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Lentigo maligna (LM) is a melanoma in situ with distinct clinical features and histology. It commonly affects men after the sixth decade of life. Incidence rates of LM have increased based on early 21st century data from different countries; however, data are suboptimal. Data from England show a plateauing crude incidence between 2013 and 2019. By comparison, invasive melanoma and other types of melanoma in situ commonly appears in younger age groups (median age 58 and 67 years old, respectively) and incidence is rising. The most important risk factors for LM include fair skin and cumulative ultraviolet solar radiation exposure. Although LM is limited to the epidermis and connected skin adnexa, it may progress to invasive LM melanoma. The reported rate of malignant progression varies, reflecting a challenge for LM epidemiology research as often lesions are removed on diagnosis. LM poses a challenge in diagnosis and management. Although it can be diagnosed clinically or dermoscopically, histopathological assessment of biopsied skin tissue remains the gold standard. Reflectance confocal microscopy allows for better appreciation of the complexity of LM at a cellular level, often progressing beyond clinical margins. Management of LM may involve Mohs micrographic surgery or excision, although recurrence may occur even with 5 mm clinical margins. Imiquimod cream may be effective, but incomplete treatment and recurrence has been reported. Conservative management with observation or radiotherapy may be used in selected patients' cases. Five-year net survival rates are excellent. This paper reviews the natural history, epidemiology, aetiology, pathogenesis, diagnosis and management of LM. [ABSTRACT FROM AUTHOR]

Background Porocarcinoma (PC) is a cutaneous malignancy that differentiates towards (possibly arises from) the sweat ducts and glands. Lack of histological diagnostic markers makes clinical and pathological diagnosis complex. The limited data available suggest the incidence is increasing; however, this remains to be established in national epidemiological studies. Objectives To report the incidence, treatment and survival of patients with PC in England from 1 January 2013 to 31 December 2018 using national cancer registry data. Methods PC diagnoses in England during 2013–2018 were identified from the National Disease Registration Service using morphology and behaviour codes. These were registered from routinely collected pathology reports and cancer outcomes and services datasets. The 2013 European age standardized incidence rates (EASRs), Kaplan–Meier all-cause survival and log-rank test were calculated. Results In total, 738 tumours (396 in males and 342 in females) were diagnosed. The median age at diagnosis was 82 years old (interquartile range 74–88). The most frequently affected site were lower limbs (35.4%), followed by the face (16%). The majority of the cohort received surgical excision (73.0%). The Kaplan–Meier all-cause survival was 45.4% at 5 years, which was lower than in previous studies. The EASR for the whole population was 0.25 [95% confidence interval (CI) 0.23–0.27] per 100 000 person-years (PY)]. PC incidence rates in the East of England (EASR of 0.54, 95% CI 0.47–0.63 per 100 000 PY) were three times higher than the South West (EASR of 0.14, 95% CI 0.10–0.19 per 100 000 PY) where the regional rates were the lowest. Conclusions This study shows that there is large variation in the EASRs of PC across England. This may reflect differences in how PC is diagnosed and registered in different regions in England. These data support national assessment of the management of PC, which will inform future studies and guideline development. [ABSTRACT FROM AUTHOR]

The clinical features, histological subtypes and management of dermatofibrosarcoma protuberans (DFSP) are reviewed in this article. DFSP is an uncommon cutaneous sarcoma first described in 1890. It has a high local recurrence rate, low metastatic rate and low mortality. The crude incidence rate in England in 2019 was reported as 3.0 per million person-years. A fusion of platelet-derived growth factor subunit B (PDGFB) and COL1A1 , t(17;22)(q22;q13), has been found in over 90% of people with DFSP. This fusion is thought to upregulate PDGFB expression, stimulating cell growth by activation of Ras mitogen-activated protein kinases and PI3K–AKT–mTOR, potentiating oncogenesis. DFSP usually presents as an asymptomatic flesh-coloured, thickened, rubbery plaque or nodule with an uneven surface. The most common sites are the trunk followed by lower limbs, head and neck and upper limbs. Larger tumours can infiltrate underlying local structures and around 1% metastasize. Key histological features in DFSP are spindle cells arranged in a storiform pattern with intense CD34 staining. Histological subtypes include classical DFSP, Bednar, myxoid, giant cell fibroblastoma, atrophic and DFSP–fibrosarcomatous. The gold standard management for localized tumours is surgical: current recommendations favour Mohs micrographic surgery over wide local excision. Adjuvant radiotherapy may be offered after surgery. Imatinib can be used as neoadjuvant therapy and in patients with inoperable or metastatic tumours. Further research should be conducted to better understand pathogenesis of DFSP, identify associated risk factors and standardize management. [ABSTRACT FROM AUTHOR]

