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AIMS: Our aim was to investigate the role of minimal surgery in patients with locally advanced breast cancer (LABC) who achieve a complete pathological (pCR) response to primary chemotherapy (PC) and evaluate subsequent local recurrence (LRR), disease free survival (DFS) and overall survival (OS). METHODS: Between January 2000 and April 2005, 101 patients with operable LABC (T2, T3, N0 or N1, M0) who were not suitable for conservation surgery were treated with PC. Patients were treated with doxorubicin and cyclophosphamide for four cycles (100 patients) then four cycles with paclitaxel (91 patients). Post-PC surgery consisted of multiple core biopsies and axillary clearance for patients with a complete clinical and radiological response. If a pCR was confirmed no further breast surgery was performed. The remaining patients were treated with breast conserving surgery or mastectomy and axillary clearance as appropriate. Adjuvant radiotherapy was given to all patients. RESULTS: Breast conservation was possible in 60% of patients. Overall, 20 patients achieved a pCR of which 16 were confirmed on core biopsies alone. All patients were followed-up for a mean of 33.5 months (95% CI, 30.3-36.7). There were 10 local recurrences, four following mastectomy, four after wide excision and two after core biopsies. There was no difference in DFS (chi square=0.18; p=0.67) or OS (chi square=0.67; p=0.41) between patients achieving a pCR and the remainder. CONCLUSIONS: The local recurrence rate of these poor prognosis patients is similar to other reported series but higher than in our previously reported series of patients managed according to the same protocol. Our current management therefore now includes pre-treatment marking and subsequent surgical excision.

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The Guidelines were prepared by an international expert panel on behalf of the Association of Breast Surgery. The majority of women who have a relative with breast cancer are not themselves at significantly increased risk. The Guidelines propose a management strategy, including genetic assessment, chemo-prevention, risk reducing surgery and radiological screening, based on risk assessment of the individual. The Guidelines are based on evidence where available, or on consensus statements from surgeons, radiologists, geneticists and clinical psychologists.

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BACKGROUND: The National Health Service Breast Screening Programme (NHSBSP) is an example of a nationally coordinated quality assurance programme in which all the professional groups involved participate. METHODS: Surgeons, radiologists and pathologists defined the clinical outcome measures against which they would subsequently be audited. The NHSBSP and the Association of Breast Surgery at BASO are jointly responsible for coordinating an annual audit of all surgical activities undertaken within the NHSBSP. RESULTS: The trends for key outcome measures between 1996 and 2001 are provided. The preoperative diagnosis rate (minimum standard 70 per cent or more) improved from 63 to 87 per cent. This rise was mirrored by an increase in the use of core biopsy in preference to fine-needle cytology. The proportion of patients in whom lymph node status was recorded improved from 81 to 93 per cent. There was no significant change in the number of women treated by low case-load surgeons and waiting times for surgery increased through the study interval. CONCLUSION: The BASO-NHSBSP Breast Audit has recorded major changes in clinical practice over 5 years. A key feature has been the dissemination of good practice through feedback of the results at local and national level.

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The aim of this study was to evaluate the role of surgery in patients who achieve a complete clinical response (cCR) to neoadjuvant chemotherapy for locally advanced breast cancer. A retrospective study of patients with either large central (T2 >30 mm, N0 or N1, M0) or locally advanced (T3, N0 or N1, M0) tumours who received neoadjuvant chemotherapy followed by surgery to the breast and axilla and postoperative radiotherapy. All patients had operable disease at presentation. A total of 133 patients were included. Overall, 43 (32%) patients achieved a cCR following chemotherapy. Of these, 19 patients had no pathological evidence of disease in the breast (pCR) or on imaging or core biopsy and these patients received only adjuvant radiotherapy to the breast. A further 5 patients had no pathological evidence of cancer following breast surgery. 126 patients had an axillary clearance. Increasing response to chemotherapy was related to fewer pathologically involved nodes, but 7 of 24 (29%) patients with a pCR still had evidence of axillary metastases. This is the principal conclusion of the study at the present time. The patients were followed-up for a median of 30 months (range 5-83 months) with a local recurrence rate of 3.8%. There was no difference in either distant recurrence-free or overall survival between patients experiencing a pCR and the remainder.

