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Abstract Primary cutaneous leiomyosarcoma (LMS) is a rare soft tissue tumour type with two subtypes, dermal and subcutaneous. As deeper tumours confer a worse prognosis, they require a more aggressive approach. Conversely, a more conservative surgical approach for dermal LMS has been suggested. Few studies have comprehensively reported both clinical surgical and histological excision margins. Therefore, we sought to provide margin recommendations based on our experience and review of the existing literature. We undertook a retrospective case-note review (1998–2019) of cutaneous LMS management to establish histological/surgical margins using pathology/electronic patient records. The diagnosis was made and classified by an experienced dermatopathologist according to the World Health Organization classification. In the dermal LMS cohort (n = 35), mean peripheral and deep histological margins were 5.4 mm (range 0.5–20) and 5.6 mm (range 0.1–14.5), respectively. The incomplete excision rate was 31% (11 of 35). There were no recurrences. In the subcutaneous LMS cohort (n = 10), mean peripheral and deep histological margins were 5.7 mm (range 0.2–14) and 1.1 mm (range 0.2–1.7), respectively. The incomplete excision rate was 40% (4 of 10). The recurrence rate was 20% (2 of 10) despite achieving histological clearance after 1 year. One lung metastasis occurred 1 year following an adequately excised primary scalp LMS. Thus, for dermal LMS we propose a clinical margin of 5–10 mm (depending on lesion size) at the initial excision or at scar re-excision following involved/close histological peripheral and/or deep margins (i.e. < 1 mm). For subcutaneous LMS, we suggest a clinical margin of 15–20 mm (depending on lesion size) to achieve a peripheral histological clearance of 10 mm and negative deep margin (i.e. > 1 mm), down to the periosteum/fascia/muscle according to anatomical site. If this is not achieved, a re-excision would be recommended. However, prospective studies are needed for optimal guidance. We provide a review of the existing literature and give recommendations for the management of primary cutaneous and subcutaneous leiomyosarcomas based on our experience with the largest UK cohort of patients to our knowledge. [ABSTRACT FROM AUTHOR]

Background: Only 27 cases of equine conjunctival haemangiosarcoma have been reported in the literature over the past 37 years. Out of these, 22% of cases were lost to follow-up, 52% were euthanized, and 26% survived. A scarcity of cases and information is available for this rarely seen conjunctival tumour. Aim: To describe the clinical features, management, and outcome of conjunctival hemangiosarcoma in seven horses in the UK. Methods: Optivet medical records were reviewed for equine cases seen or advised on with a histopathological diagnosis of conjunctival haemangiosarcoma between January 2013 and March 2023. Medical records were accessed for details of signalment, history, management, and follow-up. Histopathology was used to confirm the diagnosis of haemangiosarcoma and assess the surgical margins. Immunohistochemistry was performed in a minority of cases with poorly differentiated solid tumours to support vascular lineage. Results: Seven eyes from seven horses (five geldings and two mares) with a mean age of 16 years and median of 18 years (range 10-21 years) met the criteria. Serosanguinous discharge was seen in six eyes. All eyes were managed surgically; 4 by exenteration and 3 by conjunctivectomy/keratectomy. Adjunctive cryotherapy was performed in two eyes. Metastatic disease in the ipsilateral parotid salivary gland, confirmed with histopathology, was seen in one horse. Surgical margins were clear in all but one eye. Solar elastosis was noted in five eyes. All horses were healthy at the last follow-up (0.2-5 years, mean 2.9 years, and median 2 years). Conclusion: Equine conjunctival haemangiosarcoma is rare. Serosanguinous ocular discharge is a common clinical sign. Early surgical excision is highly effective. Solar elastosis is a common histopathological feature, suggesting a role for UV-light in the pathogenesis. [ABSTRACT FROM AUTHOR]

Background: Endometriosis affects 190 million women and those assigned female at birth worldwide. For some, it is associated with debilitating chronic pelvic pain. Diagnosis of endometriosis is often achieved through diagnostic laparoscopy. However, when isolated superficial peritoneal endometriosis (SPE), the most common endometriosis subtype, is identified during laparoscopy, limited evidence exists to support the common decision to surgically remove it via excision or ablation. Improved understanding of the impact of surgical removal of isolated SPE for the management of chronic pelvic pain in women is required. Here, we describe our protocol for a multi-centre trial to determine the effectiveness of surgical removal of isolated SPE for the management of endometriosis-associated pain. Methods: We plan to undertake a multi-centre participant-blind parallel-group randomised controlled clinical and cost-effectiveness trial with internal pilot. We plan to randomise 400 participants from up to 70 National Health Service Hospitals in the UK. Participants with chronic pelvic pain awaiting diagnostic laparoscopy for suspected endometriosis will be consented by the clinical research team. If isolated SPE is identified at laparoscopy, and deep or ovarian endometriosis is not seen, participants will be randomised intraoperatively (1:1) to surgical removal (by excision or ablation or both, according to surgeons' preference) versus diagnostic laparoscopy alone. Randomisation with block-stratification will be used. Participants will be given a diagnosis but will not be informed of the procedure they received until 12 months post-randomisation, unless required. Post-operative medical treatment will be according to participants' preference. Participants will be asked to complete validated pain and quality of life questionnaires at 3, 6 and 12 months after randomisation. Our primary outcome is the pain domain of the Endometriosis Health Profile-30 (EHP-30), via a between randomised group comparison of adjusted means at 12 months. Assuming a standard deviation of 22 points around the pain score, 90% power, 5% significance and 20% missing data, 400 participants are required to be randomised to detect an 8-point pain score difference. Discussion: This trial aims to provide high quality evidence of the clinical and cost-effectiveness of surgical removal of isolated SPE. Trial registration: ISRCTN registry ISRCTN27244948. Registered 6 April 2021. [ABSTRACT FROM AUTHOR]

Background: Over 30% of breast cancers in the UK are diagnosed in elderly women (age ≥ 70). Women in this age group are less likely to undergo primary surgery for breast cancer, and those who are treated with surgery are more likely to receive a mastectomy. Compared to simple wide local excision, oncoplastic breast surgery (OBS) can reduce re-operation rates, including in larger cancers, and yet maintain/improve breast aesthetics. Despite these advantages, older women are largely underrepresented in the available literature. Methods: To explore the utility of OBS in women aged ≥ 70 years in a well-established surgical practice, a retrospective review of patients undergoing breast-conserving surgery was performed. Tumour characteristics, operative variables and adjuvant treatment details of elderly patients were compared with the younger cohort. Results: A total of 325 patients underwent breast-conserving surgery during the study period including 60 who underwent OBS (22.64%). In fit/operable elderly women, despite greater cancer size, OBS was minimal (n = 1/52, 1.96%), likely due to multi-factorial reasons such as the multidisciplinary team's subconscious age bias or assumptions against qualitatively escalated surgery. In contrast, more patients (n = 6/52, 11.76%) were deemed fit for cytotoxic chemotherapy. Conclusions: Whilst OBS-related benefits certainly should be weighed against the increased risks of a longer operative time and recovery, balanced considerations should be made when considering the escalation of systemic adjuvant treatments and related side-effects vis-à-vis de-escalation of surgery and relation to physical and psychological considerations. Level of Evidence: Level IV, Risk / Prognostic Study. [ABSTRACT FROM AUTHOR]