Background This study reports early mortality and survival from colorectal cancer in relation to the pattern of treatments delivered by the multidisciplinary team (MDT) meeting at a high-volume institution in England over 14 years. Methods All patients diagnosed with colorectal cancer and discussed during MDT meetings from 2003 to 2016 at a single institution were reviewed. Three time intervals (2003–2007, 2008–2012, and 2013–2016) were compared regarding initial surgical management (resection, local excision, non-resection surgery, and no surgery), initial oncological therapy, 90-day mortality, and crude 2-year survival for the whole cohort. Sub-analyses were performed according to age greater or less than 80 years. Results The MDT managed 4617 patients over 14 years (1496 in the first interval and 1389 in the last). Over this time, there was a reduction in emergency resections from 15.5 per cent to 9.0 per cent (P < 0.0001); use of oncological therapies increased from 34.6 per cent to 41.6 per cent (P < 0.0001). The 90-day mortality after diagnosis of colorectal cancer dropped from 14.8 per cent to 10.7 per cent (P < 0.001) and 2-year survival improved from 58.6 per cent to 65 per cent (P < 0.001). Among patients aged 80 years or older (425 and 446, in the first and last intervals respectively) there was, in addition, a progressive increase in 'no surgery' rate from 33.6 per cent to 50.2 per cent (P < 0.0001) and a reduction in elective resections from 42.4 per cent to 33.9 per cent (P = 0.010). The 90-day mortality after elective resection fell from 10.0 per cent (18 of 180) to 3.3 per cent (5 of 151; P = 0.013). Conclusions Survival from colorectal cancer improved significantly over 14 years. Among patients aged ≥80 years, major changes in the type of treatment delivered were associated with a decrease in postoperative mortality. [ABSTRACT FROM AUTHOR]

Our regional burns service has gained experience in managing paediatric hand friction burns due to vacuum cleaners (VC). We aimed to evaluate our 10 year experience managing these injuries as well as reviewing national data trends in order to identify those at risk of injury.Materials and Methods: A International Burns Injury Database (IBID) request was made to review the number of burn injuries recorded due to Vacuum cleaner injuries (VCIs). In addition, a local IBID request was made to identify the number of burn injuries managed within our regional burns service.Results: We identified 288 VCIs which have increasingly occurred in England and Wales between 1996-2020 and 32 children who sustained these injuries within our regional burns service. A general theme from both national and local data highlighted that these injuries occurred in males (78%, n=25) with a mean age of 20 months (9 months-4.5 years) affecting children's hands (94%). In 25 cases (78%) these injuries involved an interphalangeal joint. 85% (n = 27) of injuries were deep dermal/full thickness with eleven children (34%) undergoing surgical excision and skin grafts.Discussion: Significant paediatric burn injuries can be sustained from VCs. Greater awareness is indicated for these injuries and legislation should be considered in order to improve the safety of vacuum cleaners. International burn societies are urged to collect data of these injuries in order to co-ordinate improved prevention strategies and change within the VC industry. [ABSTRACT FROM AUTHOR]

Background: Approximately 15%-20% of all non-small cell lung cancer (NSCLC) cases present with stage I disease. Surgical resection traditionally offers the best chance of a cure but some patients will not have this treatment due to older age, comorbidities or personal choice. Stereotactic ablative radiotherapy (SABR) has become an established curative intent treatment option for patients who are not selected for or do not choose surgery. The aim of this study is to compare survival at 90 days, 6 months, 1 year and 2 years for patients who received either lobectomy or SABR.Methods: We used data from the 2015 National Lung Cancer Audit database and linked with Hospital Episode Statistics and the radiotherapy dataset to identify patients with NSCLC stage IA-IB and performance status (PS) 0-2 who underwent surgery or SABR treatment. We assessed the likelihood of death at 90 days, 6 months, 1 year and 2 year after diagnosis and procedure date to observe survival between two patient groups.Results: We identified 2373 patients in our cohort, 476 of whom had SABR. The median difference between date of diagnosis and date of treatment for surgery patients was 17 days while for SABR patients it was 73 days. Increasing age and worsening PS were associated with having SABR rather than surgery. Survival between the two treatment modalities was similar early on but by 1-year people who had surgery did better than those who had SABR (adjusted ORs 2.12, 95% CI 1.35 to 2.31). This difference persisted at 2 years and when the analysis was restricted to patients aged <80 years and with PS 0 or 1 and stage IA only.Conclusion: Our analysis suggests that patients who have lobectomy have a better survival compared with SABR patients; however, we found considerable delays in patients receiving SABR which may contribute to poorer long-term outcomes with this treatment option. Reducing these delays should be a key focus in development and reorganisation of services. [ABSTRACT FROM AUTHOR]

