The sensitivity of needle core biopsy in combination with other investigations for the diagnosis of phyllodes tumours of the breast.

BACKGROUND: The sensitivity of needle-core biopsy (NCB) in diagnosing phyllodes tumours has only been addressed by a handful of small studies. The aim of this study was to analyse the sensitivity of NCB in the diagnosis of phyllodes tumours and to compare this to the sensitivity of other commonly performed investigations. A secondary aim was to assess the effect of various patient and disease factors on the rate of false negative test results. METHODS: Pathology databases were interrogated to identify all patients with the SNOMED term M-9020 or the word phyllodes in specimen reports. Excisional specimen reports were matched to prior FNAC reports, NCB reports and imaging reports. RESULTS: Ninety-one patients had a confirmed phyllodes tumour on excision. The sensitivity of FNAC, NCB and imaging for diagnosing phyllodes tumours was 40%, 63% and 65% respectively. The sensitivity of imaging and NCB was greater for borderline and malignant lesions. Combining cytohistological and radiological tests improved sensitivity to 76%. A younger age was associated with a greater false negative rate for all tests. Borderline and malignant phyllodes tumours were significantly associated with advancing age and greater lesion size on imaging and histology. CONCLUSIONS: This is the largest report to date assessing the sensitivity of NCB in the diagnosis of phyllodes tumours. Increased sensitivity in the diagnosis of phyllodes tumours can be achieved by combining cytohistological and radiological test results. The novel association between younger age and false negative results warrants further investigation. The most likely explanation is a reluctance to diagnose phyllodes tumours in young women given the increased prevalence of cellular fibroadenomas in this age group.

A two-millimetre free margin from invasive tumour minimises residual disease in breast-conserving surgery.

AIMS: In breast-conserving surgery, the width of free margin around a tumour to ensure adequate excision is controversial. The aim of this study was first to evaluate the frequency of residual disease in wider excision specimens in patients who undergo further surgery because of close margins of < 5 mm. Secondly, the ability of demographic and tumour-related factors to predict the close margins was appraised. PATIENTS AND METHODS: Three-hundred-and-three patients were included in the study. Patients undergoing wider excision were assessed for the presence of residual disease, and this was tested for association with the width of the initial free margin. Various factors were studied for association with close or involved margins by univariate analysis. RESULTS: Fifty-three per cent of patients were eligible for re-excision based on the need for a 5-mm clearance. With a free margin of 2 mm or more from invasive tumour, the probability of finding residual disease was 2.4%. The probability of residual disease was higher for ductal carcinoma in situ (DCIS) and did not decline with increasing the free margin width. Tumour size, lobular cancer type, vascular invasion and nodal involvement were associated with close margins. CONCLUSIONS: We suggest that a free margin of 2 mm from invasive tumour is adequate to minimise residual disease, whereas the equivalent free margin for DCIS remains unclear. Patients with large tumours and lobular cancer type should be counselled at the time of first surgery concerning the higher risk of further excision and mastectomy.

Resection-line involvement in gastric cancer: a continuing problem.

Surgeons are aware of the adverse effect that resection-line disease has on anastomotic leakage, perioperative mortality and long-term survival. In an attempt to assess the effect of this knowledge on surgical practice, patients entered into the second British Stomach Cancer Group adjuvant therapy trial were studied. The presence of resection-line disease was compared with the operative stage. Of 555 patients for whom complete data were available, resection-line disease was present in 105 (19 per cent). Of 424 patients undergoing what the surgeon considered to be a potentially curative operation, 55 (13 per cent) had involvement of one or both resection lines, rendering the surgery palliative. Only 9 per cent of patients with stage I-III disease and resection-line involvement survived beyond 5 years, compared with 27 per cent of those with clear lines. Despite knowledge of the adverse effects of resection-line disease, surgeons continue to perform inadequate resections. This demonstrates the need for a more aggressive approach to assessment of resection margins at operation.

