Background: Management of close margins following oncological breast surgery is a controversial topic. There is little evidence to support a margin width but there is consensus that the margin should be “clear” of disease. Anterior margin management is a common point of discussion in multidisciplinary meetings, including whether to re-excise the margin. If skin flaps are thin many would advocate there is no need for re-excision. The aim of our audit was to evaluate the oncological safety of re-excision in patients who have had a close anterior margin and the pathology of re-excision surgery.

Aims: Sentinel lymph node biopsy (SLNB) is an important method of staging early breast cancer because of the inherent benefits it confers on patients in terms of arm function and quality of life. Its success depends on a high level of accuracy in detecting the sentinel node. This is achieved by a dual mapping technique that employs a radio-labelled nanocolloid and a vital blue dye. The vital dyes however carry the risk of anaphylaxis, and as more surgeons employ SLNB in their daily practice, a proportionate rise in the number of anaphylactic reactions can be expected. A comprehensive review of risks and benefits associated with using vital blues dyes has not been published and therefore a retrospective review was undertaken of the different levels of anaphylaxis associated with vital dyes as well as their benefits in SLNB.Methods: An OVID MEDLINE search was performed of the English published literature using appropriate search terms to find published trial data and case series that focused on adverse reactions to vital blue dyes.Results: The risk of severe anaphylaxis (grade 3) can be as low as 0.06%, and up to 0.4% for patients undergoing SLNB when data is analysed from large trials. Furthermore, adverse reactions associated with blue dyes are reversible with appropriate management.Conclusions: Surgeons should continue to use vital dyes to ensure that SLNB remains a highly sensitive procedure. (C) 2010 Elsevier Ltd. All rights reserved.

Background: The preliminary results of the IMPACT trial have shown that aromatase inhibitors are the preferred first-line hormonal treatment for advanced breast cancer. This raises the question as to the significance of circulating testosterone levels in women with breast cancer. Method: We have measured serum testosterone and sex hormone-binding globulin (SHBG) preoperatively in women presenting with primary operable breast cancer and age-matched controls. Tumour androgen receptor (AR) expression was measured by flow cytometry on tumour biopsies from 35 patients, and serum testosterone levels were correlated with tumour expression. Results: No correlation was found between serum androgen levels and tumour androgen receptor expression. Conclusions: These results suggest that elevated circulating total testosterone has a role in the aetiology of the breast cancer, presumably by conversion to oestrogens. The finding of a significantly raised free androgen index in postmenopausal controls suggests that ‘active’ testosterone may be protective against the development of breast cancer. This is supported by cell line work, which has shown a growth-inhibitory affect of androgens on breast cancer proliferation.

AIM:To determine the incidence of pre-malignant and malignant conditions in radial scars identified from screening mammograms in women taking part in the UK NHS breast cancer screening programme.METHODS:All women in our screening population from 1988 to 2002 with a radiological diagnosis of radial scar or complex sclerosing lesion confirmed on subsequent histopathology were included in this study. Patients were investigated with fine needle aspiration cytology then localisation biopsy (n=46) or straight to localisation biopsy (n=78). Patients where divided into two groups, one with pure RS/CSL with no associated epithelial features and the second with associated ADH, DCIS or invasive cancer.RESULTS:One hundred and twenty-four lesions were confirmed histologically as radial scar or complex sclerosing lesions. The median age was 58 years. Of the 124 patients, 82 were pure RS/CSL. Forty-two had associated epithelial lesions, 22 patients had ADH and 20 patients had either in situ or invasive carcinoma. Where FNA was performed (n=46), mammograms had shown three lesions suspicious of cancer, which were not proven histologically. Mammograms picked up five malignancies out of the nine RS/CSL with associated cancers. Of these, FNA confirmed malignancy in only two patients. Where FNA was not done (n=78), mammogram had read five pure RS/CSL as cancers. It picked up only four cancers in RS lesions with DCIS/Ca out of 11.CONCLUSION:All screen-detected stellate lesions should be excised due to their association with pre-malignant and malignant conditions.

In both women and men, breast lumps are the most common presentation of breast cancer. The following cases illustrate the pathological entity of granulomatous mastitis, which can present simulating breast cancer - including the first description of this condition in a male. These cases demonstrate the difficulty in clinical diagnosis and emphasizes that although there may be clues from the history, clinical awareness that this condition can mimic breast cancer in all aspects of the triple assessment process should arouse suspicion. The importance of histological diagnosis by core or excision biopsy is stressed, as with accurate diagnosis of granulomatous mastitis there is a mandate to avoid unnecessary surgery.