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Thirty six per cent of women with breast cancer were not identified as requiring an urgent clinic appointment by their general practitioner. In contrast, large numbers of women with benign disease are graded as urgent by their general practitioner. Classification of patients with breast symptoms requiring hospital referral by general practitioner does not accurately differentiate between women with benign and malignant breast disease.

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Minimally invasive surgery is rapidly becoming an integral part of general surgery. Many general surgeons have been trained to undertake laparoscopic cholecystectomy. It has been recommended that laparoscopic appendicectomy should be the training operation for junior surgeons. The aim of our study was to assess whether laparoscopic appendicectomy training can safely be introduced to junior surgeons in a district general hospital. During the 11 month study period, 27 laparoscopic and 38 open appendicectomies were performed. The median anaesthetic time was 80 min for laparoscopic and 52.5 min for open appendicectomies. Laparoscopic appendicectomies cost, on average, 618 pounds and open appendicectomies 770 pounds per case. The complication rate between the two procedures was equal. We therefore showed that laparoscopic appendicectomy by junior surgeons is both safe and cost-effective. Although the registrar did most of the laparoscopic appendicectomies, with resultant less operating for the SHO, laparoscopic appendicectomy provided the SHO with training in diagnostic laparoscopy and laparoscopic dissection. We conclude that basic laparoscopic training should be introduced early in surgical training, after which laparoscopic appendicectomy is a safe procedure for surgical trainees.

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BACKGROUND: This phase II trial was designed to evaluate the feasibility, toxicity, relapse pattern and survival following adjuvant intraperitoneal cisplatin in patients with gastric cancer at high risk of relapse. PATIENTS AND METHODS: Patients who had undergone complete surgical resection of adenocarcinoma of the stomach and who had positive serosa and/or regional lymph nodes and/or peritoneal washings has insertion of either a Tenckhoff catheter or temporary peritoneal dialysis catheter and were treated with cisplatin 60 mg/m2 intraperitoneally every 21 days for 4-6 courses. Peritoneal lavage or cytology was done before each treatment. RESULTS: Eighteen patients were studied. Seventeen patients had serosal involvement, 11 had regional lymph node involvement and 2 had positive peritoneal washings before treatment. The median number of courses of chemotherapy was 4 (range 2-6). Radioisotope tracer studies (6 patients) showed good distribution throughout the peritoneal cavity. No WHO grade 3/4 toxicity was seen. Twelve patients (67%) have relapsed, 6 (33%) intra-abdominally, 4 (22%) with hepatic metastases and 2 (11%) outside the abdominal cavity. The median survival was 17 months. CONCLUSIONS: Cisplatin can be administered safely as adjuvant therapy to patients with gastric cancer, however, as single agent therapy the pattern of relapse and subsequent death was similar to that expected. The occurrence of distant metastases may argue for systemic rather than local adjuvant treatment.

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The records of 129 patients with thick cutaneous melanoma of the trunk or extremity treated at Memorial Sloan-Kettering Cancer Center, New York, NY, between 1974 and 1984 were reviewed with the aim of defining prognostic variables. All primary lesions invaded subcutaneous fat, were Clark level V, or of a Breslow thickness of 4.0 mm or greater. Treatment in all cases was by wide excision with or without split-thickness skin graft; all patients underwent regional lymph node dissection. Overall survival rate for the group was 47% at 5 years and 36% at 10 years. Factors independently predictive of survival were pathologic negative nodes (71% at 5 years compared with 28% for pathologic positive nodes) and extremity site (58% at 5 years compared with 33% for truncal site). Patients with node-negative thick cutaneous melanoma of the extremity had a 5-year survival rate of 82%. Patients with node-positive truncal thick cutaneous melanoma had a 5-year survival rate of only 8%. There was no difference between the 5-year survival rate of patients with node-negative truncal thick cutaneous melanoma, 52%, and patients with node-positive thick cutaneous melanoma of the extremity, 42%. Nearly half of the patients with thick cutaneous melanoma of the extremity and trunk present with locoregional disease, at a stage when an aggressive surgical approach is warranted. Prognostic variables of pathologic nodal status and site identify patients at risk for early systemic failure.

