Lesions of uncertain malignant potential (B3) on core biopsy in the NHS Breast Screening Programme: is the screening round relevant?

INTRODUCTION: Most women who have screening mammography and undergo subsequent open biopsy following an indeterminate core biopsy result are eventually found to have benign disease. However, a significant number have malignant disease and the rate of malignancy in such cases may be influenced by various factors. This study examined the effect of the type of screening round (prevalent or incident) on the likelihood of breast cancer being present. METHODS: A total of 199 women who had NHS breast screening mammograms and subsequent indeterminate (B3) core biopsy results followed by excision biopsy over an 11-year period in a single breast screening unit were reviewed. RESULTS: The rate of malignancy following excision of a lesion graded as B3 on core biopsy was 21% for women in the prevalent screening round compared to 33% in subsequent rounds (Fisher's exact test, p=0.038). CONCLUSIONS: The incidence of malignancy associated with a B3 core biopsy result appears to be related to the screening round in which the lesion is detected, being approximately 50% higher in the subsequent incident rounds compared to the initial prevalent round. This finding may be useful in formulating management plans for women who have an indeterminate biopsy result.

Long term follow-up and risk of breast cancer after a radial scar or complex sclerosing lesion has been identified in a benign open breast biopsy.

AIMS: Radial scars (RS)/complex sclerosing lesions (CSL) are rare, benign breast lesions of unknown aetiology. Associations with breast cancer have been suggested particularly with larger lesions. This study aims to identify the risk of developing subsequent breast cancer after excision of a benign RS/CSL with respect to lesion size and compared to expected rates in the normal UK population. METHODS: A prospective cohort analysis was performed on patients diagnosed with RS/CSL in benign, open breast biopsy specimens over a 20-year period. The rate of subsequent breast cancer development was compared to expected rates in the normal UK population. Subjects were divided into two groups according to lesion size and the rates of subsequent breast cancer compared. RESULTS: 149 women without proliferative breast disease were followed for an average of 68 months. Five women developed subsequent cancer, equating to a rate of 0.84% per year. This compares to 0.32% per year in the normal population (RR 2.6, 95% CI 0.86-6.0). There were two subsequent cancers in the RS group and three subsequent cancers in the CSL group, P = 0.64. CONCLUSIONS: The study finds no evidence to suggest that lesions greater than 10 mm (CSL) have any greater risk of developing cancer after excision than those below 10 mm (RS). Women treated for RS/CSL do not need any additional follow-up beyond routine mammographic breast screening. Additional surveillance should only be performed if there is associated pathology indicating an increased risk of subsequent malignancy.

Fish-tail plasty: a safe technique to improve cosmesis at the lateral end of mastectomy scars.

BACKGROUND AND AIMS: Redundant skin at the lateral end of a mastectomy scar can be unsightly and uncomfortable, especially in elderly obese patients. The aim of this study is to evaluate a technique of mastectomy wound closure designed to maximise cosmesis at the lateral end. PATIENTS AND METHODS: Thirty lateral skin flap advancements were performed in 28 patients. The procedure was performed primarily in 27 cases. In three cases a delayed scar revision was performed. Following anterior advancement of the skin overlying the latissimus dorsi muscle, two areas of redundant skin were excised and the wound closed in the shape of Y-plasty. RESULTS: The patients' mean age was 70.6 years (range 51-93) and the mean body mass index (BMI) 30.4 kg/m2 (range 21-35). The mean weight of the excised breast tissue was 1015 g (range 356-2003). The mean lengths of the two limbs of the Y-plasty were 5.3c m (range 3-10). The mean length of the base of the flap was 8.3 cm (range 4-14). One patient developed a small area of skin necrosis at the apex of the Y-plasty. Two further patients developed superficial wound infections. CONCLUSION: Fish-tail plasty is a safe and easy technique and may be recommended following mastectomy in obese patients to improve cosmesis and avoid discomfort caused by redundant skin.

The assessment of surgical skills and a simple knot-tying exercise.