Several studies have found elevated levels of adrenal androgens in postmenopausal women and depressed levels in premenopausal women with breast cancer, suggesting a role for adrenal androgens in the aetiology of breast cancer. We have measured serum dehydroepiandrosterone sulphate and androstenedione in 81 women with primary operable breast cancer and 62 age-matched controls. Results showed that serum levels of both adrenal androgens fell significantly with age in women with breast cancer (P=0.003). However, no relationship was observed between serum adrenal androgen levels and body mass index in either women with breast cancer or controls. Dehydroepiandrosterone sulphate levels were elevated in postmenopausal women with breast cancer compared to controls, and this was not due to preoperative stress. No differences were observed in androstenedione levels between premenopausal or postmenopausal women with breast cancer and controls, nor were dehydroepiandrostenedione sulphate levels significantly different between premenopausal women with breast cancer and controls. These results suggest that dehydroepiandrosterone sulphate has a role in the aetiology of postmenopausal breast cancer.

The role of androgens in the progression and aetiology of breast cancer has resurfaced in the light of effective aromatase inhibitors. We have measured serum androstenedione, dehydroepiandrosterone sulphate (DHEAS) and cortisol in 53 pre- and postmenopausal women with primary operable breast cancer and 39 age-matched controls to examine the relationship between them. Serum was taken preoperatively from patients with primary operable breast cancer and age-matched controls recruited from the diagnostic breast clinic. Enzyme-linked immunoassays (DRG diagnostics) were used to determine serum levels of androstenedione, DHEAS and cortisol. We have observed that compared to controls, adrenal androgens are elevated in patients with breast cancer. In order to examine whether levels were elevated in the patients with breast cancer due to preoperative emotional stress, we have measured serum cortisol levels. Cortisol levels were nonsignificantly raised in patients with breast cancer compared to controls; however, adrenal androgen levels were independent of cortisol levels. These findings suggest that elevated circulating adrenal androgens may have a role in the aetiology and progression of breast cancer.

The role of androgens in the progression and aetiology of breast cancer has resurfaced in the light of effective aromatase inhibitors. We have measured serum androstenedione, dehydroepiandrosterone sulphate (DHEAS) and cortisol in 53 pre- and postmenopausal women with primary operable breast cancer and 39 age-matched controls to examine the relationship between them. Serum was taken preoperatively from patients with primary operable breast cancer and age-matched controls recruited from the diagnostic breast clinic. Enzyme-linked immunoassays (DRG diagnostics) were used to determine serum levels of androstenedione, DHEAS and cortisol. We have observed that compared to controls, adrenal androgens are elevated in patients with breast cancer. In order to examine whether levels were elevated in the patients with breast cancer due to preoperative emotional stress, we have measured serum cortisol levels. Cortisol levels were nonsignificantly raised in patients with breast cancer compared to controls; however, adrenal androgen levels were independent of cortisol levels. These findings suggest that elevated circulating adrenal androgens may have a role in the aetiology and progression of breast cancer.

Background: The preliminary results of the IMPACT trial have shown that aromatase inhibitors are the preferred first-line hormonal treatment for advanced breast cancer. This raises the question as to the significance of circulating testosterone levels in women with breast cancer. Method: We have measured serum testosterone and sex hormone-binding globulin (SHBG) preoperatively in women presenting with primary operable breast cancer and age-matched controls. Tumour androgen receptor (AR) expression was measured by flow cytometry on tumour biopsies from 35 patients, and serum testosterone levels were correlated with tumour expression. Results: No correlation was found between serum androgen levels and tumour androgen receptor expression. Conclusions: These results suggest that elevated circulating total testosterone has a role in the aetiology of the breast cancer, presumably by conversion to oestrogens. The finding of a significantly raised free androgen index in postmenopausal controls suggests that ‘active’ testosterone may be protective against the development of breast cancer. This is supported by cell line work, which has shown a growth-inhibitory affect of androgens on breast cancer proliferation.

