Retrorectal tumours: optimization of surgical approach and outcome

Aim The aim was to identify the radiological features of retrorectal tumours that influence management and to highlight technical points that facilitate safe surgical excision. Method A consecutive series of patients was identified from a prospective database. All cases were discussed within a multidisciplinary team. Medical records, radiology and pathology reports were also checked retrospectively. Results Fifty‐six patients [37 women; median age 51 (20–88) years] underwent excision of retrorectal tumours between 2002 and 2010 under the care of one surgeon. Seventeen (37.5%) had a malignant tumour. The commonest symptom was pain or discomfort. Features identified after MRI that suggested malignancy included heterogenous signal intensity (15/17 malignant lesions vs 5/39 benign lesions), an irregular infiltrative margin (14/17 malignant lesions vs 4/39 benign lesions) and enhancement (14/17 malignant lesions vs 2/39 benign lesions) (all P < 0.05). An abdominal approach was used in 27 (48%) patients, a perineal/trans‐sacral approach in 20 (36%) and a composite abdomino‐sacral approach in nine (16%). The perineal approach was used if the tumours were below the middle of S3 without sacral, pelvic side‐wall or visceral involvement. The three most common types of tumour were schwannoma (n = 11), tail gut cyst (n = 13) and chordoma (n = 9). Over a median follow‐up period of 46 (6–90) months there were two local recurrences among the malignant tumours (both resected) and two deaths (both sarcomas). Conclusion MR imaging, avoidance of routine preoperative biopsy and careful clinical evaluation result in a good outcome after surgical excision of retrorectal tumours.     

Treatment and outcome of cystosarcoma phyllodes in Brunei: a 13-year experience

Cystosarcoma phyllodes is a rare tumour of the breast whose clinical behaviour does not correlate well with histological findings. The optimal treatment of this tumour remains controversial. A retrospective study on the treatment and outcome of women diagnosed with cystosarcoma phyllodes between 1986 and 1998 in Brunei was undertaken. Twenty-seven women were diagnosed over the 13-year study period. Follow-up was complete in 26 cases. The mean age at diagnosis was 35 years. There were 19 (73%) histologically benign lesions, 3 (12%) borderline lesions and 4 (15%) malignant lesions. The mean follow-up period was 37 months. Four patients (16%) had recurrences after surgery (1 benign, 1 borderline and 2 malignant lesions). Mean time to recurrence was 9 months. Breast-conserving surgery with adequate resection margin is advocated in benign and borderline lesions. For malignant lesions, simple mastectomy without routine axillary dissection is recommended. More research is required to determine the role of adjuvant chemotherapy and radiotherapy in the management of malignant cystosarcoma phyllodes [corrected].     

Phyllodes tumours of the breast--a retrospective study from 1982-2000 of 50 cases in Portsmouth

INTRODUCTION: This study is a retrospective analysis of 50 phyllodes tumours to determine the optimal surgical procedure for these types of tumours. We have also reviewed rates of recurrence, metastases and mortality based on choice of procedure and histological type. PATIENTS AND METHODS: Cases were ascertained from pathology databases and clinical details extracted from the hospital records. Fifty patients with phyllodes tumours were identified. These comprised 29 benign, 12 borderline and 9 malignant phyllodes tumours. RESULTS: All benign phyllodes tumours were treated with breast-conserving surgery, these included 16 tumours over 40 mm. Borderline and malignant lesions were treated by breast-conserving surgery or mastectomy. The median follow-up period was 35 months (range, 4-96 months). The recurrence rate for all tumours was 14%. Malignant and borderline phyllodes tumours had a recurrence rate of 28%. Tumours excised with a wide margin did not seem to recur. Breast-conserving surgery appeared to be as effective as mastectomy. The choice of procedure was less important than the width of the excision margin. Recurrence occurred in 1/29 benign tumours. Excision margin width did not influence rate of recurrence. One patient died of metastases after mastectomy. CONCLUSIONS: Breast-conserving surgery is the treatment of choice for all benign lesions. For borderline and malignant lesions, excision with a wide margin reduces the rate of recurrence. If a diagnostic local excision biopsy or enucleation is performed, it should be followed by a definitive wider excision.     