Basic surgical skills courses are mandatory for all surgical trainees taking the MRCS examination. An important aspect of these courses is the level of practical skill achieved by junior surgeons attending them. We present a simple knot-tying exercise, which may be used to assess the baseline skill level of trainees at the outset of the course and against which their progress can be judged after tuition and practice.

Delayed presentation of spilled gallstones.

The authors describe a case of a cutaneous sinus at the umbilical port site following spillage of gallstones during laparoscopic cholecystectomy. The sinus tract was explored using a flexible cystoscope, the stones found within were removed, and the tract itself was curetted. The consequences of spillage of gallstones and its prevention are discussed.

HIV and tuberculosis co-infection in an inner London hospital--a prospective anonymized seroprevalence study.

OBJECTIVES: Since 1987 there has been an increase in tuberculosis notifications in the U.K., with this increase disproportionately affecting London. A recent national survey suggests that co-infection with HIV occurs in less than 5% of tuberculosis patients. This study asked if local co-infection rates in Inner London differed from the national results. METHODS: 157 consecutive patients starting antituberculous chemotherapy were venesected 2 weeks into treatment. Anonymized blood samples were screened for antibodies for HIV-1 and HIV-2 by enzyme-linked immunosorbent assay (ELISA). Epidemiological data were collected on each patient which was also coded before HIV test results were known. RESULTS: Of 157 patients commencing antituberculous therapy, 39 patients (24.8%) were found to be co-infected with HIV-1. HIV-negative and positive patients were similar in terms of age and sex. When 98 patients giving their country of origin as other than Europe were considered there were 22 co-infected with HIV (22.4%). Of the 39 HIV-positive identified in this study, 37 were also identified by our voluntary HIV testing programme. CONCLUSIONS: This study has shown that there may be very different rates of co-infection at a local level in the U.K. The local variation may be missed by national surveys and diverse local testing procedures. Anonymous testing identified only two patients with tuberculosis and HIV infection who were not identified by our voluntary HIV testing programme and this suggests that offering HIV tests to patients with tuberculosis is largely taken up by those at risk of HIV infection. Surveillance studies of this type are important in identifying marked local variation from the national pattern of HIV and Mycobacterium tuberculosis infection.

Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case.

We present a case of life-threatening retroperitoneal sepsis after injection sclerotherapy for first-degree hemorrhoids.

How long should suction drains stay in after breast surgery with axillary dissection?

Daily suction drainage volumes were recorded for 63 patients after wide local excision of a breast carcinoma with axillary dissection (n = 37) or mastectomy with axillary dissection (n = 26). Suction drains were removed at the discretion of the clinical ward staff after a median of 4 days (range 1-7 days). In all, 32 patients (51%) later developed seromas requiring needle aspiration. Minor wound infection rate was not significantly higher in patients who developed seromas than those who did not (5 vs 2). Seroma formation was associated with a larger total suction drain volume (mean 480 ml (range 28-1150 ml) vs 240 ml (range 10-635 ml); P = 0.0001). The median yield of axillary lymph nodes was significantly greater in those who developed seromas (11 (range 4-20) vs 8 (range 1-19); P = 0.002). There was no difference in the volume drained in the 24 h preceding drain removal (mean 60 ml (range 0-150 ml) vs 50 ml (range 0-290 ml); NS). Keeping drains in situ longer did not protect against seroma formation. By 48 h, 74% of the total volume drained by each drain had been collected. Seroma formation after breast surgery with axillary dissection is an inconvenience for a high proportion of patients. This complication does not seem to be reduced by prolonged suction drainage of the wound, which in itself delays patient discharge and causes further inconvenience.

Case report: coincident granular cell tumour of the breast with invasive ductal carcinoma.

Granular cell tumours of the breast are rare lesions which are almost always benign. They are of interest because their clinical, radiological and pathological appearances often closely resemble those of malignancy. A case is described in which screening mammography in an asymptomatic woman led to the diagnosis of simultaneous invasive intraductal carcinoma in one breast and benign granular cell tumour in the other. Granular cell tumour of the breast coincident with other breast tumours is very rarely described and an association with breast carcinoma is unknown.

Ultrasound localization of screen detected impalpable breast tumours.