AIM To determine whether the introduction of a standard reporting proforma has led to an improvement in the completeness of histopathology reports for breast cancer excision specimens. METHODS A standard reporting proforma was designed using the Royal College of Pathologists' minimum dataset for breast cancer histopathology reports and the national histopathology reporting form of the National Health Service (NHS) breast screening programme. This was introduced into our department in June 1999, with reports generated from the proforma replacing the standard text reports. The pathological information contained in 50 text reports issued before the introduction of the proforma and 50 reports generated using the proforma was compared with the minimum dataset and NHS breast screening programme guidelines. RESULTS A general improvement in documentation of individual pathological features was noted after introduction of the proforma. This was most significant in relation to documentation of features, such as microcalcification and ductal carcinoma in situ. In addition, important features such as tumour grade, tumour size, and hormone receptor status were documented more frequently in the proforma group. There was an overall increase in the number of reports regarded as complete after introduction of the proforma. CONCLUSIONS The introduction of a standard proforma led to a significant improvement in the completeness of breast cancer histopathology reports in this centre, but continued vigilance is needed to ensure that standards continue to improve.

AIMSTo review our institution's practice of treatment of a mammographically detected population of ductal carcinoma in situ (DCIS) patients and to determine the outcome.METHODSBetween April 1989 and March 1994, 304 women with median age 59 years (range 51-65) with DCIS detected on screening mammogram, were treated in the Newcastle General and Royal Victoria Infirmary Hospitals, Newcastle-upon-Tyne, UK. More than half of the women (n=176, 57.8%) decided to have mastectomy. Other treatment options were wide local excision (WLE) with radiotherapy (n=97, 32%) and WLE alone (n=31, 10.2%). All except five received adjuvant hormone treatment.RESULTSPredominant DCIS was comedo in 122 (42%), followed by cribriform in 87 (30%) and micropapillary in 44 (15%) cases. Grade I was found to be commonest grade (54%) followed by grade II (27%) and grade III (11%). With a median follow-up of 88 months, there were six (2%) recurrences, all of which were in women who were given breast conservation treatment, WLE with radiotherapy (n=1, 1%) and without radiotherapy (n=5, 16.6%). Mastectomy in this series was not associated with any recurrence at all. In three cases the recurrence was invasive, one of who also had distant metastasis.CONCLUSIONSThe findings of this study suggest that in women with DCIS suitable for breast conservation, WLE when combined with radiotherapy is associated with a very low recurrence rate.

PURPOSE: Retroflexion of the endoscope during rectal examination may increase diagnostic yield but is not routinely performed because of concerns about safety and a lack of appreciation of its importance. The purpose of this study was to examine the yield, safety, and tolerance of endoscopic rectal retroflexion. METHODS: Prospective cohorts of subjects undergoing unsedated screening flexible sigmoidoscopy were examined with and without routine retroflexion. Pain scores were recorded. RESULTS: A total of 526 subjects (mean age 60 (range, 55–66) years) underwent flexible sigmoidoscopy in the first period when the endoscope was not routinely retroflexed. Of these, 480 (mean age 60 (range, 55–66) years) were subsequently examined with routine retroflexion. Retroflexion was impossible in 17 subjects (3.5 percent) because of discomfort. In the second group, 12 subjects (2.5 percent) had polyps in the lower rectum seen only on retroflexion. Of these, eight had metaplastic and four had adenomatous polyps (3 tubular <5 mm, 1 tubulovillous 15 mm). There was no difference in mean pain scores between the groups (no retroflexion=2.13, retroflexion=2.18). CONCLUSION: With an adenoma pick-up rate of 8 to 12 percent for screening flexible sigmoidoscopy, retroflexion increases adenoma detection by approximately 1 percent without adverse effects and should be an integral part of flexible sigmoidoscopy.

It is well documented that patients who are HIV positive develop lymphomas as a result of their immunosuppression, the most common being high grade B cell non-Hodgkin’s lymphoma,’ development of which constitutes one of the definitions of AIDS.2 The lymphomas are frequently extranodal and in unusual sites including the brain, bone marrow, and the heart.’ Non-Hodgkin’s lymphoma represents 2.5-2.9s of all new AIDS case presentations in Europe.3

This study prospectively examined tumour bed biopsies in 135 consecutive patients undergoing conservative surgery for breast carcinoma. All had wide resection of the primary tumour and histologically clear margins. Twelve patients (9%) had positive tumour bed biopsies. Two subgroups of patients had positive bed biopsies; those with ductal carcinoma in situ, and a second group with more aggressive disease characterized by lymph node involvement, vascular invasion and a higher grade and mitotic count. As the majority of recurrences from breast carcinoma occur in the region of the primary tumour, bed biopsy may aid in the identification of a group of patients with multifocal or aggressive disease who are at increased risk of local recurrence.