Objective: Breast cancer is the most commonly diagnosed malignancy and the second leading cause of cancer-related deaths in women. It is estimated that one in 11 women in developed societies, one in nine women in the UK, and one in eight women in the USA experience breast cancer at some point in their lives. Early diagnosis of breast cancer reduces mortality and morbidity. According that, in this retrospective study, the superiority of the radio-guided occult lesion localization (ROLL) method and the wire-guided localization(WGL) method to one another was investigated considering the data including lesion size, duration of surgical excision, surgical margin, and the need for re-resection in non-palpable lesions suspected of malignancy. Methods: The study included 79 female patients who had non-palpable breast lesions and suspicious findings for malignancy on mammography and breast ultrasonography. The marking was made on the operation day at the radiology clinic for all patients. All surgeries were performed under general anesthesia. All surgical operations were performed by the same surgeon, all markings were made by the same radiologist, and the material was prepared for ROLL by the same nuclear medicine clinic. Results: The specimen volume was 36.2±19.6 cc in the ROLL group and 40.8±22.8 cc in the WGL group (p=0.34). The duration of surgical excision was 13.2±4.2 min in the ROLL group and 18.2±6.7 min in the WGL group (p<0.001). The closest distance to the lesion was 4.5±3.0 mm in the ROLL group and 4.0±3.1 mm in the WGL group (p=0.52). Eight patients in the ROLL group and 14 patients in the WGL group required re-resection (p=0.07). No significant difference was found between the groups except for the duration of surgical excision. Conclusion: In the ROLL method, the duration of the operation significantly shortens compared to WGL, and the re-resection rate is lower. [ABSTRACT FROM AUTHOR]

Background: Nonmelanoma skin cancers (NMSC) have an incidence of 152,000 cases per year in the United Kingdom (UK), which continues to rise. Incomplete excision rates for NMSC are estimated to be around 10 percent and result in patients having a higher risk of recurrence or having to undergo further treatment.Objective: The objective of our study was to determine whether the use of dermoscopy as an adjunct to clinical examination could improve the rates of incomplete excision in NMSC lesions.Methods: Electronic literature search of MEDLINE, EMBASE, and Cochrane Central databases plus manual reference checks of articles on dermoscopy use in surgery between inception and November 2020. Two levels of screening were used on 452 studies. A random effects model was used in the meta-analysis, with the DerSimonian-Laird method used to pool data.Results: A total of six fully extracted studies were included with a total of 592 patients; with five of these studies reported on basal cell carcinomas and one reported on squamous cell carcinomas. The odds ratio of incomplete excision when guided by dermoscopy was 0.29 (95%CI 0.25; 0.34). Heterogeneity was assessed with the I2 statistic and was found to be 0 percent.Limitations: The number of studies included was small, with three of the studies from the same authors. Studies included are nonrandomized and as such hold a significant risk of bias.Conclusion: Incomplete excision rates were reduced when using dermoscopy to mark surgical excision margins in comparison to naked eye evaluation alone. [ABSTRACT FROM AUTHOR]

Malignant soft tissue tumors of the foot and ankle are rare but diagnostic imaging and/or interventional biopsy are vital to establish the nature and grading of a suspicious tumor prior to definitive surgical intervention. The purpose of the study is to provide an account on how a symptomatic mass of the plantar aspect of the foot warranted a referral to a sarcoma center, highlighting the importance of having access to diagnostic imaging and a pathway to refer suspected cases to specialist centers. A single patient with a symptomatic soft tissue tumor of the plantar foot was referred from our service to the regional sarcoma center who considered to be benign, and therefore, open surgical resection was performed by our team. Histopathological analysis identified the excised mass as a lipoma. At 2 years, postoperatively there was no recurrence, and the patient presented with an asymptomatic foot. United Kingdom (UK) guidelines suggest that all soft tissue masses of suspicious nature, greater than 50 mm, deep seated irrespective of size, or fast growing lesions should be referred to a sarcoma unit prior to surgical management. European guidance identifies a threshold of 15 mm for a mass in the foot. Patients presenting with red flag symptoms irrespective of size of mass should be referred to a sarcoma center. Advanced imaging and multidisciplinary input to enable appropriate surgical planning is recommended for suspicious soft tissue tumors that present to the foot and ankle surgeon. [ABSTRACT FROM AUTHOR]

Non-melanoma skin cancer (NMSC) is the most common type of cancer in the UK and Ireland, accounting for approximately 20% of all new malignancies recorded, with evidence of increasing incidence. Surgical excision is regarded as the gold standard treatment for such lesions; however, incomplete excision incurs both physical and financial strain on patients and the healthcare service. Our aim is to identify which anatomical regions of the head and neck pose greater risk of incomplete excision and raise awareness for future surgical practice. Manual data collection was carried out on all patients admitted to the OMFS department for surgical excision of NMSCs between January 2016 and December 2017. Information collected included clinical notes and MDT outcomes. NMSCs excised via Mohs surgery. All tumours incompletely excised and requiring further treatment were noted with particular emphasis on the site of the lesion within the head and neck region, and the location of the positive margin on the specimen itself. A total of 506 NMSCs were excised (307 BCC, 199 SCC). Of these, 7.8% (n=24) and 6.0% (n=12), respectively, required further treatment due to incomplete excision. The incompletely exised lesions were predominately located on the nose (13.3%), temple (15.0%), and ear (12.8%). Our results demonstrate that our department is successfully excising NMSCs with minimal cases requiring further management. This study has identified anatomical profiles posing a higher risk of incomplete removal. Alongside the conventionally challenging sites of the nose and ear, we have highlighted additional risk within the temporal region. We therefore propose that Mohs surgery or a two-stage procedure should be considered as management for the temple at future MDTs. [ABSTRACT FROM AUTHOR]

• Minimising harms is critical in lung cancer screening implementation. • We report cumulative real-world lung cancer screening data from the UK. • Reported harms, including false positive and benign resection rates, are low. • Outcomes are comparable to, and in some aspects superior to, published RCTs. Low-dose CT (LDCT) screening reduces lung cancer specific mortality. Several countries, including the UK, are evaluating the clinical impact and cost-effectiveness of LDCT screening using the latest evidence. In this paper we report baseline screening performance from five UK-based lung cancer screening programmes. Data was collected at baseline from each screening programme. Measures of performance included prevalence of screen detected lung cancer, rate of surveillance imaging for indeterminate findings and surgical resection rates. Screening related harms were assessed by measuring false positive rates, number of invasive tests with associated complications in individuals without lung cancer and benign surgical resection rates. A total of 11,148 individuals had a baseline LDCT scan during the period of analysis (2011 to 2020). Overall, 84.7% (n = 9,440) of baseline LDCT scans were categorised as negative, 11.1% (n = 1,239) as indeterminate and 4.2% (n = 469) as positive. The prevalence of screen detected lung cancer was 2.2%, ranging between 1.8% and 4.4% for individual programmes. The surgical resection rate was 66% (range 46% to 83%) and post-surgical 90-day mortality for those with lung cancer 1.2% (n = 2/165). The false positive rate was 2% (n = 219/10,898) and of those with a positive result, one in two had lung cancer diagnosed (53.3%). An invasive test was required in 0.6% (n = 61/10,898) of screening attendees without lung cancer; there were no associated major complications or deaths. The benign surgical resection rate was 4.6% (n = 8/173), equating to 0.07% of the screened population. The performance of UK-based lung cancer screening programmes, delivered within or aligned to the National Health Service, compares favourably to published clinical trial data. Reported harms, including false positive and benign surgical resection rates are low. Ongoing monitoring of screening performance is vital to ensure standards are maintained and harms minimised. [ABSTRACT FROM AUTHOR]

Introduction: The British Thyroid Association (BTA) recommends ultrasound assessment of thyroid nodules using the U classification. The American College of Radiologists (ACR) recommend assessment with the Thyroid Imaging Reporting and Data System (TIRADS). We conduct the first UK study to compare these two systems. Methods: Ultrasound (US) reports of patients who underwent surgical excision of thyroid nodules over a 10‐year period in one UK centre were reviewed. US findings were collected, and the classifications were retrospectively applied. The systems were compared to histopathological diagnosis. Results: 308 nodules in 296 patients are included. 135 nodules (43.8%) were malignant. U classification showed sensitivity of 88.1% in recommending FNA, significantly higher than TIRADS at 73.3% (p =.0002). The U classification showed specificity of 41.6%, significantly lower than TIRADS at 64.2% (p=<0.0001). PPV between classifications at equivalent levels showed no significant difference at U3/TR‐3 (p=.81), U4/TR‐4 (p=.30) or U5/TR‐5 (p=.90). Discussion: Classification systems enable risk stratification of potentially malignant thyroid nodules. This study shows BTA U classification has a higher sensitivity but lower specificity than TIRADS. [ABSTRACT FROM AUTHOR]