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The management of large carcinoid tumors of the anorectum is controversial. Most carcinoid tumors of the rectum and anus are early lesions, adequately treated by local excision. However, because of their relative rarity, the number of advanced cases seen at most institutions is small. Forty-three patients with anorectal carcinoid tumors were treated at our institution between 1960 and 1988 with complete follow-up. The median age of onset was 56 years. Eleven patients had no symptoms and the tumor was detected incidentally in eight additional patients with other diseases. Twenty tumors were larger than 2 cm in diameter and all patients had symptoms. Eight patients had another malignancy and three patients had ulcerative colitis. An association between ulcerative colitis and rectal carcinoid tumors is not widely appreciated. Eighteen tumors were treated by local excision, 16 by radical surgery, and nine underwent only biopsy. With complete resection of the primary lesion, local recurrence was never a problem. The median survival from diagnosis was 38 months in this series and 23 patients died of disease. After detection of metastases, the median survival time was 10 months. Tumors more advanced that T2 or larger than 2 cm in diameter were always fatal. All 13 patients with involved lymph nodes died of metastatic disease, with a median survival of 10 months, although one lived 9 years. Advanced rectal carcinoid tumors are aggressive malignancies. Adequate local excision controls regional disease but rectal carcinoid tumors are cured only when they are discovered before the T3 stage, measure less than 2 cm in diameter, and when lymph nodes are not involved. Consequently if a local excision permits complete resection, radical extirpative surgery will provide little benefit.

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The polymerase chain reaction (PCR) was used to detect malignant lymphoma cells with the bcl-2 gene rearrangement in the peritoneal washings and bone marrow of a patient with an apparently localised gastric lymphoma. After four courses of cytotoxic drug treatment the cells could no longer be detected in either site. PCR is a useful addition to the staging investigations of non-Hodgkin lymphoma and can also be used to monitor response to treatment.

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Between 1978 and 1981, 73 patients with colonic or rectal cancer were randomized to have their anastomoses made by either a single interrupted layer of braided polyester sutures, or by a circular stapling instrument. Of these operations, 20 were considered to have been palliative, the remaining 53 being potentially curative. The incidence of local recurrence in the latter group was analyzed in relation to initial septic and anastomotic complications. The 53 patients were followed for a median of 36 months (range, 1 to 87); 24 were alive and well and 22 had died of disseminated cancer or unrelated causes. Seven patients died with local recurrent disease proved at laparotomy or autopsy after a median of 33 months (range, 3 to 72). Thirty anastomoses were stapled and 23 sutured; of the seven patients who died with local recurrent disease, six had stapled anastomoses (Fisher's exact probability F2 = 0.12; log rank chi-square = 3.53, 0.05 less than P less than 0.10). Two patients who died with locally recurrent disease had had clinically apparent anastomotic leaks and one other patient had had a radiologically demonstrated leak. This compares with a total of seven leaks (clinical or radiologic) in the remaining group of 46 patients with no recurrence (Fisher's exact probability F2 = 0.11). These results tend to support the hypothesis that anastomotic leaks may lead to locally recurrent disease, particularly after stapled anastomoses.

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Complete daily intake and output charts were available for 218 patients with acute pancreatitis. The patients were divided into three groups according to the relation between fluid intake and output. In 105 patients in whom there was negligible fluid sequestration (daily output within 2 litres of intake) there were six deaths (5.8 per cent). In 69 patients the daily fluid intake exceeded the output by 2 litres or more but this imbalance lasted for 48 h or less; six patients died (8.7 per cent). The remaining 44 patients sequestered 2 litres or more of fluid per day for more than 48 h or until death. Thirty-eight patients in this group died (86.4 per cent). Fluid sequestration of 2 litres or more per day, and lasting longer than 48 h, is an accurate and simple predictor of mortality in acute pancreatitis. In this study it had a sensitivity of 76 per cent and a specificity of 96 per cent. The predictive value of a positive result was 86 per cent and of a negative result 93 per cent (efficiency 92 per cent).