Background: Recent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England.Methods: A retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications.Results: 112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs.Conclusion: Overall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced. [ABSTRACT FROM AUTHOR]

Background: Chemotherapy response and surgical margins have been shown to be associated with the risk of local recurrence in patients with osteosarcoma. However, existing surgical staging systems fail to reflect the response to chemotherapy or define an appropriate safe metric distance from the tumor that will allow complete excision and closely predict the chance of disease recurrence. We therefore sought to review a group of patients with primary high-grade osteosarcoma treated with neoadjuvant chemotherapy and surgical resection and analyzed margins and chemotherapy response in terms of local recurrence.Questions/purposes: (1) What predictor or combination of predictors available to the clinician can be assessed that more reliably predict the likelihood of local recurrence? (2) Can we determine a better predictor of local recurrence-free survival than the currently applied system of surgical margins? (3) Can we determine a better predictor of overall survival than the currently applied system of surgical margins?Methods: This retrospective study included all patients with high-grade conventional osteosarcomas without metastasis at diagnosis treated at one center between 1997 and 2012 with preoperative chemotherapy followed by resection or amputation of the primary tumor who were younger than age 50 years with minimum 24-month followup for those still alive. A total of 389 participants matched the inclusion criteria. Univariate log-rank test and multivariate Cox analyses were undertaken to identify predictors of local recurrence-free survival (LRFS). The Birmingham classification was devised on the basis of two stems: the response to chemotherapy (good response = ≥ 90% necrosis; poor response = < 90% necrosis) and margins (< 2 mm or ≥ 2 mm). The 5-year overall survival rate was 67% (95% confidence interval [CI], 61%-71%) and 47 patients developed local recurrence (12%).Results: Intralesional margins (hazard ratio [HR], 9.9; 95% CI, 1.2-82; p = 0.03 versus radical margin HR, 1) and a poor response to neoadjuvant chemotherapy (HR, 3.8; 95% CI, 1.7-8.4; p = 0.001 versus good response HR, 1) were independent risk factors for local recurrence (LR). The best predictor of LR, however, was a combination of margins ≤ 2 mm and a less than 90% necrosis response to chemotherapy (Birmingham 2b HR, 19.6; 95% CI, 2.6-144; p = 0.003 versus Birmingham 1a; margin >2 mm and more than 90% necrosis HR, 1). Two-stage Cox regression model and higher Harrell's C statistic demonstrate that the Birmingham classification was superior to the Musculoskeletal Tumor Society (MSTS) margin classification for predicting LR (Harrell's C statistic Birmingham classification 0.68, MSTS criteria 0.59). A difference in overall survival was seen between groups of the Birmingham classification (log-rank test p < 0.0001), whereas the MSTS margin system was not discriminatory (log-rank test p = 0.14).Conclusions: Based on these observations, we believe that a combination of the recording of surgical margins in millimeters and the response to neoadjuvant chemotherapy can more accurately predict the risk of local recurrence than the current MSTS system. A multicenter collaboration study initiated by the International Society of Limb Salvage is recommended to test the validity of the proposed classification and if these findings are confirmed, this classification system might be considered the standard practice in oncology centers treating patients with osteosarcomas and allow more effective communication of margin status for research.Level Of Evidence: Level IV, prognostic study. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic surgery is being increasingly used in colorectal cancer resections. The aim of this national study was to determine whether laparoscopy confers a long-term survival advantage in colorectal cancer.Methods: A national administrative data set (Hospital Episode Statistics-HES) encompassing all elective hospital admissions in England between 2001 and 2011 was analysed. All patients that had a colorectal cancer resection (open or laparoscopic) were identified. Cox hazard regression was used to determine differences in overall survival (10 year) between the open and laparoscopy groups.Results: A total of 141,682 patients underwent elective surgery for colorectal cancer, of which 20.9 % (n = 29,550) had a laparoscopic procedure. The median 5-year survival in the open group was 36.1 months compared with 46.1 months in the laparoscopic group (p = <0.001). Survival analysis demonstrated laparoscopy to be an independent predictor of survival. Patients who underwent laparoscopic resection were 18 % less likely to die than patients who had an open CRC resection (HR 0.82, CI 0.79-0.83, p < 0.001). This survival benefit persisted even when initial post-operative mortality (90 day) was excluded (HR 0.87, CI 0.85-0.90, p < 0.001). Subgroup analysis, exploring the effect of CRC laparoscopic surgery on survival in the elderly (>79 years old), demonstrated similar survival benefit amongst patients treated using laparoscopy (HR 0.90, CI 0.86-0.94, p < 0.001). Patients not undergoing adjuvant chemotherapy were more likely to survive if they underwent laparoscopic resection (HR 0.81, CI 0.78-0.83, p < 0.001). Similarly, patients undergoing adjuvant chemotherapy demonstrated a survival benefit if a minimal access surgical approach was utilised (HR 0.86, CI 0.81-0.91, p < 0.001).Conclusion: Laparoscopy confers a survival benefit, irrespective of age and administration of adjuvant chemotherapy, beyond the initial post-operative period in patients selected for elective colorectal cancer resection. [ABSTRACT FROM AUTHOR]