The insular cortex is an eloquent island of mesocortex surrounded by vital structures making this region relatively challenging to neurosurgeons. Historically, lesions in this region were considered too high risk to approach given the strong chance of poor surgical outcome. Advances in recent decades have meant that surgeons can more safely access this eloquent region. Seizure outcome after excision of insular low-grade gliomas is well reported, but little is known about seizure outcomes after excision of insular high-grade gliomas. A retrospective analysis was performed of all patients presenting with new-onset seizures during 2015–2019 who underwent excision of an insular high-grade glioma at 3 regional neurosurgical centers in the United Kingdom. We identified 38 patients with a mean (SD) age of 45.7 (15.3) years with median follow-up of 21 months. At long-term follow-up, of 38 patients, 23 were seizure-free (Engel class I), 2 had improved seizures (Engel class II), 6 had poor seizure control (Engel class III/IV), and 7 died. Excision of insular high-grade gliomas is safe and results in excellent postoperative seizure control. [ABSTRACT FROM AUTHOR]

Reconstructive options in nonmelanomatous skin tumors of the head and neck region are limited in the frail, elderly patient group, where split skin thickness or full thickness grafts may not be a viable option. This study examines the use decellularized cadaveric dermis (DCELL), an acellular dermis product produced in the United Kingdom for the reconstruction of these skin defects. This was a single-center, prospective study of patients undergoing single stage wide local excision of nonmelanomatous skin cancer and reconstruction with decellularized dermis. Our inclusion criteria included any patient that required a curative excision but had risk factors where conventional local flap or free tissue transfer could have a potential adverse outcome. Thirty-seven wounds were treated with DCELL in 31 patients. Mean age was 81.6 years (range 61–94 years) and at the time of operation, 25 patients (80.7%) were ASA 3 or above. The scalp was the most common anatomical area operated on ( n  = 28, 75.7%). The overall proportion of wounds with complete closure was 89.2% (33 out of 37 wounds), with a failure rate of 10.8% (four complete graft failures). Device-related complications included one episode of crusting over the graft which resolved with topical antibiotics, and a hypertrophic scar over the wound edges. Cosmesis was satisfactory in all cases. DCELL demonstrated a very good take rate with equally satisfactory cosmetic outcomes in patients where standard reconstructive approaches may have adverse outcomes. Further research is needed to better define its role in the management of these skin cancers. [ABSTRACT FROM AUTHOR]

Purpose: Currently there are no specific guidelines for the post-operative follow-up of chromophobe renal cell carcinoma (chRCC). We aimed to evaluate the pattern, location and timing of recurrence after surgery for non-metastatic chRCC and establish predictors of recurrence and cancer-specific death. Methods: Retrospective analysis of consecutive surgically treated non-metastatic chRCC cases from the Royal Free London NHS Foundation Trust (UK, 2015–2019) and the international collaborative database RECUR (15 institutes, 2006–2011). Kaplan–Meier curves were plotted. The association between variables of interest and outcomes were analysed using univariate and multivariate Cox proportional hazards regression models with shared frailty for data source. Results: 295 patients were identified. Median follow-up was 58 months. The five and ten-year recurrence-free survival rates were 94.3% and 89.2%. Seventeen patients (5.7%) developed recurrent disease, 13 (76.5%) with distant metastases. 54% of metastatic disease diagnoses involved a single organ, most commonly the bone. Early recurrence (< 24 months) was observed in 8 cases, all staged ≥ pT2b. 30 deaths occurred, of which 11 were attributed to chRCC. Sarcomatoid differentiation was rare (n = 4) but associated with recurrence and cancer-specific death on univariate analysis. On multivariate analysis, UICC/AJCC T-stage ≥ pT2b, presence of coagulative necrosis, and positive surgical margins were predictors of recurrence and cancer-specific death. Conclusion: Recurrence and death after surgically resected chRCC are rare. For completely excised lesions ≤ pT2a without coagulative necrosis or sarcomatoid features, prognosis is excellent. These patients should be reassured and follow-up intensity curtailed. [ABSTRACT FROM AUTHOR]

Purpose: Attitudes to surgery for paediatric thalamic tumours have evolved due to improved preoperative imaging modalities and the advent of intraoperative MRI (iMRI) as well as enhanced understanding of tumour biology. We review the developments in our local practice over the last three decades with particular attention to the impact of iMRI. Methods: We identified all paediatric patients from a prospectively maintained neuro-oncology database who received surgery for a thalamic tumour (n = 30). All children were treated in a single UK tertiary paediatric neurosurgery centre between January 1991 and June 2020. Twenty patients underwent surgical resection, the remainder (10) undergoing biopsy only. Pre-operative surgical intent (biopsy versus debulking, near-total resection, or complete resection) as well as the use of iMRI were prospectively recorded. Complications recorded in clinical documentation between postoperative days 0 and 30 were retrospectively graded using a modified version of the Clavien Dindo scale. The extent of resection with respect to the pre-determined surgical aim was also recorded. Data on patient survival and disease progression status were obtained retrospectively. Results: In our series, there were 42 procedures (25 craniotomies, 17 biopsies) performed on 30 patients (17 male, with a median age of 8 at surgery). Of the 25 surgical resections performed, complete resection was achieved in 9 (36%), near-total resection in 10 (40%), and limited debulking in 6 (24%). The predetermined surgical aim was achieved or exceeded in 91.3% of cases. The proportion of craniotomies for which substantial resection was achieved, increased from 37.5 to 94.2% with use of iMRI (p = 0.014). Surgical morbidity was not associated with greater extent of surgical resection. High-grade histology is identified as the only independent significant factor influencing overall survival as calculated by Cox proportional hazards model (p = 0.006). Conclusion: We note a significant change in the rate and extent of attempted resection of paediatric thalamic tumours that has developed over the last 3 decades. Use of iMRI is associated with a significant increase in substantial tumour resection surgeries. This is not associated with any significant level of surgical morbidity. Improvements in pre- and intra-operative imaging alongside better understanding of tumour biology facilitate patient selection and a surgically more aggressive approach in selected cases whilst maintaining safety and avoiding operative morbidity. [ABSTRACT FROM AUTHOR]

Summary: Scirrhous cord (SC) is an uncommon complication of castration, characterised by chronic infection of the spermatic cord remnant. It is reported that surgical excision of the infected tissue is the most effective means of treatment, but there are few published studies assessing the outcomes of horses treated for SC. The aims of this retrospective study were to describe the clinical features and short‐term outcomes in horses treated for SC at two equine hospitals in the UK. The clinical records of horses diagnosed with SC over a 10‐year period were reviewed. A diagnosis of SC was made if the gelding presented with typical clinical signs with confirmation at surgery. Thirty‐two cases of SC were identified at the two equine hospitals. The mean age at presentation was 6 years (range 2–14 years, n = 22), and the median time from castration to presentation was 29.5 days (range 20–2500 days). Mean age at castration was 4.3 years (range 6 months to 10 years, n = 10). Clinical signs included scrotal swelling, discharging wounds, hindlimb lameness and pyrexia. Five horses demonstrated hyperfibrinogenaemia (n = 8). Microbial culture isolated various bacterial species. All 32 cases were treated with surgical excision of the infected tissue and discharged from the hospitals between 1 and 10 days post‐operatively. A limitation of this study is that it was a retrospective study with no long‐term follow‐up available. It was concluded that the results of this study confirm that SC can present at variable time points following castration, even many years later, and that a variety of bacterial species may be involved. Surgical excision of infected tissue is a successful treatment with a good short‐term prognosis for survival. [ABSTRACT FROM AUTHOR]