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A randomized controlled clinical trial was undertaken in 542 consecutive emergency and elective abdominal operations, with one group of patients receiving tetracycline peritoneal and wound lavage and the other a single intravenous injection of 1 g latamoxef at induction of anaesthesia. Seventy-five patients were withdrawn because no potentially contaminated hollow viscus was opened, and a further 36 because they could not be assessed for wound infection. Of the remaining 431 patients, 212 received latamoxef resulting in 5 major and 8 minor wound infections in hospital; another 4 minor infections occurred at home (total incidence 8.0%). In the tetracycline group (n = 219) there were 7 major and 19 minor wound infections in hospital and 10 minor infections later (total incidence 16.4%). This is significantly higher than the rate with latamoxef (P = 0.012). Monitoring of operative and postoperative bleeding revealed no evidence (except in one doubtful case) of excessive bleeding associated with the use of a single dose of latamoxef. It is concluded that single-dose preoperative latamoxef is more effective than peroperative tetracycline lavage for the prevention of wound infections after potentially contaminated abdominal operations.

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On the hypothesis that incisional defects occur soon after operation but the resulting hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation). He had no knowledge of the results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients were found to have incisional hernias, and correlation with the measurements on the one-month X-rays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back to events during the first month after operation and that they are not the result of later weakening of a well-healed laparotomy wound.

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Some surgeons drain the gallbladder bed routinely, some selectively and some not at all. We aimed to clarify this confusion by entering 155 consecutive patients undergoing emergency and elective cholecystectomy without exploration of the common bile duct into a random control clinical trial. In 78 patients a 3 mm suction drain was left in the gallbladder bed and in 77 the abdomen was closed without drainage. There were no withdrawals, one death (in the drainage group) from myocardial infarction and one intraperitoneal abscess complicating postoperative pancreatitis (in the no-drainage group). Other events studied were postoperative pyrexia, wound infection, respiratory tract infection and duration of hospital stay. In none of these did the two groups differ either clinically or statistically. We conclude that drainage or non-drainage of the gallbladder bed must remain a matter of individual preference.

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The status of oestrogen and progesterone receptors has been measured in 147 primary breast tumours. In addition to the measurement of cytoplasmic oestrogen receptors, the ability of these receptors to bind to oligo(dT)-cellulose has been assessed. This indicates the capability for activation of cytoplasmic receptors to a form able to bind in the nuclear compartment in vivo and thus be part of a functional receptor pathway. All the receptor concentrations measured were increased in the postmenopausal group of patients. All nuclear oestrogen receptors in this group were available for labelling at 4 degrees C, in contrast to the premenopausal group. The apparent functionality of the oestrogen receptor pathway could be equally assessed either by the co-presence of cytosol progesterone receptor with nuclear oestrogen receptor (30 or 4 degrees C) or with activated cytosol oestrogen receptor. The presence of activated cytosol oestrogen receptor was as reliable (80%) as the presence of either nuclear oestrogen receptor at 30 (83%) or 4 degrees C (81%) in predicting the response of breast tumours to endocrine therapy.

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Fifty-five patients with locally advanced breast cancer treated with initial endocrine therapy have been followed up for periods of between 6 and 64 months (median 17 months) with regular clinical and radiological examination. The aim of the study was to evaluate the role of mammography in initial assessment, and subsequent follow-up. Fifty patients were available for evaluation and were classified by clinical, and by mammographic data independently. The clinical assessment, using UICC criteria of response, estimated 36 patients (72 per cent) as responders (complete response, partial response and no change). Mammographic assessment of response, using 8 radiological features of malignancy, agreed with the clinical estimate in 48 per cent of cases and 32 patients (64 per cent) were assessed as responders. Where clinical and mammographic assessment differed, it was usually due either to a smaller radiological reduction in tumour size, or mammography demonstrating features of progressive disease not observed clinically. Two other mammographic features studied were of prognostic significance. In 70 per cent of the responders in which microcalcifications were present, they became reduced in number but increased in size, a change not seen in non-responders. A curvilinear band, or 'rainbow sign', is described which is an early sign of localized skin infiltration and was associated with a poor prognosis.

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