Labelled antibody imaging in pancreatic cancer, cholangiocarcinoma, chronic pancreatitis and sclerosing cholangitis.

Pancreatic and biliary carcinomas are difficult to differentiate clinically from their benign counterparts, chronic pancreatitis and sclerosing cholangitis. Immunohistochemical differences in CEA expression have previously been demonstrated in these conditions. We have therefore investigated the use of a monoclonal anti-CEA antibody (11-285-14) in distinguishing between these conditions in vivo. Twenty-five patients with these four conditions underwent radioimmunolocalisation studies. Diagnosis was confirmed by laparotomy and biopsy (n = 21), CT scanning (n = 1) or ERCP (n = 3). Positive images were obtained in 11/12 pancreatic cancers and 2/3 biliary tumours. However, 4/8 cases of chronic pancreatitis and 1/2 cases of sclerosing cholangitis also had positive images. This high false positive rate suggests that antibody imaging is unable to differentiate reliably between benign and malignant pancreatico-biliary conditions.

Haemoccult testing as an indicator of recurrent colorectal cancer: a 5-year prospective study.

A prospective study was conducted to assess the value of routine haemoccult testing as an indicator of early luminal recurrence of colorectal cancer. One hundred patients (mean age 72 years) undergoing radical resection (70% Dukes' B and 30% Dukes' C) for colorectal carcinoma were asked to provide 3-monthly haemoccult tests to a special follow-up clinic for a minimum of 5 years. Positive tests underwent further investigation with barium enema and colonoscopy. Patient compliance was 84%. Positive tests were obtained in 14 asymptomatic individuals, five of whom proved to have anastomotic recurrence. Recurrence was also identified in a further patient despite a negative haemoccult test. Three patients with anastomotic recurrence were able to undergo further radical surgery; two were still alive over 5 years after detection of recurrent disease. Haemoccult screening appears to detect increased numbers of patients with luminal recurrence (7.2%) when compared to historical controls (2.1%). Larger studies will be needed to determine if this increased detection rate results in improved long-term survival.

Early detection of gastric cancer.

OBJECTIVE: To see whether investigation of dyspeptic patients aged over 40 after their first consultation with the general practitioner would increase the proportions with early and operable gastric cancers. DESIGN: Prospective study of gastric cancer in dyspeptic patients aged over 40 from a defined population. SETTING: 10 General practices (six in central Birmingham, four in Sandwell); the Queen Elizabeth Hospital, Birmingham; and Sandwell District General Hospital. PATIENTS: 2659 Patients aged 40 or over referred with dyspepsia. MAIN OUTCOME MEASURE: Increase in early and operable gastric cancers detected in middle aged patients with dyspepsia. RESULTS: Disease was identified in 1992 patients (75%). Fifty seven were found to have gastric cancer, 36 being treated by potentially curative resection, including 15 with early cancer. CONCLUSIONS: The investigation of dyspeptic patients over 40 at first attendance can increase the proportion of early gastric cancers detected to 26% and the proportion of operable cases to 63%. Such a policy has the potential to reduce mortality from gastric cancer in the population.

Biodegradable emboli and antibody targetting of colorectal and gastric hepatic metastases: a pilot study.

The effect of degradable starch microspheres (DSM) on the passage of a low molecular weight marker through the liver of patients with metastases was compared with the passage of an anti-carcinoembryonic antigen monoclonal antibody. In all six patients studied DSM reduced the passage of the marker into the systemic circulation. In three patients who received labelled whole antibody, DSM had no effect. In two of three who received antibody fragments a similar delay to the low molecular weight marker was observed. This delay is likely to be a result of the smaller size of the fragments and may represent accumulation within the extravascular space.

Infection of an abdominal aortic aneurysm from an appendix abscess.

We report a case of gram negative anaerobic infection developing in an abdominal aortic aneurysm due to direct involvement by an appendix abscess. Diagnosis, management and successful treatment of this unusual and often lethal condition are discussed.