Background: The role of adjuvant therapy in patients with oesophagogastric adenocarcinoma treated by neoadjuvant chemotherapy is contentious. In UK practice, surgical resection margin status is often used to classify patients for receiving adjuvant treatment. The aim of this study was to assess the survival benefit of adjuvant therapy in patients with positive (R1) resection margins. Methods: Two prospectively collected UK institutional databases were combined to identify eligible patients. Adjusted Cox regression analyses were used to compare overall and recurrence‐free survival according to adjuvant treatment. Recurrence patterns were assessed as a secondary outcome. Propensity score‐matched analysis was also performed. Results: Of 616 patients included in the combined database, 242 patients who had an R1 resection were included in the study. Of these, 112 patients (46·3 per cent) received adjuvant chemoradiotherapy, 46 (19·0 per cent) were treated with adjuvant chemotherapy and 84 (34·7 per cent) had no adjuvant treatment. In adjusted analysis, adjuvant chemoradiotherapy improved recurrence‐free survival (hazard ratio (HR) 0·59, 95 per cent c.i. 0·38 to 0·94; P = 0·026), with a benefit in terms of both local (HR 0·48, 0·24 to 0·99; P = 0·047) and systemic (HR 0·56, 0·33 to 0·94; P = 0·027) recurrence. In analyses stratified by tumour response to neoadjuvant chemotherapy, non‐responders (Mandard tumour regression grade 4–5) treated with adjuvant chemoradiotherapy had an overall survival benefit (HR 0·61, 0·38 to 0·97; P = 0·037). In propensity score‐matched analysis, an overall survival benefit (HR 0·62, 0·39 to 0·98; P = 0·042) and recurrence‐free survival benefit (HR 0·51, 0·30 to 0·87; P = 0·004) were observed for adjuvant chemoradiotherapy versus no adjuvant treatment. Conclusion: Adjuvant therapy may improve overall survival and recurrence‐free survival after margin‐positive resection. This pattern seems most pronounced with adjuvant chemoradiotherapy in non‐responders to neoadjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Aim: To report the outcome of 150 patients using the Hologic LOCalizer RFID (radiofrequency identification) tag system, including the first reported use of RFID tags in the axilla.Materials and Methods: Data were collected prospectively from the first tag insertion (12 June 2019) until 150 consecutive patients had undergone surgery (excision date 9 January 2020).Results: A total of 177 tags were targeted to 177 malignant lesions in 150 women. Tags were inserted an average of 7.8 days before surgery (range 0-71 days). One hundred and twenty-six tags were targeted to a single lesion in one breast only; the remainder of tags were targeted to multiple lesions in one or both breasts, as well as to axillary lymph nodes. In addition, two cases involved the use of two tags to bracket microcalcification. All except three tags were satisfactorily deployed at their initial intended target. The majority of target lesions were masses (n=142, mean size 13.8 mm), with a range of other targets including post-vacuum-assisted biopsy cavities, marker clips post-neoadjuvant chemotherapy, architectural distortions, and clipped metastatic lymph nodes. All tags were successfully retrieved at surgical excision. Re-excision rate was 8.7%. There were no tag-specific surgical complications.Conclusions: The RFID tag system demonstrates many advantages over guidewires, and is effective at targeting axillary lymph nodes and multiple sites within the same breast. [ABSTRACT FROM AUTHOR]

Aim: A 'watch and wait' (W&W) strategy after neoadjuvant long‐course chemoradiotherapy (NACRT) remains controversial. Whilst encouraging short‐term data exist, the strategy will be judged on long‐term data. We present long‐term, real‐world UK data from a single National Health Service trust. Methods: An analysis was performed of a prospectively maintained W&W database over 9 years between 2010 and 2018. Outcome measures include incidence and time to regrowth and overall and disease‐free survival. Results: We diagnosed 563 rectal cancers in 9 years. In all, 283 patients underwent rectal resection (50.3%). NACRT was used in 155 patients for margin‐threatened tumours on staging MRI. Forty‐nine patients (31.6%) experienced either a 'near complete' or a complete clinical response (cCR) at their 10 weeks post‐NACRT assessment (MRI and endoscopy). The median age was 69 years (range 44–83), and the male to female ratio was 32:17. The median follow‐up was 38 months (range 12–96). The median tumour distance from the anal verge was 7 cm (1–15 cm). Twenty‐two patients had a cCR on initial assessment and 27 patients had a 'near' cCR. Of those 27 who experienced a 'near' cCR, 17 (63%) progressed to cCR on repeat assessment and 10 (37%) did not. Of these 10 patients, seven underwent standard surgical resection and three were unfit for surgery. R0 for the seven with delayed resection was 100%. Of 39 patients (22 cCR and 17 'near' cCR who progressed to cCR) (25.2% of those receiving NACRT), six patients experienced local regrowth (15.4%). The median time to local regrowth was 29 months (15–60 months). One of these six patients underwent salvage abdominoperineal resection, one was advised to have contact radiotherapy and four opted against surgery and also had contact radiotherapy. The overall survival was 100% at 2 years and 90% at 5 years. Disease‐free survival was 90.47% at 2 years and 74.8% at 5 years. Conclusion: A W&W treatment strategy was employed safely in this patient cohort with acceptable rates of local regrowth and survival. [ABSTRACT FROM AUTHOR]

Aim: The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. Methodology: This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. Results: There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5‐year overall survival (69.2% vs 80.1%, P = 0.16) or 5‐year disease‐free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. Conclusions: This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery. [ABSTRACT FROM AUTHOR]

Background. The incidence of melanoma in situ (MIS) is increasing faster compared to invasive melanoma. Despite varying international practice, a minimum of 5 mm surgical excision margin is currently recommended in the UK. There is no clear guidance on the minimum histological peripheral clearance margins. Aim. This study compares the histological peripheral clearance margins of MIS using wide local excision (WLE) to the rate of recurrence and progression to invasive disease. Methods. A retrospective single-center review was performed over a 5-year period. Inclusion criteria consisted of MIS diagnosis, ≥16 years of age, and treatment with WLE with curative intent. Those patients with a recurrence of a previous MIS or with a reported focus of invasion/regression were also included. Clinicopathological data and follow-up were recorded. Results. 167 MIS were identified in 155 patients, 80% of which were lentigo maligna subtype. Of patients with completely excised MIS on histology (>0 mm), 9% had recurrence with a median time to recurrence of 36 months. Three (1.8%) cases recurred as invasive disease. Age, MIS site, MIS subtype, and histological evidence of foci of invasion/regression did not predict recurrence nor progression to invasive disease (p > 0.05). The recurrence rate of MIS with a histological excision margin ≤3.0 mm was 13% compared to 3% in those with histology margins of >3.0 mm (p = 0.049). Conclusion. A histological peripheral clearance of at least 3.0 mm is advocated to achieve lower recurrence rates. The follow-up duration should be reviewed due to the median recurrence occurring at 36 months in our cohort. Cumulative work on MIS needs to be collated and completed in a large multicenter study with a long follow-up period. [ABSTRACT FROM AUTHOR]

Skin cancer is one of the most common cancers in the world. Specifically incidence of non-melanoma malignancy in the UK has increased by 56% in the last decade. Cutaneous squamous cell carcinoma (cSCC) is a type of non-melanoma skin cancer that if caught early can be successfully treated. Conservative excision surgery is the most common treatment modality with high cure rates even if tumours are advanced. Radical surgery is rarely required, and amputations, especially when the distal part of the upper extremity is involved, are very uncommon. Here, we describe a case of an invasive cutaneous squamous cell carcinoma of the elbow that required trans-humeral arm amputation. [ABSTRACT FROM AUTHOR]

Background The COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center. Methods All patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated. Results Overall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P  = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications. Conclusion Care must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care. [ABSTRACT FROM AUTHOR]

Ano-uro-genital (AUG) mucosal melanomas are rare cancers associated with poor outcomes and limited evidence-based management. The United Kingdom AUG mucosal melanoma guideline development group used an evidence-based systematic approach to make recommendations regarding the diagnosis, treatment and surveillance of patients diagnosed with AUG mucosal melanomas. The guidelines were sent for international peer review, and are accredited by The National Institute for Health and Clinical Excellence (NICE). A summary of the key recommendations is presented. The full documents are available on the Melanoma Focus website. • Mucosal melanomas of ano-uro-genital structures are rare malignancies with poor prognoses. • Owing to their rarity, there is limited evidence in the literature to guide clinical decision making. • We provide a summary of the evidence and recommendations for the management of AUG melanoma. [ABSTRACT FROM AUTHOR]

Purpose: Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients.Methods: All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database.Results: 35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series.Conclusion: Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients. [ABSTRACT FROM AUTHOR]

The article reports on Diathermy‐assisted axillary sentinel lymph node biopsy for breast carcinoma risks. Topics include The presence of axillary lymph node metastasis is an essential prognostic factor in breast carcinoma and may guide treatment decisions regarding the use of adjuvant cytotoxic chemotherapy; Sentinel lymph node biopsy and histological examination is the current standard for detection of axillary lymph node metastasis in invasive breast carcinoma or high grade in situ disease.

