Left gastric artery aneurysm rupture: a rare cause of retroperitoneal bleeding: a case report.

INTRODUCTION: Visceral artery aneurysms are very rare. Patients usually present as emergency secondary to the sudden rupture of the aneurysm or as an incidental finding on ultrasound, MRI or abdominal computed tomography. Among these, splenic artery aneurysms are the most common ones accounting for 60% of all splanchnic aneurysms and gastric and gastroepiploic aneurysms account for only about 4%. CASE PRESENTATION: We present a 61-year-old Caucasian male previously fit and well, presenting with sudden onset epigastric pain due to retroperitoneal haemorrhage secondary to ruptured left gastric artery aneurysm. Apart from a tender epigastrium, there were no other obvious signs elicited on abdominal examination. He had persistent tachycardia and haemoglobin drop from 10 g/dl to 6.7 g/dl. He underwent a contrast computed tomography which identified the ruptured left gastric artery. The aneurysm was controlled successfully with coil embolisation of the left gastric artery. At three-month follow-up, there was no evidence of the aneurysm. CONCLUSION: Clinical presentations that do not correlate with examination finding should prompt immediate extensive investigation. The aid of contrast computed tomography and minimally invasive radiological interventional is the key to a fruitful outcome for this very rare entity.

Primary breast osteosarcoma: a case report and review of literature.

BACKGROUND: Primary soft tissue sarcomas are uncommon. We report a case of primary breast osteosarcoma which was treated successfully. This case report is combined with a literature review of this rare breast malignancy. METHODS: Electronic literature search of databases: Pubmed/Medline, Ovid and EMBASE, in addition to the search engines Google/Google Scholar and Bing. The keywords used were breast osteosarcoma, soft tissue sarcoma and breast cancer. Searches were screened and those studies thought to be relevant had full text versions retrieved. The references to all retrieved texts were searched for further relevant studies. CONCLUSION: Primary breast osteosarcoma is a rare breast malignancy that affects elderly patients. Diagnosis is often challenging and can be debatable due to its rarity, non-specific radiological findings and the complicated histopathological subtypes. Surgery is the treatment of choice.

Quality and readability of online information and materials on post-surgery breast seroma.

Aims/Background Seroma formation is the most common complication following breast surgery. However, there is little evidence on the readability of online patient education materials on this issue. This study aimed to assess the accessibility and readability of the relevant online information. Methods This systematic review of the literature identified 37 relevant websites for further analysis. The readability of each online article was assessed through using a range of readability formulae. Results The average Flesch-Reading Ease score for all patient education materials was 53.9 (± 21.9) and the average Flesch-Kincaid reading grade level was 7.32 (± 3.1), suggesting they were 'fairly difficult' to read and is higher than the recommended reading level. Conclusion Online patient education materials regarding post-surgery breast seroma are at a higher-than-recommended reading grade level for the public. Improvement would allow all patients, regardless of literacy level, to access such resources to aid decision-making around undergoing breast surgery.

Necrotising fasciitis of the breast: A rare but deadly disease.

INTRODUCTION: Necrotising fasciitis is a rare but deadly bacterial infection causing soft tissue and fascial necrosis. It is associated with a mortality rate of 25%. It is characterised by; erythematous skin, which turns dusky blue before haemorrhagic bullae develop; localised pain; and inflammation. It is most commonly found in the extremities, the abdomen or the perineum but is rarely seen in the breast. CASE PRESENTATION: We describe a 54-year-old lady who presented with breast erythema and raised inflammatory markers. Initially treated as cellulitis, however when her symptoms did not improve and despite IV antibiotics her bloods worsened, a CT scan was performed which showed a large volume of interstitial soft tissue gas with diffuse fat stranding, consistent with necrotising fasciitis. Debridement of her breast alongside the use of sensitive antibiotics and ITU support led to a satisfactory outcome. DISCUSSION: We discuss how an early diagnosis can be made by the recognition of a triad of symptoms common in necrotising fasciitis, and how optimal management can be achieved with the incorporation of imaging to successfully identify the condition and allow targeted debridement of the areas of necrotising fasciitis. CONCLUSION: A high index of suspicion should be held if pain is disproportionate to the signs or sepsis is present. To aid an early diagnosis, imaging of the breast should be performed early to avoid delay in treatment.

