Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall.

BACKGROUND: Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort. METHODS: Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres. RESULTS: The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort. CONCLUSION: A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Novel technique using tensor fascia lata graft to reconstruct a floor of mouth postablative defect from invasive ectopic papillary carcinoma of the thyroglossal duct tract.

We describe a rare case of ectopic papillary thyroid cancer in the thyroglossal duct tract invading the floor-of-mouth musculature. The postablative defect was reconstructed with a bone-anchored tensor fascia lata graft to resuspend the floor of mouth to the mandible as a neogeniohyoid sling, enabling maintenance of a functional tongue position for normal speech and swallowing. This reconstruction should be considered when suprahyoid musculature is resected without breaching the oral lining.

A novel airway management strategy for cervical necrotising fasciitis secondary to Bezold's abscess.

We describe a rare case of cervical necrotising fasciitis caused by mastoiditis and Bezold's abscess. This case was complicated by a tracheostomy delaying wound healing. A novel strategy to repair the tracheotomy defect using Permacol™, an acellular porcine dermal substitute, and a local muscle flap not previously reported in the literature is described to allow the use of negative pressure wound therapy dressing. This technique may be employed in similar applications for non-healing tracheotomy wounds.

A low temperature method of isolating normal human articular chondrocytes.

OBJECTIVE: Numerous methods for isolation of human chondrocytes are reported in the literature, most based on isolation from animal cartilage. Normal human articular cartilage (NHAC) poses particular problems for isolating chondrocytes when compared to animal or other types of human cartilage: a hardy matrix, combined with few and friable chondrocytes makes isolation difficult. Our objective was to develop an efficient method of isolating chondrocytes from NHAC without jeopardising the viability of these cells. DESIGN: In this study we demonstrate that lowering the enzymatic digestion temperature to 27 degrees C increases cell yield and chondrocyte viability. We then optimised this low temperature isolation of chondrocytes from NHAC by comparing the relative efficacies of trypsin and protease and hyaluronidase in combination with different types of collagenase (I, II and XI) at releasing chondrocytes from their surrounding cartilaginous matrix. Enzymes were tested at different concentrations and for differing times. Outcome measures included determining the amount of cartilage digested, the number of viable chondrocytes isolated per gram of cartilage and cell adherence rates. CONCLUSIONS: From these set of experiments, the method that maximised cell yield without jeopardising cell viability proved to be a two stage process: pre-digestion step using trypsin for 15 min; followed by overnight digestion with a combination of two types of collagenase (types I and II) and at a lower temperature of 27 degrees C. This has resulted in an efficient and robust method of releasing chondrocytes from cartilage, without jeopardising the viability of these cells.

Hirudo Medicinalis and the plastic surgeon.

Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.

Plastic surgery senior house officers in the UK and Ireland: academic background, publication rates and research plans.

Academic achievements by surgical trainees may vary according to the competitiveness of the subspecialty and desirability of the consultant post. Plastic and reconstructive surgery is a competitive specialty. In order to assess the level of achievement of current trainees, we investigated the academic qualifications, publication rates and future research plans of 100 senior house officers in plastic surgery working in units in the United Kingdom and Ireland. Selected results from our survey show that 30% had intercalated degrees, 6% had higher degrees, 58% of trainees had MRCS, 37% had previous plastic surgery experience and 57% had published (range 1-13). We believe this study provides interesting information concerning the current crop of plastic surgery trainees in the United Kingdom and Ireland. This survey may provide a benchmark for consultants to refer to when shortlisting for SHO posts. We also believe it will be of interest to those junior trainees hoping to pursue a career in plastic surgery.

Historical Article: Hirudo medicinalis: ancient origins of, and trends in the use of medicinal leeches throughout history.

Blood letting and the therapeutic use of Hirudo medicinalis date back to ancient Egypt and the beginning of civilisation. Their popularity has varied over the years, reaching such a peak in Europe between 1825 and 1850 that supplies were exhausted. Towards the end of the century they fell out of favour and, during this period, the leech, once used by the physicians of emperors and influential academic surgeons, became associated with lay therapists and quackery. Leeches have enjoyed a renaissance in reconstructive microsurgery during the last 15 years, having been used by maxillofacial [Br. J. Oral Maxillofac. Surg 41 (2003) 44] and other reconstructive surgeons to aid salvage of compromised microvascular free tissue transfers [Laryngoscope 108 (1998) 1129; Br. J. Plast. Surg. 34 (1984) 358], replanted digits [Int. J. Microsurg. 3 (1981) 265], ears [Ann. Plast. Surg. 43 (1999) 427], lips [Plast. Reconstr. Surg. 102 (1998) 358; J. Reconstr. Microsurg. 9 (1993) 327] and nasal tips [Br. J. Oral Maxillofac. Surg. 36 (1998) 462]. Peer-reviewed evidence suggests that the survival of compromised, venous-congested tissues is improved by early application of a leech [J. Reconstr. Microsurg. 12 (1996) 165; Arch. Otolaryngol. Head Neck Surg. 114 (1988) 1395; Br. J. Plast. Surg. 45 (1992) 235]. Leeches have also recently been used to treat a wide range of conditions, including periorbital haematomas [Br. J. Ophthalmol. 75 (1991) 755], severe macroglossia [Otolaryngol. Head Neck Surg. 125 (2001) 649; J. Laryngol. Otol. 109 (1995) 442] and purpura fulminans [Ann. Plast. Surg. 35 (1995) 300]. The first medicinal leech farm, Biopharm, was set up in Swansea in 1981 by Dr Roy Sawyer, and now supplies leeches to hospitals all over the world. In this paper, we summarise the history of treatment with Hirudo medicinalis from its origin to the present day, and take a brief look at the possible future of the annelid.