Objective We assessed the association between population resection rates, hospital procedure volume and death rates in pancreatic cancer patients in England. Design Patients diagnosed with pancreatic cancer were identified from a linked cancer registration and Hospital Episode Statistics dataset. Cox regression analyses were used to assess all-cause mortality according to resection quintile and hospital volume, adjusting for sex, age, deprivation and comorbidity. Results There were 31,973 pancreatic cancer patients studied, 2580 had surgery. Increasing resection rates were associated with lower mortality among all patients (χ 2 (1df) = 176.18, p trend < 0.001), with an unadjusted hazard ratio (HR) of 0.78 95%CI [0.75 to 0.81] in the highest versus the lowest resection quintile. Adjustment changed the estimate slightly (HR 0.82, 95%CI [0.79 to 0.85], (χ 2 (1df) = 99.44, p trend < 0.001)). Among patients that underwent surgery, higher procedure volume was associated with lower mortality (HR = 0.88 95%CI [0.75–1.03] in hospitals carrying out 30+ versus <15 operations a year, shared frailty model, χ 2 (1df) = 1.82, p trend = 0.177). Conclusion Higher population resection rates were associated with lower mortality. The association with hospital procedure volume was less clear possibly due to small number of patients who underwent surgery. Nevertheless these results suggest survival is higher in hospitals that carry out a greater number of operations a year, particularly those doing 30+ operations, supporting the benefit of centralising perioperative expertise in specialist centres. Ensuring people are increasingly diagnosed when they are suitable candidates for surgery, and have access to these specialist centres may lead to an increase in the proportion of patients that undergo surgical resection which could plausibly increase survival of pancreatic cancer patients. [ABSTRACT FROM AUTHOR]

Background:Survival from breast cancer in the United Kingdom is lower than in other developed countries. It is unclear to what extent waiting times for curative surgery affect survival.Methods:Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 53 689 women with localised breast cancer, aged 15 years, diagnosed between 1996 and 2009, who had surgical resection with curative intent within 62 days of diagnosis. We used relative survival and excess risk modelling to determine associations between waiting times and 5-year survival.Results:The median diagnosis to curative surgery waiting time among breast cancer patients was 22 days (interquartile range (IQR): 15-30). Relative survival was similar among women waiting between 25 and 38 days (RS: 93.5%; 95% CI: 92.8-94.2%), <25 days (RS: 93.0%; 95% CI: 92.5-93.4%) and between 39 and 62 days (RS: 92.1%; 95% CI: 90.8-93.4%). There was little evidence of an increase in excess mortality with longer waiting times (excess hazard ratio (EHR): 1.06; 95% CI: 0.88-1.27 comparing waiting times 39-62 with 25-38 days). Excess mortality was associated with age (EHR 65-74 vs 15-44 year olds: 1.23; 95% CI: 1.07-1.41) and deprivation (EHR most vs least deprived: 1.28; 95% CI: 1.09-1.49), but waiting times did not explain these differences.Conclusion:Within 62 days of diagnosis, decreasing waiting times from diagnosis to surgery had little impact on survival from localised breast cancer. [ABSTRACT FROM AUTHOR]

Objective This study assessed the associations between hospital volume, resection rate and survival of oesophageal and gastric cancer patients in England. Design 62 811 patients diagnosed with oesophageal or gastric cancer between 2004 and 2008 were identified from a national population-based cancer registration and Hospital Episode Statistics-linked dataset. Cox regression analyses were used to assess all-cause mortality according to hospital volume and resection rate, adjusting for case-mix variables (sex, age, socioeconomic deprivation, comorbidity and type of cancer). HRs and 95% CIs, according to hospital volume, were evaluated for three predefined periods following surgery: <30, 30-365, and >365 days. Analysis of mortality in relation to resection rate was performed among all patients and among the 13 189 (21%) resected patients. Results Increasing hospital volume was associated with lower mortality (ptrend=0.0001; HR 0.87, 95% CI 0.79 to 0.95 for hospitals resecting 80+ and compared with <20 patients a year). In relative terms, the association between increasing hospital volume and lower mortality was particularly strong in the first 30 days following surgery (ptrend<0.0001; HR 0.52, (0.39 to 0.70)), but a clinically relevant association remained beyond 1 year (ptrend=0.0011; HR 0.82, (0.72 to 0.95)). Increasing resection rates were associated with lower mortality among all patients (ptrend<0.0001; HR 0.86, (0.84 to 0.89) for the highest, compared with the lowest resection quintile). Conclusions With evidence of lower short-term and longer-term mortality for patients resected in high-volume hospitals, this study supports further centralisation of oesophageal and gastric cancer surgical services in England. [ABSTRACT FROM AUTHOR]