Bifid vermiform appendix: a case report.

INTRODUCTION: Appendiceal anomalies are extremely rare: they have a reported incidence of between 0.004% and 0.009% of appendectomy specimens. The authors report a case of a patient who was found to have 2 appendices at emergency laparotomy, review the classification system used, and discuss the potential clinical pitfalls of similar cases. CASE REPORT: A 23-year-old man was admitted as an emergency with abdominal pain and vomiting. The operative finding was of a bifid appendix. One appendix was grossly gangrenous and lacked a mesoappendix, whereas the other had a mesoappendix and appeared macroscopically normal. The appendices shared a common base that arose from the cecum in the typical anatomical position. No other intra-abdominal malformations were present at inspection during laparotomy. Histology confirmed features of gangrenous appendicitis. His postoperative recovery was uneventful, and he was discharged after 4 days. CONCLUSION: Although rare, it is important for several reasons that surgeons are aware of the potential anatomical anomalies and malpositions of the vermiform appendix: first, a missed second appendix may result in serious clinical and medico-legal consequences; second, a double appendix can be confused with other intra-abdominal conditions; and finally, they can be associated with other congenital abnormalities.

Atypical breasts cancers.

INTRODUCTION: With increasing incidence of breast cancers there are now a larger number of cases diagnosed with rare malignancies. These can be diagnostic dilemmas and management strategy can be different by various breast multi-disciplinary teams (MDT). We aim to discuss the evidence-based approach for management of these atypical breast cancers which were identified in patients from a single breast screening unit. METHOD: Patient with unusual breast malignancies (all types except invasive ductal and lobular) treated under the care of a single surgeon were identified during the breast multi-disciplinary discussion from 2011 to 2015. The histology and management of these cases were reviewed and literature search of electronic databases via PubMed and the search engines Google/Google Scholar was performed. Emphasis on keywords based on the histology type was used to limit search. Search was focused on the diagnosis, management and prognosis of these unusual breast cancers. CONCLUSION: This series aims to focus on the evidence-based management of these rare breast malignancies; the diagnosis of which is crucial as it affects the overall treatment and prognosis.

Porcine acellular dermis-based breast reconstruction: complications and outcomes following adjuvant radiotherapy.

BACKGROUND: Acellular dermal matrices (ADM) such as StratticeTM are increasingly used in UK during implant-based reconstruction. However, there are mixed opinions regarding the compatibility of radiotherapy treatment in pre- and post-reconstructed breasts. The aims of this study are to audit the rates of radiation induced complications in patients who underwent breast reconstruction using StratticeTM and establish whether there is an association between timing of radiotherapy and complication rates. METHODS: Retrospective data collection was performed for all patients who underwent skin-sparing mastectomy and immediate or delayed StratticeTM-based reconstruction, and received pre- or post-reconstruction radiotherapy from July 2010 to November 2014. RESULTS: The age ranged from 33 to 78 years (mean age 51 ± 10.6) with a mean follow-up time of 21 months. There were 25 StratticeTM-based reconstructions performed. Sixteen had delayed reconstruction, and 9 had skin-sparing mastectomy and immediate reconstruction. There were 4 (16 %) abandoned procedures due to inability to stretch the mastectomy flap secondary to poor skin compliance. Two women (8 %) presented 4 and 9 months later with wound breakdown. One case (4 %) developed severe capsular contracture following radiotherapy post-reconstruction and 1 case (4 %) of implant rupture. There were no episodes of extrusion or implant infection. Overall complication rates were 32 %. The majority (75 %) of complications occurred in breasts reconstructed post-radiotherapy; however, this is not significant when analysed using chi-square (p = 0.43). CONCLUSIONS: Our evidence suggests that there is no difference in complication rates in pre- and post-radiation individuals; this would suggest that implant-based reconstruction using StratticeTM should not be an absolute contraindication in pre- or post-radiotherapy patients. However, when planning these procedures, it is paramount that the increased risks are emphasised to patients in order to better manage patient expectation in cases where complications arise. Level of Evidence: Level III, risk / prognostic study.