Phyllodes tumour of the breast: a retrospective analysis of 30 cases

Phyllodes tumour (PT) is a rare neoplasm of the female breast that resembles fibroadenoma but occurs in an older age group. We retrospectively reviewed the medical records of 30 women who were treated for phyllodes tumour in our centre. Histological examination was performed by an experienced breast pathologist in all cases and tumours were classified as benign, border line malignant or malignant according to standard histological criteria. The mean age at diagnosis was 49 years (range: 19-80 years). Twenty-one (70%) of 30 tumours were benign and 9 (30%) were malignant (n=7) or borderline malignant (n=2). The mean tumour size was 46 mm (range: 20-100 mm). The final microscopic margins contained tumour in 13 (43%) of 30 cases and were free of tumour in 17 (57%) of 30 patients. After a median follow-up period of 6 years (range: 6 months-20 years), the tumour recurred locally in 5 (17%) patients. One patient had six local recurrences over an 18-year period. Local recurrences were more frequently observed in patients with malignant tumours compared with those with benign lesions (33% versus 10%). However, this association failed to reach statistical significance. There was no association between local recurrence, patient age, tumour size or positive microscopic margins. There was one death (3%) associated with a completely excised malignant tumour. The present study suggests that histological type and margins do not accurately predict the clinical course of PT and that there is a need to identify novel biological markers that more accurately predict the behaviour of this rare neoplasm.     

Primary bony chest wall tumours

A retrospective review of 81 cases of primary chest wall tumours was carried out to analyse their clinical, radiological and surgical features. There were 37 malignant and 44 benign lesions; 72 were found in the ribs and nine in the sternum, of which five were malignant and four benign. Benign tumours of the ribs outnumbered malignant ones by a ratio of 5:4. The distinction between benign and malignant lesions is difficult clinically and radiologically unless cortical destruction and soft tissue swelling are present. The pathological differentiation is also not possible in all cases. All the patients with benign tumours were treated by excision with no recurrences or deaths. The overall 5-year survival for primary malignant chest wall tumours was 43% and 10-year survival was 27%. These were the results of radical en bloc excisions. Based on our experiences we believe that all tumours of the bony chest wall should be considered potentially malignant and wide excision should be performed, not only to provide adequate tissue for diagnosis but also to allow the best chance of cure in malignant lesions.     

Factors leading to local recurrence or death after surgical resection of phyllodes tumours of the breast

BACKGROUND: Local recurrence and death from metastases are occasional, but consistent, themes in reports of patients with phyllodes tumours. Factors that might contribute to these outcomes were sought. METHODS: Data from 38 patients with a phyllodes breast tumour were reviewed retrospectively, reclassifying the pathological material using the Pietruszka and Barnes criteria. RESULTS: At a median of 12 months, nine patients had developed a local recurrence and four had died from metastases. Following local excision in 24 patients (for diagnosis in 13, for 'fibroadenoma' in nine and for phyllodes tumour in two patients), 13 had no further surgery and five had local recurrence (three of eight benign tumours, two of two malignant tumours). Wide local excision or mastectomy in 18 patients was followed by four recurrences (one of eight borderline tumours, three of ten malignant tumours). All patients with recurrence had margin involvement on histological examination, but not all patients with margin involvement developed recurrence. Lack of statistical correlation between local recurrence and age, delay, size, grade or type of surgery was confounded by selection bias for more extensive surgery for malignant tumours. Death correlated with size (P = 0.05) and grade (P = 0.03) of tumour. CONCLUSION: Inadequate preoperative diagnosis ('fibroadenoma' or failure of triple assessment) frequently led to local excision with positive margins. Without revision this often resulted in local recurrence. Local recurrence of any grade was usually followed by further recurrence. Death was related to tumour size and histological grade, confirming these as prognostic factors.     

Surgical strategy in primary retroperitoneal tumours

Sixty-nine patients with primary retroperitoneal tumours (17 benign, 52 malignant including 4 malignant tumours of uncertain origin) were reviewed to determine the best form of surgical strategy. Total resection was performed in 88 per cent of benign cases and in 65 per cent of malignant cases. In 62 per cent of the total resections for malignant tumours, en bloc excision included adjacent organs or anatomical structures. Operative mortality rate (in terms of the total number of operations performed) was 5 per cent. Postoperative complications occurred in 14 per cent and recurrences in 35 per cent. The overall 5-year survival rate was 67 per cent in patients with totally resected tumours and zero in patients whose tumours were treated by partial resection or biopsy. An aggressive surgical approach aimed at total excision of the tumour is the best form of therapy currently available. In the totally resected retroperitoneal tumour, the use of adjuvant radiotherapy and/or chemotherapy depends on the grade of the malignancy and clearance as assessed histologically. Careful follow-up based on the use of computerized axial tomography and ultrasound allows early identification of recurrence at a stage when the recurrence is amenable to total resection.     