Background: An excessively long-blind end of the alimentary limb following a Roux-en-Y gastric bypass (RYGB), known as a 'candy cane' (CC), may cause symptoms including abdominal pain, regurgitation and vomiting. Very few studies have examined the efficacy of surgical resection of the CC.Objectives: The aim of this study was to assess sensitivity of preoperative diagnostic tools for CC, as well as perioperative outcomes and symptom resolution after CC revision surgery.Setting: High volume bariatric centre of excellence, United Kingdom.Methods: Observational study of CC revisions from 2010 to 2017.Results: Twenty-eight CC revision cases were identified (mean age 45 ± 9 years, female preponderance 9:1). Presenting symptoms were abdominal pain (86%), regurgitation/vomiting (43%), suboptimal weight loss (36%) and acid reflux (21%). Preoperative tests provided correct diagnosis in 63% of barium contrast swallows, 50% of upper gastrointestinal endoscopies and 29% computed tomographies. Patients presenting with pain had significantly higher CC size as compared with pain-free group (4.2 vs. 2 cm, p = 0.001). Perioperative complications occurred in 25% of cases. Complete or partial symptom resolution was documented in 73% of patients undergoing CC revision. Highest success rates were recorded in the regurgitation/vomiting group (67%).Conclusion: Surgical revision of CC is associated with good symptom resolution in the majority of patients, especially those presenting with regurgitation/vomiting. However, it carries certain risk of complications. CC diagnosis may frequently be missed; hence more than one diagnostic tool should be considered when investigating symptomatic patients after RYGB. [ABSTRACT FROM AUTHOR]

Objective: There is a paucity of data describing long‐term outcomes of paediatric patients with pituitary adenoma. In this report, we describe clinical features, treatment and outcomes of a paediatric cohort. Design: Retrospective cohort study. Patients: Twenty‐four white Caucasian patients aged <16 years from a single tertiary care centre in the United Kingdom at diagnosis followed for (median, range) 3.3, 0.7‐8.4 years. Measurements: Clinical and radiological data at diagnosis and follow‐up. Results: Thirteen patients had prolactinomas (54.1%, age: 15.2 years, 13.2‐15.8 years; all females), including ten macroadenomas (11.0‐35.0 mm). Patients presented with menstrual disorders (91%), headache (46%), galactorrhoea (46%) and obesity (body mass index [BMI] SDS > 2): (38%). Ten patients with prolactinoma were treated with dopamine agonist alone, 3 also required surgery and 2 patients, cabergoline, surgery plus radiotherapy. Five patients had Cushing's disease (20.8%, age: 14.0, 4.0‐15.7 years; 2 female), including one macroadenoma (24 mm). Patients presented with obesity (100%), short stature (60%) and headache (40%). Transsphenoidal resection resulted in biochemical cure (09.00 cortisol < 50 nmol/L). Two patients relapsed 3‐ and 6 years following surgery, requiring radiotherapy. One patient also required bilateral adrenalectomy. Six patients had nonfunctioning pituitary adenoma (25.0%, age: 15.8, 12.5‐16.0 years; 2 female), including two macroadenomas (20.0‐53.0 mm). Patients presented with obesity (67%), visual field defects (50%) and headache (50%). Four required surgical resections; two recurred following surgery and required radiotherapy. On latest follow‐up; 13 (54.1%) patients were obese (BMI 3.09 SDS; range: 2.05‐3.73 SDS). Conclusion: Obesity is common at diagnosis of pituitary adenoma in childhood and may persist despite successful treatment. Adenomas were larger, more resistant to treatment, and more likely to recur than in adult populations. [ABSTRACT FROM AUTHOR]

Primary tumours of the meninges are rare accounting for only 0.4–4.6% of all paediatric tumours of the central nervous system. Due to the rarity of these tumours in children, and the consequent absence of collaborative prospective trials, there is no clear consensus on how the unique characteristics of paediatric meningiomas impact clinical status, management approach, and survival. Much of the evidence and treatment recommendations for paediatric meningiomas are extrapolated from adult data. Translating and adapting adult treatment recommendations into paediatric practice can be challenging and might inadvertently lead to inappropriate management. In 2009, Traunecker et al. published guidelines for the management of intracranial meningioma in children and young people on behalf of UK Children's Cancer and Leukaemia Group (CCLG). Ten years later we have developed the updated guidelines following a comprehensive appraisal of the literature. Complete surgical resection is the treatment of choice for symptomatic meningiomas, while radiotherapy remains the only available adjuvant therapy and may be necessary for those tumours that cannot be completely removed. However, significant advances have been made in the identification of the genetic and molecular alterations of meningioma, which has not only a potential value in the development of therapeutic agents but also in surveillance of childhood meningioma survivors. This guideline builds upon the CCLG 2009 guideline. We summarise recommendations for the diagnosis, treatment, surveillance and long-term follow-up of children and adolescents with meningioma. [ABSTRACT FROM AUTHOR]

Introduction: Warthin's tumor (WT) is a common benign salivary gland neoplasm with a negligible risk of malignant transformation. However, there is a risk of malignant tumors being misdiagnosed as WT on cytology and inappropriately managed conservatively. Methods: Patients from nine centers in Italy and the United Kingdom undergoing parotid surgery for cytologically diagnosed WT were included in this multicenter retrospective series. Definitive histology was compared with preoperative cytological diagnoses. Surgical complications were recorded. Results: A total of 496 tumors were identified. In 88.9%, the final histological diagnosis was WT. In 21 cases (4.2%) a malignant neoplasm was diagnosed, which had been incorrectly labeled as WT on cytology. Conclusions: The risk of undiagnosed malignancy should be balanced against surgical risks when considering the management of WT. Although nonsurgical management remains an appropriate option, there may be a rationale for serial clinical or radiological evaluation if surgical excision is not performed. [ABSTRACT FROM AUTHOR]

INTRODUCTION Longer waiting times from diagnosis to surgical resection have been found to negatively impact the overall survival and quality of life of women with endometrial cancer. The Cancer Care Pathway Directorate adopted the UK National Waiting Times Monitoring Dataset Guidance, to improve the timeliness of services along the cancer care pathway. From this, three key targets were identified: 1) Maximum 14-day wait from urgent GP referral for suspected cancer to first outpatient attendance (operational standard of 93%), 2) Maximum 31-day wait from decision to treat to first definitive treatment (operational standard of 96%), and 3) Maximum 62-day wait from urgent GP referral for suspected cancer to first treatment (operational standard of 85%). The aim of this baseline audit was to chart the time-frames of the various stages in the endometrial cancer pathway of patients diagnosed with this disease between 2015 and 2016 to assess for and identify delays in referral, investigation and care. METHODS A tool was developed following consultation with key stakeholders. Data protection clearance was obtained. Patient medical and oncology files, hospital databases, and MDT documentation for confirmed endometrial cancer cases were reviewed between September 2017 - March 2018. RESULTS A total of 101 endometrial cancer cases were included in the audit. The proportion of cases which met the 14-day, 31-day and 62- day wait KPIs operational standards were 39.1%, 81.2% and 17.2% respectively. CONCLUSION The endometrial cancer care pathway timeframes did not meet the KPIs operational standards. Fast-track coordinators and nurse navigators could improve continuity and coordination of patient care. [ABSTRACT FROM AUTHOR]