Aim Management of malignant colorectal polyps (MCP) is contentious, with no randomized controlled trials comparing endoscopic with surgical management. This study reviews the management and outcomes of MCPs across a UK region. Method Patients with a malignant polyp were identified using the NORCCAG (NORthern Colorectal Cancer Audit Group) database between April 2006 and July 2010. All histopathology reports and follow-up procedures were reviewed. Results Of 386 patients identified, 165 (42.7%) had the polyp biopsied and 221 (57.3%) had an endoscopic local excision (37 piecemeal excision, 184 polypectomy). All patients having an endoscopic biopsy underwent surgery. 103 (46.6%) having a local excision had follow-up surgery, of whom 79 (76.7%) had no residual cancer. Of the 118 patients managed endoscopically, none had residual cancer on follow-up endoscopy. The 21 (5.4%) Dukes C cancers were associated with Kikuchi SM3/Haggitt 4 lesions (χ2 = 10.85, P = 0.005) and lesions with an involved/unsure excision margin (χ2 = 7.44, P = 0.017). Predictors of finding residual tumour at surgery after local excision were Kikuchi SM3/Haggitt Level 4 (χ2 = 17.07, P < 0.001) and an involved/unsure excision margin (χ2 = 20.45, P < 0.001). An excision margin > 0 mm was associated with the finding of no residual tumour (χ2 = 25.21, P < 0.001). There was no difference in survival between surgical and endoscopic management (χ2 = 0.634, P = 0.426) after a mean follow-up of 25.1 months. Conclusion Endoscopic management of a subgroup of MCPs appears safe. A clear resection margin (> 0 mm) appears sufficient to avoid surgery, except in locally advanced lesions (Kikuchi 3/Haggitt 4) which have a greater risk of residual cancer at surgery and lymph node metastasis. [ABSTRACT FROM AUTHOR]

Aim The changes in the management and outcome of rectal cancer in Oxford were studied over a 10-year period. Method Rectal cancer data using a prospectively collected data base were divided into curative (global) and palliative groups. The global curative group was further divided into those with and without (selected group) the following features: emergency cases, local excision, salvage surgery for recurrence or incomplete local excision, metastatic disease, perioperative death, hereditary cancer, inflammatory bowel disease-related cancer, and synchronous cancer. Results Between 1994 and 2003, 709 cases of rectal cancer were treated, 532 for cure and a selected group of 393 after removing patients with the aforementioned exclusions. For the selected group, the average follow-up was 51.2 months, overall survival 65.4% and cancer-specific survival 75.3%. There was no 2-year survival difference between each of the 10-year periods of study. Two-year local recurrence was 5.6% for the first 5-year period and 2.3% for the second ( P = 0.11). MRI staging increased during the 10 years (0% in 1994; 66.7% in 2003) as did use of definitive chemoradiotherapy (dCRT) (0% in 1994; 64.7% in 2003). The anastomotic leakage rate was significantly higher in the second 5-year period (2.6% vs 9.6%; P = 0.01). Conclusion Despite increasing use of MRI and dCRT, 2-year survival and local recurrence were not significantly different within the 10 years studied. [ABSTRACT FROM AUTHOR]

The article focuses on a study on the treatment of children with first branchial cleft anomalies, conducted at the Paediatric Otolaryngology Department at Great Ormond Street Hospital in London, England. It discusses the method of the examination performed for the patients as well as highlights the cause of such defect. It provides details on the surgical operation performed for the patients, treated by surgical excision through superficial parotidectomy with facial nerve identification.

