Phyllodes tumour of the breast and margins: How much is enough

Summary: Phyllodes breast tumours are fairly uncommon, and they can be benign, borderline or malignant. General surgeons usually encounter them following the surgical excision of a breast lump that had the appearance of a fibroepithelial lesion. The surgeon is then faced with the question of what to do to establish an acceptable treatment margin. In this discussion, we recommend a plan for the management of Phyllodes tumours based on a review of the recent literature, confirmed by a retrospective review of the results from our centre. A negative margin is acceptable treatment following a lumpectomy for Phyllodes tumours. Only patients with a positive margin should undergo a revision.

Primary breast cancer in the elderly: a systematic literature review on histological type and clinical outcome.

The objective was to determine whether histological types of breast cancer in elderly women influence clinical outcome. Four major databases were searched. All relevant articles, from January 1990 to December 2013, were screened. After applying inclusion and exclusion criteria, 11 studies were included. Invasive ductal carcinoma was the commonest (68.5-87.1%) histological type, followed by lobular carcinoma (6.9-17.7%). Four studies reported on survival. However, none specifically looked at survival according to different histological types. There are very little data on the influence of histological type on clinical outcome in primary breast cancer in elderly patients. Further studies may elucidate any potential influence and its relationship with tumor biology.

Variations in the anatomical distribution of peripheral vascular disease according to gender.

BACKGROUND: While large epidemiological studies have suggested that the male gender is more frequently afflicted with intermittent claudication, there is little data whether there are gender differences in the distribution of peripheral vascular disease (PVD). The aim of this study was to clarify this issue on the basis of angiographic findings in patients presenting with claudication. PATIENTS AND METHODS: The radiology department computerised database was used to identify all lower limb angiograms performed for investigation of PVD. Patients undergoing incomplete assessment and those with normal angiograms were excluded. Demographic details for each patient were collected together with details of uni- or bilaterality of disease, the number of lesions present and their anatomical distribution according to the major named vessels. Only lesions reported as radiologically significant were included in the analysis. RESULTS: Five hundred consecutive angiograms fitting the defined study criteria were assessed. There were 310 males and 190 females giving a male to female ratio of 1.6:1. The most common distribution for both genders was multiple bilateral lesions. There were no significant differences in the number of stenoses in terms of ratio of bilateral to unilateral (2.39 vs 2.77) or ratio of multiple to single lesions (1.5 vs 1.7) between the female and male groups. Disease was more common in males at all anatomical locations, the most significant differences being for lesions of the common femoral and profunda femoris arteries. CONCLUSIONS: PVD is more commonly diagnosed in males than females. The disease process is more commonly bilateral in both genders and PVD affects more numerous sites in the male claudicant than in the female claudicant. Nevertheless, there does not appear to be any difference in the anatomical distribution of disease between genders.

Molecular characterization of dermal lymphatic endothelial cells from primary lymphedema skin.

BACKGROUND: Lymphatic endothelial cells from primary lymphedema skin have never been cultured nor characterized. A subgroup of patients with primary lymphedema undergo surgery to bring about an improvement in their quality of life. The aim of this study was to culture and characterize LECs from the skin of these patients. METHODS AND RESULTS: Lymphatic endothelial cells were isolated and cultured from the skin of patients with primary lymphedema and from normal skin. The isolated cells were compared in their ability to form microvascular networks in a three-dimensional culture medium, and in their response to treatment with vascular endothelial growth factors A, C, and D. Whole tissue transcriptional profiling was carried out on two pools of isolated lymphatic endothelial cells--one from primary lymphedema skin and the other from normal skin. Lymphatic endothelial cells from primary lymphedema skin form tubule-like structures when cultured in three-dimensional media. They respond in a similar fashion to stimulation with the vascular endothelial growth factors A, C, and D. Comparative analysis between lymphedema tissue and normal tissue (fold change >2) showed differential expression of 2793 genes (5% of all transcripts), 2184 upregulated, and 609 downregulated. Genes involved in cellular apoptosis (vascular endothelial growth inhibitor, zinc finger protein), extracellular matrix turnover (matrix metalloproteinase inhibitor-16), and type IV collagen deposition were upregulated. Various pro-inflammatory genes (interleukin-6, interleukin-8, interleukin-32, E-selectin) were downregulated. CONCLUSION: Cellular adhesion, apoptosis, and increased extracellular matrix turnover play a more prominent role in primary lymphedema than previously thought. In addition, the acute inflammatory response is attenuated as evidenced by the downregulation of various pro-inflammatory genes.This sheds further light on the interplay of the various pathological processes taking place in primary lymphedema.

Aortic replacement in aorto-occlusive disease: an observational study.

BACKGROUND: For many patients with aorto-occlusive disease, where stent deployment is not possible, surgery remains the only treatment option available. The aim of this study was to assess the results of aortic reconstruction surgery performed in patients with critical ischaemia. METHODS: All patients with critical ischaemia undergoing surgery during 1991-2004 were identified from a prospectively maintained database. Mortality data was verified against death certificate data. Demographic and clinical data were obtained from the clinical notes and the radiology database. Disease was classified as: type I - limited to aorta and common iliac arteries; type II - external iliac disease and type III combined aortic, iliac and infra-inguinal disease. RESULTS: 86 patients underwent aortic replacement surgery all of whom had critical ischaemia consisting of: type I (n = 16); type II (n = 37) and type III (n = 33). The 30-day mortality rate was 10.4%, the one-year patient survival was 80%, and the 1-year graft survival was 80%. At 2 years the actual patient survival was 73% and no additional graft losses were identified. All patients surviving 30 days reported excellent symptomatic relief. Early, complications occurred in 6 (7%) patients: thrombosis within diseased superficial femoral arteries (n = 4); haemorrhage and subsequent death (n = 2). Ten (14%) late complications (> 12 months) occurred in the 69 surviving patients and included: anastomotic stenosis (n = 3); graft thrombosis (n = 4), graft infection (n = 3). Four patients developed claudication as a result of more distal disease in the presence of a patent graft, and 1 patient who continued smoking required an amputation for progressive distal disease. CONCLUSION: Aortic reconstruction for patients with extensive aorto-occlusive disease provides long-standing symptomatic relief for the majority of patients. After the first year, there is continued patient attrition due to co-existent cardiovascular disease but no further graft losses.