• Primary scrotal SCC is rare with 10 cases identified over 10 years at our single center. • There are currently no international or national guidelines on the management of scrotal SCC. Management especially inguinal nodal staging is based on penile cancer guidelines. • Tumor resection and inguinal node staging are required as the majority had invasive disease and around half had inguinal node or distant metastasis at presentation. Squamous cell carcinoma (SCC) of the scrotum is a rare and aggressive cancer. There are no established guidelines on the management of scrotal SCC. To analyze the clinical management and outcomes of scrotal SCC. A retrospective analysis of patients diagnosed with primary scrotal SCC over a 10-year period was performed. The type of surgery, tumor stage and histological subtypes, recurrence rate and metastases, cancer-specific mortality (CSM), and other-cause mortality (OCM) were analyzed. Between 2012 and 2022, a total of 10 men were identified with primary scrotal SCC. The median (interquartile, IQR) age was 65.5 (55–77) years. Wide local excision was performed in 9 patients and 1 patient underwent a total scrotectomy. The pathological T-stage was: pT1, n = 3; pT2, n = 1; pT3, n = 5 (50%); pT4, n = 1. Four patients had pathologically positive inguinal lymph nodes and 2 had distant metastatic disease at presentation. At a median (IQR) follow-up of 10.5 (4–31) months 5 patients died, of which 3 died from scrotal SCC. Scrotal SCC is extremely rare in the UK with only 10 primary cases identified in our center over the past 10 years. Surgical resection of the tumor and appropriate inguinal node staging are required due to a high proportion of cases which metastasize to the inguinal lymph nodes. Scrotal cancer is rare. 10 cases were diagnosed over 10 years at a single center. Around half had disease spread to the groin nodes or distant organs at presentation. Surgical resection was required in all patients. At the time of analysis, half of the patients are alive. Due to the rarity and aggressiveness of the cancer, management should be carried out within a specialist center. [ABSTRACT FROM AUTHOR]

There is increasing use of local excision (LE) for definitive treatment of early-stage anal squamous cell carcinoma (ASCC) to avoid the morbidity associated with chemoradiotherapy (CRT). However, the importance of different histological variables on risk of recurrence is poorly understood. A detailed analysis of patient characteristics, histology results, recurrence patterns and salvage treatment was conducted in consecutive T1/T2N0 ASCC patients treated by LE 2010–2021 across a UK regional cancer network multi-disciplinary team (MDT). Associations between potential predictors of disease recurrence were explored using chi-squared and Kruskal-Wallis tests for categorical and continuous variables respectively. Of 621 ASCC patients discussed in the network MDT, 164 had early-stage disease (T1/T2 N0). Of these, 36 (22%) were deemed suitable for LE (median age 61 years, female to male ratio 2:1). Twenty-two LE tumours were T1; 14 were T2. There were 12 well-differentiated tumours, 21 moderate and 3 poorly-differentiated. Seven out of 36 LE patients (19.4%) developed recurrence, all of whom went on to have salvage treatment with CRT (n = 4), re-excision (n = 2) or radiotherapy (n = 1). Predictors of disease recurrence following LE were: tumour differentiation (p = 0.024), tumour depth (p = 0.033) and R1 resection margin (p = 0.034). Tumour stage and site (margin/canal) were non-significant. LE for T1/T2 N0 ASCC of the margin or canal is a viable treatment strategy to avoid the morbidity associated with CRT and salvage treatments are still available for patients that develop recurrence. Tumour differentiation, depth and margin status are all important factors to consider when discussing management of early-stage ASCC. [ABSTRACT FROM AUTHOR]

Surgical resection and tracheal reconstruction are the most effective treatment options for airway stenosis. Tracheal surgery is challenging and requires a multidisciplinary approach and a highly specialized team of anesthesiologists and thoracic surgeons that are "sharing the airways". Several airway management tools, different devices, and various approaches can be required to ensure ventilation and gas exchange. We describe the case of a patient affected by tight tracheal stenosis, submitted to tracheal resection and reconstruction via combined cervicotomy and sternotomy surgical approach. Airway management was successfully performed by i-gel® (Intersurgical, UK) supraglottic device. [ABSTRACT FROM AUTHOR]

The article highlights the results of survey of Great Britain breast surgery trainees related to Axillary lymph node dissection (ALND) training. It mentions the results of this survey suggest that a significant number of breast surgery trainees in the Britain feel that they are not getting adequate exposure to ALNDs during their training and addresses such training gaps to ensure satisfactory skills acquisition prior to completion of training.

Background: Personal cancer risk assessments enable stratified care, for example, offering preventive surgical measures such as risk-reducing mastectomy (RRM) to women at high risk for breast cancer. In scenario-based experiments, we investigated whether different benefit–harm ratios of RRM influence women’s consideration of this, whether this consideration is influenced by women’s perception of and desire to know their personal cancer risk, or by their intention to take a novel cancer risk-predictive test, and whether consideration varies across different countries. Method: In January 2017, 1,675 women 40 to 75 years of age from five European countries—Czech Republic, Germany, UK, Italy, and Sweden—took part in an online scenario-based experiment. Six different scenarios of hypothetical benefit–harm ratios of RRM were presented in accessible fact box formats: Baseline risk/risk reduction pairings were 20/16, 20/4, 10/8, 10/2, 5/4, and 5/1 out of 1,000 women dying from breast cancer. Results: Varying the baseline risk of dying from breast cancer and the extent of risk reduction influenced the decision to consider RRM for 23% of women. Decisions varied by country, risk perception, and the intention to take a cancer risk-predictive test. Women who expressed a stronger intention to take such a test were more likely to consider having RRM. The desire to know one’s risk of developing any female cancer in general moderated women’s decisions, whereas the specific desire to know the risk of breast cancer did not. Conclusions: In this hypothetical scenario-based study, only for a minority of women did the change in benefit–harm ratio inform their consideration of RRM. Because this consideration is influenced by risk perception and the intention to learn one’s cancer risks via a cancer risk-predictive test, careful disclosure of different potential preventive measures and their benefit–harm ratios is necessary before testing for individual risk. Furthermore, information on risk testing should acknowledge country-specific sensitivities for benefit–harm ratios. [ABSTRACT FROM AUTHOR]

Background and Purpose: We reviewed our experience of synovial sarcoma to identify factors predictive of local recurrence and overall survival, the impact of chemotherapy and outcomes after surgical excision alone.Materials and Methods: 81 patients were treated between 1997 and 2014 of mean age 39 years (8-78). Tumours were in the extremity in 55 (67%). 9 patients presented with metastases and 10 with unresectable disease. Mean follow-up was 3.7 years (SD 3.8). Treatment groups were palliative, surgery only, surgery and radiotherapy, or surgery with chemotherapy (with or without radiotherapy).Results: Local recurrence-free survival (LRFS) was 73% at 5 years, and 68% at 10 and 15 years. In multivariate analysis, positive surgical margins were an independent predictor of LRFS. Overall survival (OS) was 50% at 5 years for all patients, and 62% at 5 years for those treated with curative intent. Larger tumour size and non-extremity locations were predictors of poorer OS. Patients who had chemotherapy did not have significantly better OS or LRS than others.Interpretation: These results show that where feasible, curative resection should not be delayed for chemotherapy. Treatment with surgery only can be associated with good outcomes in selected patients with smaller extremity tumours; although our series is small. [ABSTRACT FROM AUTHOR]

Background Factors influencing long-term outcome after surgical resection for duodenal adenocarcinoma are unclear. Methods A prospectively created database was reviewed for patients undergoing surgery for duodenal adenocarcinoma in six UK hepatopancreaticobiliary centres from 2000 to 2013. Factors influencing overall survival and disease-free survival ( DFS) were identified by regression analysis. Results Resection with curative intent was performed in 150 (84·3 per cent) of 178 patients. The postoperative morbidity rate for these patients was 40·0 per cent and the in-hospital mortality rate was 3·3 per cent. Patients who underwent resection had a better median survival than those who had a palliative surgical procedure (84 versus 8 months; P < 0·001). The 1-, 3- and 5-year overall survival rates for patients who underwent resection were 83·9, 66·7 and 51·2 per cent respectively. Median DFS was 53 months, and 1- and 3-year DFS rates were 80·8 and 56·5 per cent respectively. Multivariable analysis revealed that node status (hazard ratio 1·73, 95 per cent c.i. 1·07 to 2·79; P = 0·006) and lymphovascular invasion (hazard ratio 3·49, 1·83 to 6·64; P = 0·003) were associated with overall survival. Conclusion Resection of duodenal adenocarcinoma in specialist centres is associated with good long-term survival. Lymphovascular invasion and nodal metastases are independent prognostic indicators. [ABSTRACT FROM AUTHOR]