Abdominoperineal resection (APR) has been shown to have poor outcomes compared with anterior resection (AR) in the treatment of rectal cancer. We compared APR outcomes with those for low AR. Lower third rectal cancers treated at the John Radcliffe Hospital with APR and low AR were examined using a prospectively collected database augmented with review of patient records. For all cases (APR and low AR), a range of patient, cancer and outcome data were collected. A selected group was created on the basis of exclusions. Outcomes for the global and selected APR and low AR groups were compared using the Kaplan-Meier method. CRM+ve and CRM−ve APR cases were compared. Between 1994 and 2003, 70 APR and 93 low AR were performed. After exclusions, 42 APR and 81 low AR remained. Median follow-up was 4.8 years. Five year survival for the APR group was significantly worse than for the low AR group. The APR group showed significantly fewer T0 cancers and significantly more T3 cancers. CRM R1 involvement was significantly higher for the APR group. The CRM+ve APR group contained significantly more later stage cancers, more defective resection specimens, more abscesses and fistulas and was associated with more local recurrence. These data showed that APR led to worse results than low AR in terms of overall survival and circumferential margin involvement, but that the cancers treated with APR tended to be more locally advanced. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Phadnis S, Atilade A, Young M, Evans H, Walker P. The volume perspective: a comparison of two excisional treatments for cervical intraepithelial neoplasia (laser versus LLETZ). BJOG 2010;117:615–619. Objective To compare two excisional treatments, laser cone biopsy and large loop excision of the transformation zone (LLETZ), in terms of the volume of tissue removed, and to determine the relation between the height and the total volume of the cone specimen. Design Retrospective cross-sectional study. Setting Large teaching hospital in London. Population A total of 1136 eligible excisional treatments (laser cone or large loop excision of the transformation zone, LLETZ). Methods Eligible excisional treatments (laser cone or LLETZ) performed between 1 January 2002 and 31 December 2007 in our colposcopy unit were identified using the Infoflex® database. The total volume of the cone biopsy was calculated mathematically using the data provided in the histopathology reports. Main outcome measures The volume of the cone biopsy was compared with the technique of excision and the histology grades. Results Three hundred and thirty-nine laser cone biopsies were performed, whereas 797 LLETZ biopsies were recorded, during the study period. There was no difference in the mean age in the two groups. However, there is a proportional increase in the volume of the cone as the height of the cone increases, and a significant number of the values are skewed, suggesting that the diameter of the base of the cone contributes significantly to the total volume. Laser cone biopsies (median volume 1.84 cm3, 95% CI 1.98–2.54 cm3) account for a larger volume of tissue excised compared with LLETZ (median volume 0.78 cm3, 95% CI 0.91–1.02 cm3) ( P < 0.0001). This relationship is not altered when the two procedures are stratified for grade of lesion, i.e. excision for low-grade cervical intraepithelial neoplasia (CIN) (laser median volume 1.55 cm3, 95% CI 1.46–2.06; LLETZ median volume 0.62 cm3, 95% CI 0.73–0.88 cm3) ( P < 0.0001) or high-grade CIN (laser median volume 1.84 cm3, 95% CI 2.11–2.53 cm3; LLETZ median volume 0.82 cm3, 95% CI 0.94–1.07 cm3) ( P < 0.0001). Conclusions The volume of cervical tissue removed during laser conisation is significantly more than that removed with LLETZ. The indication of the cone biopsy does influence the volume of tissue removed. [ABSTRACT FROM AUTHOR]

Introduction Hartmann’s procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate. Method Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann’s procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann’s. Results Approximately 3950 Hartmann’s procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann’s were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann’s were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann’s procedure and reversal was 284.5 days (interquartile range 181–468.25). Conclusion This study represents the single largest cohort in whom outcome after Hartmann’s procedure has been studied. A majority of Hartmann’s are performed as an emergency for benign diseases and most of them are not reversed. [ABSTRACT FROM AUTHOR]

Summary: We have reviewed all the cases of flap reconstruction following resection of a gynaecological malignancy at the Royal Marsden Hospital over 12 years from 1993 until 2005. Forty-six patients were identified who required 53 flaps. The predominant site of the primary tumour was vulva, accounting for 83% of the cases, with cervix, ovary, vagina and endometrium making up the remainder. Squamous cell carcinoma was the most common histological type, accounting for 71% of cases, with adenocarcinoma, Paget disease, leiomyosarcoma, melanoma and basosquamous carcinoma making up the remainder. Most patients (73%) had recurrent disease at the time of reconstruction and most patients (80%) had been treated with radiotherapy either before and/or after surgery. Local flaps accounted for 49% of the reconstructions performed, with 16 rhomboid flaps, five lotus petal flaps and five advancement flaps. Of the pedicled myocutaneous flaps, there were 21 rectus abdominis flaps, four gracilis flaps and one tensor fascia lata flap. There was one free flap. The complication rate was 53%, with wound breakdown predominating. The 5 year survival was 14%, with 67% of patients surviving 1 year. This group of patients often have advanced disease and a limited life span. The complications associated with performing a major reconstructive procedure need to be balanced against the potential wound problems associated with leaving these advanced tumours untreated surgically. [Copyright &y& Elsevier]