Rare breast malignancies and review of literature: A single centres experience.

INTRODUCTION: Breast cancer is a heterogeneous condition, with variants which are less common but still very well defined by the World Health Organization (WHO) classification. With the small number of cases each year large trials are difficult to perform. This series aims to discuss the rare breast malignancies encountered within a breast department and the evidence based approached to their management. METHOD: Literature search of electronic databases via PubMed and the search engines Google/Google Scholar were used. Emphasis on keywords: breast cancer and the type of histology used to limit search. Searches were screened and those articles suitable had full text versions retrieved. The references to all retrieved texts were searched for further relevant studies. CONCLUSION: Due to the rarity of some of these breast cancers, systematic evaluation of patient with detailed histopathology will aid accurate diagnosis and management. The series hopes to add the existing understanding of this small percentage of cases.

Rectal metastasis from Breast cancer: A rare entity.

INTRODUCTION: Breast cancer metastases occurs in around 50% of all presentation. It is the second most common type of cancer to metastasise to the GI tract but this only occurs in less than 1% of cases. PRESENTATION OF CASE: We report a case that underwent treatment for invasive lobular cancer (ILC) of the breast and 5 years later was found to have rectal and peritoneal metastasis. She is currently receiving palliative management including chemotherapy in the form of weekly Paclitaxel (Taxol(®)) and stenting to relieve obstruction. CONCLUSION: There should be high clinical suspicion of bowel metastasis in patients presenting with positive faecal occult blood with or without bowel symptoms even if the incidence is less <1% of metastases, particularly in cases where the initial breast tumour was large, with positive axillary nodes.

The role of combined assessment in preoperative axillary staging.

BACKGROUND: Axillary lymph node status is the most significant single prognostic factor in breast cancer, and preoperative axillary staging is essential in determining lymph node status. Axillary ultrasound scan (AUS) is the gold standard modality in preoperative staging. However, triple assessment-including clinical examination and radiological assessment with fine needle aspiration (FNA) with or without core biopsy-ensures high sensitivity. METHODS: Our study included 219 women diagnosed with invasive breast cancer between 2009 and 2010. All patients underwent a preoperative staging AUS that was graded from normal (U1) to malignant (U5). All patients with ultrasound scans graded U3 (indeterminate) and above underwent FNA that was graded from C1 (inadequate for diagnosis) to C5 (malignant). Patients diagnosed preoperatively with metastatic lymph nodes were offered axillary lymph node clearance. The rest of the patients were offered sentinel lymph node biopsy. RESULTS: The 219 women were diagnosed with 228 invasive breast cancers. The mean age was 60 years (range 29-90 years). The final histology report showed metastatic axillary lymph nodes in 49 (21.5%) cases. Of these 49 cases, 22 were diagnosed preoperatively with metastatic axillary lymph node and were elected for axillary lymph node clearance, and 27 were elected for sentinel lymph node biopsy that revealed metastatic lymph nodes. AUS showed abnormal (U3/U4/U5) axillary lymph nodes in 30 of 49 (61.2%) cancer cases with an overall accuracy of 91.6%. CONCLUSION: Combined triple assessment increases the sensitivity, negative predictive value, and overall accuracy of preoperative staging of the axilla.

Breast metastasis from a melanoma.