Objectives To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for nonsmall cell lung cancer (NSCLC). Design Cross-sectional study from individual patients, between 1January 2008 and 31March 2012. Setting Linked National Lung Cancer Audit and Hospital Episode Statistics datasets. Participants 95 818 English patients with a diagnosis of NSCLC, of whom 12 759 (13%) underwent surgical resection. Main outcome measure Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre. Results Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%. Conclusions Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery. [ABSTRACT FROM AUTHOR]

Objective To identify the current status of specialist preterm labour ( PTL) clinic provision and management within the UK. Design Postal survey of clinical practice. Setting UK Population All consultant-led obstetric units within the UK. Methods A questionnaire was sent by post to all 210 NHS consultant-led obstetric units within the UK. Units that had a specialist PTL clinic were asked to complete a further 20 questions defining their protocol for risk stratification and management. Main outcome measures Current practice in specialist preterm labour clinics.. Results We have identified 23 specialist clinics; the most common indications for attendance were previous PTL (100%), preterm prelabour rupture of membranes (95%), two large loop excisions of the transformation zone (95%) or cone biopsy (95%). There was significant heterogeneity in the indications for and method of primary treatment for short cervix, with cervical cerclage used in 45% of units, progesterone in 18% of units and Arabin cervical pessary in 5%. A further 23% used multiple treatment modalities in combination. Conclusions A significant heterogeneity in all topics surveyed suggests an urgent need for networking, more evidence-based guidelines and prospective comparative audits to ascertain the real impact of specialist PTL clinics on the reduction in preterm birth and its sequelae. [ABSTRACT FROM AUTHOR]

OBJECTIVES:The efficacy of thiopurines (TPs) in altering the risk of surgery in Crohn's disease (CD) remains controversial. We evaluated the impact of TP therapy, optimal timing, and duration of TP therapy on first intestinal resection rates using a population-based cohort.METHODS:We constructed a population-based cohort of incident cases of CD between 1989 and 2005. We used the Kaplan-Meier analysis to calculate time trends in TP use and first intestinal resection in three groups defined by time period of diagnosis: 1989-1993, 1994-1999, and 2000-2005 groups A, B, and C, respectively. We quantified impact of duration and timing of TP treatment on likelihood of surgery using Cox regression and propensity score matching.RESULTS:We identified 5,640 eligible patients with CD. The 5-year cumulative probability of TP use increased from 12, 18, to 25% ( P<0.0001) while probability of first intestinal resection decreased from 15, 12 to 9% (P<0.001) in groups A, B, and C, respectively. Patients treated with at least 6 months of TP therapy had a 44% reduction in the risk of surgery (hazards ratio (HR): 0.56; 95% confidence interval (CI): 0.37-0.85) and those receiving at least 12 months of TP therapy had a 69% reduction in the risk of surgery (HR: 0.31; 95% CI: 0.22-0.44). Early treatment (<12 months from diagnosis) vs. late treatment with TP showed no additional benefit in reducing risk of surgery (HR: 0.41; 95% CI: 0.27-0.61 vs. 0.21; 95% CI: 0.13-0.34).CONCLUSIONS:Over the past 20 years, TP use has doubled, whereas intestinal surgery has fallen by one-third among the UK population of Crohn's patients. Prolonged exposure is associated with a reduced likelihood of surgery whereby more than 12 months TP therapy reduces the risk of first intestinal surgery two-fold; however, early initiation of TP treatment offered no apparent additional benefit. [ABSTRACT FROM AUTHOR]

Summary: Surgical excision remains the gold standard for the management of cutaneous squamous cell cancers (SCC) and national guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumours. We retrospectively analysed all cutaneous SCC excisions performed across 4 regional Plastic surgical units in England over a consecutive 24-month period and collected data on tumour characteristics, operative and histological margins and completeness of excision. We identified 633 eligible SCC excisions of which 265 (42%) were over 2 cm in diameter with 37 recurrent tumours (5.8%). The mean radial operative margin was 6.5 mm across all tumours and 8.4 mm for tumours greater than 2 cm. The mean histological tumour diameter was 21 mm. The overall incomplete excision rate was 7.6% (7.9% for tumours >2 cm). Ninety-four percent (45/48) of incomplete excisions involved the deep margin and only 3 out of 633 excisions (0.47%) were incomplete at a radial margin only. No differences were observed in tumour size or excision margin between incompletely and completely excised tumours. Incomplete excisions were most common on the ear, nose and cheek. In summary our analysis demonstrates that despite adherence to recommended surgical margins for cutaneous SCCs the incomplete excision rate remains higher than expected. We believe that this is because most incomplete excisions are incomplete at the deep margin and question the utility of performing increasingly wide excisions, and, the generalisability of the evidence upon which recommendations for radial margins are based. [ABSTRACT FROM AUTHOR]

Background Lung cancer resection rates are low in England, but reports have indicated an increase in recent years. We analysed the recent trends in surgical resection by age, sex, socioeconomic deprivation and surgical procedure in England. Methods Data on 286 217 patients with non-small cell lung cancer diagnosed between 1998 and 2008 were extracted from the English Cancer Repository Dataset and information on surgical resection for these patients was retrieved from linked Hospital Episode Statistics records. We calculated the OR of undergoing surgery per 1-year increment by age, sex, socioeconomic deprivation and surgical procedure. A multinomial logistic regression model was used to assess the association between age and type of surgery. Results The proportion of patients with non-small cell lung cancer undergoing surgery increased from 8.8% in 1998 to 10.6% in 2008. The increase was similar between levels of socioeconomic deprivation, slightly more pronounced among women (OR=1.023 per 1-year calendar increment, 95% CI 1.016 to 1.029) than men (OR=1.010, 95% CI 1.005 to 1.015) and most prominent with increasing age (75-79 age group: OR 1.051, 95% CI 1.041 to 1.062; 80-84 age group: OR 1.102, 95% CI 1.080 to 1.124; and 85+ age group: OR 1.130, 95% CI 1.069 to 1.193). Increasing age was associated with a decreased likelihood of undergoing pneumonectomy (OR 0.88, 95% CI 0.87 to 0.89 per 5-year age increment) or sleeve resection (OR 0.75, 95% CI 0.71 to 0.79) compared with lobectomy, and a slightly increased likelihood of undergoing a wedge resection (OR 1.08, 95% CI 1.06 to 1.10). Conclusion Resection rates have increased in England in recent years and most markedly so in the older age groups. [ABSTRACT FROM AUTHOR]

Aim The study investigated whether experience gained during a UK laparoscopic colorectal fellowship enabled the fellow subsequently to train consultant colleagues in laparoscopic surgery. Method In one unit a newly appointed post-laparoscopic fellowship consultant (PFC) mentored his other two colleagues. Prospectively collected data regarding surgical outcome were compared with those of the year preceding the PFC appointment. Results In the preceding year 18.5% of 260 resections were attempted laparoscopically. This increased to 92.6% (of 270) in the year after ( P < 0.0001). Respective conversion rates were 4.2% and 8.4% ( P = 0.5524). In the first 6 months after PFC appointment, mentored consultants performed 23 supervised cases. In the second 6 months they carried out 58 procedures independently and trainees performed 38 supervised cases. There was no significant difference in anastomotic leakage and readmission and 30-day mortality rates between the pre- and post-PFC periods. Conclusion A laparoscopic fellowship enables the PFC to mentor consultant colleagues safely and effectively. [ABSTRACT FROM AUTHOR]