Objective: To determine the variation in the rates of use of abdominoperineal excision (APE) by cancer network, hospital trust and surgeon across England between 1998 and 2004 and determine if any variation could be explained by differences in patient characteristics such as stage of disease, age, gender or socioeconomic deprivation. Design: Retrospective study of a population-based dataset comprised of cancer registry and hospital episode statistics data. Setting: All NHS providers of rectal cancer surgery within England. Patients: 31 223 patients diagnosed with rectal cancer and receiving a major abdominal procedure within the NHS in England between 1998 and 2004. Main outcome measure: Rates and odds of use of APE were determined in relation to patient case-mix and each patient's managing surgeon, trust and cancer network. Results: The rate of use of APE decreased from 30.5% in 1998 to 23.0% in 2004. Males, the economically deprived and those managed by surgeons operating on fewer than seven rectal cancer cases per year were all significantly more likely to receive an APE. There were also significant variations in the odds of receiving an APE over time and between individual surgeons and hospital trusts inde- pendently of patient case-mix. Conclusions: Over the study period the use of APE decreased but statistically significant variation was observed in its application independently of case mix. Reducing this variation will remove inequalities, reduce colostomy rates, and improve outcomes in rectal cancer. Rates of APE use could be a national performance measure. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic appendicectomy is increasingly used in children. This national retrospective study compared outcomes of paediatric open and laparoscopic appendicectomy.Methods: Length of stay, readmission rates and mortality in children undergoing open and laparoscopic appendicectomy in English NHS Trusts between 1 April 1996 and 31 March 2006 were compared. Procedures coded as emergency excision of appendix (OPCS-4 H01) on the Hospital Episode Statistics (HES) database in patients less than 15 years of age were included. Multivariate analysis was used to identify independent predictors of length of hospital stay and mortality.Results: Eighty-nine thousand, four-hundred and ninety-seven (89,497) appendicectomies were studied; of which, 2,689 (3%) were performed laparoscopically. The percentage of laparoscopic cases rose from 0.6 to 8.4% between 1996 and 2006 (Pearson's r = 0.954, P < 0.001). Length of stay (median 3, interquartile range 2 days, P = 0.068) and 28-day readmission rates were similar (6.3 vs. 7.2%, respectively; P = 0.072) between groups. No independent hospital stay advantage for laparoscopy was observed (P = 0.121). No difference in 30-day mortality (P = 0.986) or 365-day mortality (P = 0.598) was demonstrated.Conclusion: Hospital stay, readmission rates and mortality are similar following laparoscopic and open appendicectomy in children. [ABSTRACT FROM AUTHOR]

This is a study to detect the correlation between laparoscopic diagnosis of endometriosis and histological findings. It is a retrospective study of 63 patients undergoing laparoscopy for pelvic pain at the University Hospital of North Durham, of whom 48 had excision of endometriosis. Scissors and graspers were used to dissect suspected endometriotic lesions laparoscopically. The tissues obtained were examined at the histology department to confirm the diagnosis. Positive histology for endometriosis was confirmed in 75% of cases, the histology was negative in 18.7% and in 6.3% was non-diagnostic. The study confirmed that correlation between laparoscopic findings and positive histology was dependant on the site of lesion and the stage of endometriosis. As more information was provided to the laboratory and as the pathologists became accustomed to looking for the disease, there was a higher detection of endometriosis. [ABSTRACT FROM AUTHOR]

Background: Non-anatomical liver resections have become more common in the management of colorectal liver metastases. This study examined survival and patterns of recurrence following surgery for colorectal liver metastases. Methods: Data were collected prospectively on all patents who had hepatic surgery for colorectal liver metastases at St James' University Hospital, Leeds between 1993 and May 2003, and analysed with respect to type of resection. Results: A total of 96 patients underwent non-anatomical liver resection, 280 patients had an anatomical resection, and 108 patients had a combined procedure. There was no significant difference in overall survival between the anatomical and non-anatomical groups (hazard ratio 1.14 (95 per cent confidence interval 0.60 to 2.17); P = 0.691). Intrahepatic recurrence was significantly less common in the anatomical group, whereas morbidity and mortality rates were lower in the non-anatomical group. On multivariable analysis, multiple metastases and poorer primary T stage predicted poorer overall survival and a positive resection margin predicted poorer disease-free survival. Conclusion: Non-anatomical resection can be performed with lower rates of surgical morbidity and mortality than anatomical resection, and does not disadvantage the patient in terms of overall survival. [ABSTRACT FROM AUTHOR]