Benign and primary malignant breast tumors are quite common, but secondary tumors in the breast from metastatic malignancies are rare. Nevertheless, metastasis to the breast must be considered in any patient with a known primary malignant tumor history who presents with a breast lump. We report a case of a premenopausal woman diagnosed with a metastatic melanoma in her breast.

Pyoderma gangrenosum: a rare cause of breast ulceration.

Breast ulceration is an alarming sign for clinicians and places a significant physical and psychological burden on the patient. We report a rare presentation of pyoderma gangrenosum of the breast in a patient known to have ulcerative colitis but no active underlying disease process and no history of breast tissue trauma. This case report with literature review highlights the importance of considering pyoderma gangrenosum as a differential diagnosis in breast ulcers.

Breast cancer mimicking fibroadenomas in postmenopausal women.

INTRODUCTION: Fibroadenomas (FADs) are benign breast lesions usually seen in late teens less so common in postmenopausal women. This is a case series of postmenopausal patients, where breast cancer looked like fibroadenoma on imaging. The aim of this study was to identify the important role of tissue diagnosis in FAD like lesions on imaging and highlight the deceiving imaging findings. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients at our Breast unit who were treated for breast cancer under one surgeon in the period of Feb 2009 to Jan 2010. Patients underwent triple assessment as per protocol of the breast screening unit. All had fine needle aspiration and core biopsy of the lesions. Appropriate surgery was offered and the size, grade and lymph node status were evaluated and Nottingham Prognostic Index (NPI) used to predict survival. RESULTS: 5 patients were identified with breast cancers that had initial radiological diagnosis of fibroadenoma. All patient lesions were screen detected on NHS screening programme. One patient out of five was discharged after triple assessment and represented with a lump 18 months later. The Median age was 56 years (range 50-66 years). The mammogram showed these to be benign-looking lesions and ultrasound scans suggested fibroadenomas as reported by specialist breast radiologist. Seven lesions were identified in 5 patients. One patient had 3 lesions. Lesions size ranged between 8 mm and 25 mm on mammogram (median 14 mm) and 8-20 mm on ultrasound (range 8-20). Fine needle aspiration cytology was C5 in the two lesions, C4 in 2 and C3 in 1 lesion. Two patients had unifocal grade 3 tumours. One patient had multifocal cancer (3 cancers - in unilateral breast) all were grade 3 cancers with lymph node involvement. One patient had grade 2 cancer and 1 was found to have adenoid cystic adenocarcinoma and therefore the grade and NPI were not assessed. NPI was good in 1, moderate in 2 and poor in 1 patient. CONCLUSION: Our case series suggested that one should have a high index of suspicion for FAD in the postmenopausal ladies and triple assessment should include thorough tissue sampling in the form of FNA and core biopsy.

Use of self-expandable stents for obstructive distal and proximal large bowel cancer: a retrospective study in a single centre.

AIM: The aim of our retrospective study was to determine the effectiveness and safety of self-expandable metal stents in patients presenting with large bowel obstruction secondary to colorectal cancer (regardless of the tumour site), in a district general hospital setting. METHODS: All patients who had endoscopic colonic stents insertion for obstructive colorectal cancer between 2001 and 2005 at our centre were identified retrospectively from patients' discharge database and the unit database. The patients were divided into the 'palliation group' where the stents were inserted to relief symptoms only and the 'bridge group' where patients with resectable cancer underwent colonic stenting as a bridge to improve patient's general condition before definite surgery. RESULTS: Thirty-eight patients were included in the final analysis. Thirty-three tumours were in the distal colon and five were in more proximal lesions. Stent insertion was successful in 35 patients (92%). Overall clinical success was 71%. All five proximal colonic tumours (13%) had successful stent insertion. Mortality related to procedure was 2%, and the average survival in all patients was 141 days from time of stent insertion. CONCLUSION: Colonic stent is a safe and effective method for relief of immediate symptoms of malignant distal and proximal large bowel obstruction.