Accurate localization of a tumour is imperative before excision biopsy for impalpable breast lesions seen on screening mammography. Ultrasound localization has the advantages of being simple, quick and noninvasive. In a 3-year period from September 1989, 185 women have required localization of a breast tumour prior to biopsy, 159 were performed using a wire localization technique and 26 (14%) were performed using ultrasound alone. Twenty-two out of the 26 were malignant lesions. The mean maximum diameter of tumour diagnosed by ultrasound compared to histological sample was 10.6 mm (8.5-12.7*) to 11.1 mm (8.9-13.3*) with a correlation of r = 0.87. In the malignant cases the mean maximum diameter of tissue excised was 63.0 mm (57.2-65.9*). Complete excision was obtained in 21 out of the 22 patients with malignant disease by one operation. Ultrasound alone has been used successfully as a means of preoperative localization in selected cases prior to excision biopsy of a breast tumour.

Spontaneous cholecystcutaneous fistulae secondary to calculous cholecystitis.

Spontaneous external biliary fistulae tend to occur in elderly patients, often those with systemic diseases. Cholecystectomy and fistulectomy is not always required or even appropriate.

Recurrent endometrial adenocarcinoma presenting as an umbilical metastasis (Sister Mary Joseph's nodule).

A case of recurrent endometrial adenocarcinoma metastatic to the umbilicus is reported. The possible modes of spread, management and prognosis of this rare manifestation of visceral malignancy are discussed.

Granular cell tumour (myoblastoma): two cases and a review of the literature.

Granular cell tumour is a rare neoplasm consisting of nests or ribbons of polyhedral cells with granular eosinophilic cytoplasm and small, dense nuclei. It may occur at various sites throughout the body. Two cases, one of the tongue and one of the rectum, are reported and the pathology and management of this uncommon neoplasm are discussed.

Diagnosis of soft tissue tumours by Tru-Cut biopsy.

Tru-Cut biopsies were obtained from 52 consecutive patients referred with soft tissue tumours. Forty-five patients had soft tissue sarcomas; seven had benign soft tissue tumours. Of the biopsies 96 per cent provided adequate material for diagnosis. The histological diagnosis made from the Tru-Cut biopsy was compared with that made from the resected specimen. There were no false positive diagnoses of malignancy. The accuracy of Tru-Cut biopsy was 98 per cent for the diagnosis of malignancy and 94 per cent for the diagnosis of sarcoma. Tumour subtype was correctly specified in 85 per cent of sarcomas and tumour grade in 88 per cent. Tru-Cut biopsy should replace open biopsy as the primary means of diagnosis of soft tissue tumours unless a satisfactory tissue sample cannot be obtained.

Silicone implant to prevent visceral damage during adjuvant radiotherapy for retroperitoneal sarcoma.

The incidence of local recurrence after surgery for retroperitoneal sarcoma is reduced by high-dose adjuvant radiotherapy but treatment is restricted by the effects of irradiation on adjacent viscera. By securing a silicone gel-filled implant (breast prosthesis) in the tumour bed after excision of the tumour, adjacent viscera are displaced from the site of maximum irradiation and may thereby be protected. We used this technique in three patients in whom excision of a retroperitoneal sarcoma was followed by high-dose adjuvant radiotherapy. Post-operative radiotherapy was well tolerated but local recurrence developed in one patient, and delayed perforation of the large bowel occurred in another. Both cases underwent further surgery at which the implant was removed. The same two cases also developed asymptomatic hydronephrosis on the side of the implant, attributed to local fibrosis.

Long term venous access using a totally implantable drug delivery system in patients with cystic fibrosis and bronchiectasis.

A completely implantable, subcutaneous, venous access system (Port-a-Cath) has been used for antibiotic therapy in 26 patients with cystic fibrosis or bronchiectasis over a period of 45 months. During this period there were ten complications in eight patients and in four patients all or part of the system had to be replaced. Nevertheless, the actuarial median functional survival of the implanted system exceeded 30 months. The Port-a-Cath system provides longer periods of venous access and has a lower complication rate than conventional, percutaneous central venous lines.