Background: The 2001 UK National Health Service guidance on improving outcomes recommended centralization of oesophageal resection. The aim of this study was to analyse national trends in oesophageal resection in England to determine whether centralization has occurred and its impact on outcomes. Methods: The study used data from Hospital Episode Statistics for 1997-1998 to 2003-2004 and included patients who had resection for oesophageal cancer. The annual hospital volume was grouped into five categories based on the recommendation for annual volume for a designated centre. Results: A total of 11 838 oesophageal resections were performed. The total number of hospitals performing resections decreased, mainly owing to a fall in the number of very low-volume hospitals (117 in 1997 to 45 in 2003). The proportion of resections performed in very high-volume hospitals increased from 17.8 per cent during 1997-1999 to 21.9 per cent during 2002-2003 (P < 0-001). The overall in-hospital mortality rate was 10.1 per cent, with a significant reduction over time (from 11.7 to 7.6 per cent; P < 0.001). The decline in mortality rate may be due to increased numbers of patients undergoing surgery in higher-volume hospitals. There was an increase in the annual number of new patients from 5672 to 6230 during the study, although a fall in the proportion of resections from 31.5 to 26.0 per cent (P < 0.001). Conclusion: Centralization and multidisciplinary team expertise partly explain the improvement in mortality rate, but changes in preoperative selection also play a part. [ABSTRACT FROM AUTHOR]

The author reflects on the lack of clinical trials to test the effectiveness of surgical resection in lung cancer. According to a study in England, the proportion of patients undergoing lung cancer surgery has risen from 8.8 percent to 10.6 percent but overall survival for lung cancer remains poor. It also informs that randomised trials are the best method to prove conclusively the efficacy of the treatments.

Squamous cell carcinoma of the scrotum is a tumor that is of interest for clinical and historical reasons. It was the first cancer linked to occupational exposure when, in 1775, Perivall Pott described it in chimney sweeps in England. Other occupations that had a preponderance of the disease included people who worked with the distillates of coal and men exposed to mineral oil. Currently, the disease is very rare and most cases are thought to result from poor hygiene and chronic irritation. Surgery with a negative resection margin offers the best hope of cure as adjunctive therapy has not proved useful. Prognosis correlates with the extent of nodal involvement. [ABSTRACT FROM AUTHOR]

B Introduction: b Resection of the primary tumour in women with metastatic breast cancer is normally reserved for select patients for symptomatic relief. B Results: b 6550 women were diagnosed between January 2014 and December 2017 with metastatic disease (n=2683 (41%) aged 50-69 years, n=3867 (59%) aged 70+ years), of which 1210 (18.5%) women received breast surgery (61.8% had a mastectomy and 38.2% breast conserving surgery). B Conclusion: b In England and Wales, around 1 in 6 women with metastatic breast cancer have breast surgery within 3-years of diagnosis. [Extracted from the article]

We provide a non-melanoma skin cancer (NMSC) service for skin cancers of the head and neck in the south-west of England. We hypothesised that certain anatomical sites such as the nose and eyelid would have a higher incidence of close or involved margins than others, and that the choice of repair might influence the excised margins. We therefore retrospectively analysed the data of 500 consecutive NMSC that were operated on in the oral and maxillofacial surgery unit of Taunton and Somerset NHS Trust. The database reports were crosschecked against the Trust's own pathology reporting system to ensure that they were accurate. Data collected included clinical and personal details of patients, anatomical sites, type of reconstruction, histopathological diagnosis, excision margins, and complications. Of the 500 patients reviewed 362 (72%) were basal cell carcinomas (BCC) and 138 (28%) squamous cell carcinomas (SCC). The outcomes of 243 patients treated by primary closure, 134 treated by reconstruction with local flaps, and 123 treated by skin grafts, were reviewed with particular attention paid to the anatomical site and excision margins. There was an overall incomplete excision rate of 10.8% (n=54) and 29 patients developed complications (5.8%). We confirmed that rates of close or incomplete margins are more likely in certain anatomical sites such as the nose, forehead, and ear. The rate of involved margins was unaffected by choice of surgical technique., (Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

The article focuses on the conclusion gained with the combined Hospital Episode Statistics (HES) and Cancer Registry data in England between 1998 and 2004. It notes that the variation in abdomino-perineal excision of rectum (APE) rates mandates direct and immediate intervention in rectal cancer surgery. However, a concern was raised concerning the naivety of the data's statement on the use of APE and anterior resection (AR) as clinical techniques.

Discusses a retrospective study of melanomas excised in general practice in northwest Hertfordshire, England. Female/male ratio of the patients; Mean time interval between first presentation and removal of the melanoma; Need for general practitioners performing routine minor surgery to receive additional training in the diagnosis of skin lesions.

The article reports on the two-week wait scheme for specialist consultation implemented at the Norfolk and Norwich University Hospital in England in September 2000. Doctors in one cancer unit state that better outcomes for upper gastrointestinal cancer can be credited more to the introduction of nurse endoscopists than the British government's two-week wait scheme. After the scheme was introduced, there was an increase in the curative resection in their unit in two years.

Discusses the abstract of the study "Mortality following oesophageal resection for malignancy in England 1997-2001," presented at the annual scientific meeting of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland on September 25-26, 2003.

Reports on an audit of malignant melanoma excision performed in the Mid and North Staffordshire Health Authorities in England. Specialties of the medical practitioner who performed the initial excision.