Summary: Sentinel lymph node biopsy provides prognostic information for melanoma patients, and the Department of Health states that it should be available across the country by 2012. We review the setting up of a melanoma sentinel lymph node biopsy service with specific consideration to resources, service implications and patient outcomes. In total, 164 patients underwent sentinel lymph node biopsy for melanoma from August 2008 until March 2010. The median time for sentinel lymph node excision was 26 min. The median total operative time, which includes melanoma excision and sentinel node biopsy was 65 min, compared with 22 min for excision of the melanoma performed during the previous 19 months. The complication rate was 8.5%, with only 1.2% requiring operative treatment. After the initial outlay for two gamma probes, it was possible to deliver a cost neutral service within the National Tariff. Despite a significant increase in demand for the service in the second half of the study period, and 106% increase in the number of regional lymphadenectomies, only 1 patient (0.6%) breached the ‘Going Further on Cancer Waits’ target. In conclusion, a sentinel lymph node biopsy service for malignant melanoma can be effectively delivered within the majority of UK plastic surgery departments. [ABSTRACT FROM AUTHOR]

Women undergoing surgery and/or radiotherapy for treatment of gynaecological cancers are at risk of developing lower limb lymphoedema. However, unlike patients undergoing treatment for breast cancer, specific information and advice to reduce the risk of developing this condition is rarely discussed pre- or post-operatively. Moreover, referral for early and effective treatment to reduce the swelling is often left too late, further affecting the physical and psychological distress often seen after such cancer treatment. This article illustrates the significant effect that lower limb lymphoedema can have on quality of life after surgery for gynaecological carcinoma. It demonstrates the benefit of lymphoedema treatments, including the introduction of a new bandaging system to minimise distressing symptoms and urges early referral for assessment. The importance of patient education for those at risk is also stressed. [ABSTRACT FROM AUTHOR]

Recalcitrant warts remain a challenging problem to treat, with considerable morbidity for patients. Our technique uses the carbon dioxide (CO2) laser as a bloodless scalpel to excise and treat recalcitrant warts. This paper reviews the results of patients with recalcitrant warts treated by the senior author using this technique. Methods. A retrospective case note review and questionnaire-based survey of patients treated by this technique. Results. Seventy-one recalcitrant warts treated in 22 patients, all as day case procedures. A total of 54.5% of patients had complete remission after one treatment and the average length of follow-up was 71.5 months. Recurrence occurred on average 5.29 months following treatment. Of those patients, 90% were successfully retreated, giving an overall rate of 95.5%. In total, 46.7% of patients were left with scarring, but all felt this was acceptable given the benefits of the treatment, and 80.0% of patients would have the procedure again. Four patients had spontaneous regression of warts at other body sites not treated with the CO2 laser. Conclusion. This study illustrates the efficacy of our technique with a favourable outcome comparable to published studies. Recurrence occurred within 12 months; therefore, we would recommend this as a minimum follow-up period. In addition, the disappearance of warts at distant sites suggests that the effects of the CO2 laser therapy modulate the immune system, thereby extending it beyond simple excision or ablation. [ABSTRACT FROM AUTHOR]

Background: Trauma is leading cause of death in young adult in UK. Penetrating abdominal injury implies either Gunshot wound or stab wound. Stabbing are more common than Gun Shot. Stabbing involves the transfer of low level of energy, with damage confined to the course of the wound track; tissue away from the tract is unaffected unless transaction of neurovascular supply occurs. Methodology: Study Design: Prospective Descriptive Setting: Department of Surgery at Liaquat University of Medical & Health Sciences, Jamshoro. Sample Size: 50 patients of penetrating abdominal trauma followed up for 3 months. Results: The age of the patients ranged from 7 to 65 years with mean age of 30 years. Out of these 50 patients, 4 (8%) patients were females and 46 (92%) male. Majority of the patient had firearm injuries 68% while stab injuries were only seen in 32% of cases (Table I). Mean lapse time between trauma and surgical intervention was 4.25 hours. A total of thirteen patients (26%) were having hepatic injury with other associated injuries to other abdominal organs. Out of these, eleven patients (22%) had gunshot injuries, and two (4%) got stab injury. Hepatic trauma varied from a small laceration to complete shattering of the liver lobe Conclusion: Liver is the most commonly injured solid organ in which coupting suturing is sufficient in 50% of the patients. Splenectomy still is safe option to deal with splenic trauma in our set up. In cases of pancreatic trauma peri-pancreatic drainage is an acceptable and safe option. Resection of the pancreas is not a desirable emergency procedure. [ABSTRACT FROM AUTHOR]

Background Despite major advances in therapies for liver metastases, colorectal cancer remains one of the commonest causes of cancer-related deaths in the UK. Sources of data The international literature on the management of colorectal liver metastases (CLM) was reviewed. Areas of agreement Due to a combination of highly active systemic agents and low perioperative mortality achieved by high-volume centres, a growing number of patients are being offered liver resection with curative intent. Patients with bilobar and/or extrahepatic disease who would previously have received palliative treatment only, are undergoing major surgery with good results. This review focuses on preoperative evaluation, surgical planning and the role of adjuvant therapies in the management of patients with CLM. Areas of controversy Can ablative therapies match the outcomes of surgical resection? How can even more patients be rendered resectable? Growing points The use of other therapies, such as radiofrequency ablation and selective internal radiation therapy. Areas timely for developing research New chemotherapy regimens for neo-adjuvant therapy and the development of new modalities of liver tumour ablation. [ABSTRACT FROM PUBLISHER]

Aim To undertake full economic evaluation of stapled hemorrhoidopexy (PPH) to establish its cost-effectiveness and investigate whether PPH can become cost-saving compared to conventional excisional hemorrhoidectomy (CH). Methods A cost-utility analysis in hospital and health care system (UK) was undertaken using a probabilistic, cohort-based decision tree to compare the use of PPH with CH. Sensitivity analyses allowed showing outcomes in regard to the variations in clinical practice of PPH procedure. The participants were patients undergoing initial surgical treatment of third and fourth degree hemorrhoids within a 1-year time-horizon. Data on clinical effectiveness were obtained from a systematic review of the literature. Main outcome measures were the cost per procedure at the hospital level, total direct costs from the health care system perspective, quality adjusted life years (QALY) gained and incremental cost per QALY gained. Results A decrease in operating theater time and hospital stay associated with PPH led to a cost saving compared to CH of GBP 27 (US $43.11, €30.50) per procedure at the hospital level and to an incremental cost of GBP 33 (US $52.68, €37.29) after one year from the societal perspective. Calculation of QALYs induced an incremental QALY of 0.0076 and showed an incremental cost-effective ratio (ICER) of GBP 4316 (US $6890.47, €4878.37). Taking into consideration recent literature on clinical outcomes, PPH becomes cost saving compared to CH for the health care system. Conclusions PPH is a cost-effective procedure with an ICER of GBP 4136 and it seems that an innovative surgical procedure could be cost saving in routine clinical practice. [ABSTRACT FROM AUTHOR]

Anastomotic leakage after low anterior resection may incompletely resolve, resulting in sinus tracts that persist on repeated contrast studies. This case series evaluated the factors that may contribute to sinus healing or to safe reversal of the defunctioning ileostomy. All patients ( n = 8) who developed an anastomotic sinus after low anterior resection over an 8-year period were identified from a prospective database. All patients had been treated with low anterior resections with defunctioning stomas for rectal carcinoma [median follow up 43.5 (13-84) months]. Two patients with an unhealed subclinical leak had the stoma reversed successfully. Of the six patients with clinical leakage, two healed spontaneously, one healed after application of fibrin glue, one developed an anastomotic stricture that was successfully treated by dilatation with subsequent stoma reversal, and one developed recurrent cancer and was not reversed. One patient underwent reversal, despite persistence of the sinus, followed by rectal perforation requiring laparotomy and faecal diversion. Bowel function was satisfactory where the sinus healed spontaneously, but poor where reversal was carried out without sinus healing. Tracks that persist for longer than 1 year are unlikely to heal, but the stoma can be reversed if there had been a subclinical leak previously. A persistent anastomotic sinus leading to a cavity may not be suitable for stoma closure. [ABSTRACT FROM AUTHOR]