weight and cosmesis is unknown and evidence to support a 20 g upper limit is lacking. Patient satisfaction following all benign biopsies weighing more than 20 g (n = 49) and a random sample of 30 of those weighing less than 20 g (n = 103) performed by one screening unit, over a 6 year period, was assessed by a postal questionnaire. Overall, 32% of patients were unhappy with the cosmetic outcome of their surgery. Patient dissatisfaction appeared to increase with specimen weight (6/23 [26%] < 20 g versus 13/36 [36%] > 20 g) but no statistically significant relationship between weight and cosmesis was apparent (P = 0.57). Reducing benign breast biopsy specimen weights to a minimum is a desirable objective. However, the current quality standard is not evidence-based, is too stringent and should be revised. Strategies need to be introduced to improve patient satisfaction following breast wire-localisation biopsies. In particular, patients should be counselled pre-operatively regarding possible adverse cosmetic outcome.

A survey of the management of breast cancer in England and Wales.

The management of breast cancer is controversial. In order to obtain an overview of the way that surgeons manage breast cancer in England and Wales and to assess trends in management by comparisons with the results of previous surveys a postal questionnaire was sent to all consultant general surgeons in England and Wales (n = 985). The response rate was 61%. Fine-needle aspiration is now the preferred technique to obtain a tissue diagnosis by 85% of surgeons. The majority of surgeons now treat early breast cancer either by breast-conserving surgery or offer the patient the choice of conservation or mastectomy. Comparisons with previous surveys carried out in the last 10 years suggest that fewer surgeons now recommend mastectomy. In all, 83% of surgeons indicated that they would biopsy the ipsilateral axilla routinely. Opinion is divided with regard to treatment of breast cancer in the elderly and treatment of an incompletely excised tumour, although the majority perform a mastectomy for a local recurrence after conservative surgery. Follow-up was regarded as worthwhile by 90%, but the majority do not routinely do follow-up investigations on asymptomatic patients apart from mammography. This study has shown very little consensus regarding the management of breast cancer in England and Wales. We suggest that the management of breast cancer should be in the hands of those with a special interest in the subject, as these surgeons will be more aware of ongoing clinical trials and current literature, more patients will then be entered into clinical trials and further trials instigated.

Seat-belt trauma of the breast in a pregnant woman causing milk-duct injury: a case report and review of the literature.

Injury to the milk-duct following a road traffic accident has not been reported in the literature. This case report describes a 25-year-old postpartum lady with massive swelling of the breast due to milk-duct injury and collection of milk within the breast. We describe the possible mechanism of milk-duct injury, its presentation and management, and also review the literature on seat-belt injury to the breast.

Phyllodes tumours.

Phyllodes tumours are rare fibroepithelial lesions that account for less than 1% of all breast neoplasms. With the non-operative management of fibroadenomas widely adopted, the importance of phyllodes tumours today lies in the need to differentiate them from other benign breast lesions. All breast lumps should be triple assessed and the diagnosis of a phyllodes tumour considered in women, particularly over the age of 35 years, who present with a rapidly growing "benign" breast lump. Treatment can be by either wide excision or mastectomy provided histologically clear specimen margins are ensured. Nodal metastases are rare and routine axillary dissection is not recommended. Few reliable clinical and histological prognostic factors have been identified. Local recurrence occurs in approximately 15% of patients and is more common after incomplete excision. It can usually be controlled by further surgery. Repeated local recurrence has been reported without the development of distant metastases or reduced survival. Approximately 20% of patients with malignant phyllodes tumours develop distant metastases. Long term survival with distant metastases is rare. The role of chemotherapy, radiotherapy, and hormonal manipulation in both the adjuvant and palliative settings remain to be defined.

Azygos reflux: a CT sign of cardiac tamponade.

Three patients who were investigated with dynamic contrast medium enhanced computed tomography (CT) of the thorax were noted to have pericardial effusions with reflux of contrast medium back along the azygos vein. The diagnosis of cardiac tamponade was not made clinically, but in each case was suggested from the CT findings. Confirmation of the diagnosis was made in all three cases, two patients with echocardiography and one at post mortem. One patient made a rapid recovery following the insertion of a pericardial drain, another made a temporary recovery after pericardiocentesis but the third died. Thirty CT scans performed with similar protocol were reviewed and none of these demonstrated reflux along the azygos vein. The presence of contrast medium refluxing into the azygos vein implies significant haemodynamic disturbance, and in the presence of a pericardial effusion suggests the diagnosis of cardiac tamponade.

Long-term follow-up of the antheor inferior vena cava filter.

The first long-term follow-up of the use of the Antheor inferior vena cava (IVC) filter is presented. Between December 1994 and December 1996, 20 Antheor IVC filters were inserted. Seven patients subsequently died and of the 13 patients remaining alive, 11 were available for long-term follow-up. One death was due to migration of the filter to the main pulmonary artery 6 weeks after insertion and because of this case, and other similar reports, the filter has now been withdrawn from clinical use. Of the 11 filters assessed at follow-up, three were fractured. One filter contained thrombus and one IVC was occluded. Our experience highlights the problem of central migration, but also shows a high incidence of filter fracture which has not previously been described with this design of filter.

Urgent contrast enhanced computed tomography in the diagnosis of acute bowel infarction.

Bowel infarction commonly presents as an acute abdomen that rapidly progresses to severe shock. The diagnosis is often not clinically suspected. Three cases are described where the diagnosis was made during dynamic contrast enhanced computed tomography (CT), when gas was demonstrated in the portal venous system and liver. Two patients died during surgery, the third survived because of the prompt diagnosis made on CT, and subsequent surgical treatment. The radiological findings are reviewed.

Core biopsy of the bowel wall: efficacy and safety in the clinical setting.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and complications of percutaneous 18-gauge core biopsies of lesions of the bowel wall using CT and sonographic guidance. A retrospective study was made of 15 biopsy procedures performed on 12 patients with suspected neoplasia of the gastrointestinal tract. The biopsies were performed when there were no sites of metastatic disease more readily accessible to biopsy and the lesion was inaccessible to endoscopic techniques or when the endoscopic biopsy findings were negative. CONCLUSION: Three biopsy procedures provided inadequate samples and the biopsies were repeated, giving a total of 15 biopsy procedures. A tissue diagnosis was made in all 12 patients. All procedures were well tolerated, and no immediate or delayed complications occurred. Percutaneous core biopsy of bowel wall masses is a safe technique that allows a histologic diagnosis to be obtained in difficult cases when other methods cannot provide an adequate tissue sample.