Endoscopic diagnosis of gastric ulcer. Evaluation of the benefits of endoscopic follow-up observation for malignancy

Examinations at an endoscopy unit in 1976 gave diagnoses of gastric cancer in 31 patients, malignant lymphoma in 3 and new benign gastric ulcer in 223 patients. Correctness of diagnosis was judged to be verified following surgery, autopsy, clinical follow-up or five-year survival. All the malignant lesions were macroscopically and/or microscopically recognized at the first examination, except for one that was then considered to be a submucosal or extragastric tumour, but was correctly diagnosed at surgery prompted by the endoscopic findings. Of the 223 benign ulcers, 219 received a correct diagnosis at the first examination. In the other four cases malignancy was macroscopically or microscopically suspected, but was excluded following surgical excision or repeat examination. Based on these data, the authors suggest that routine endoscopic follow-up of gastric ulcer to exclude malignancy is unnecessary if the primary examination has been performed by an experienced endoscopist, and if both the macroscopic and the microscopic (biopsy) judgement unreservedly are that the lesion is benign.     

Cerebellar astrocytomas: Therapeutic management

Summary The therapeutic management of cerebellar astrocytomas is almost exclusively surgical. Although a few patients survive for long periods without treatment, the majority die without surgery. Total excision is advised to prevent recurrence which almost always follows non-total removal of tumour. Moreover, radical excision is feasible since the cerebellum has a remarkable capacity to compensate after large amounts of tissue have been removed. Morbidity is related to damage to the deep cerebellar nuclei, infiltration of the brain stem, secondary adhesions, and infection. Tumours may not be macroscopically visible at the time of first operation which in turn emphasizes the need for a detailed radiological work-up using, in particular, the CT scan. Biopsy alone, decompression alone, and/or aspiration are usually followed by rapid recurrence and no more than 30% of patients thus treated are recurrence-free five years after surgery. Approximately 40% of patients have subtotal resections and, of these, only 35% are recurrence-free five years post-operatively. Despite the high risk of recurrence following subtotal removal, subtotal excision may still be followed by prolonged survival since two thirds of the patients in the present study were still alive ten years or more after surgery. This is due in part to the unpredictable behaviour of cerebellar astrocytomas, a fact clearly demonstrated by serial CT studies of patients with partially excised tumours which demonstrate that residual tumour may occasionally regress or even remain static for many years. Total removal, when possible, is the treatment of choice and was carried out in 41% of patients in the present study. Ninety-five per cent of patients were free of recurrence for 25 years or more following total removal. In fact, recurrence following total removal has only rarely been recorded and is more often found when the initially excised tumour contains atypical and/or malignant features. Still, a benign histology does not preclude recurrence even when a total macroscopic excision has been achieved. This again emphasises the unpredictable nature of these tumours and the need for long-term radiological follow-up. Overall, operative mortality should be around 5% and even less for unilateral, hemispheric, circumscribed, nodular cerebellar astrocytomas. Conversely, the operative mortality for tumours of the vermis may approach 30% and generally increase with each subsequent operation, being maximal in the first post-operative month.Radiotherapy does not reduce the rate of recurrence nor prolong the overall survival period to death in patients with subtotal removal of tumour. There may also be an attendant risk of radio-necrosis and radiation-induced malignancy. Nevertheless, radiotherapy may still have a place in the treatment of these tumours since there is still some evidence to suggest that craniospinal irradiation may reduce the risk of tumour dissemination from malignant cerebellar astrocytomas. Recurrence in cerebellar astrocytomas has been defined in different ways. Thus, some consider it to be the appearance of tumour following cyst aspiration, whilst others regard it to be the reappearance of tumour following either subtotal or total removal. Thirty-five recurrences were noted in the present study after all modes of surgery and the tumours recurred from 2 to 21 years postoperatively. From previous studies, it is clear that most tumours recur within three to five years and that late recurrences may be of two types. The first is an unpredictable form which behaves in a manner unrelated either to the extent of surgery or the type of histology. The second arises from a malignant change in an initially benign tumour.Long-term clinical and radiological follow-up at six month intervals is essential since the CT scan is able to detect tumours before they become symptomatic and because detection will, at the earliest stages, possibly allow the removal of recurrent tumour before brain stem infiltration has occurred. When the first operation is a simple aspiration, decompression, or subtotal removal and recurrence takes place, it may still be possible to remove tumour totally and prolong survival greatly through reoperation.     

Recurrent phyllodes tumours of the breast: pathological features and clinical implications

BACKGROUND: Phyllodes tumours (PT) of the breast are fibro-epithelial neoplasms that are known to recur locally in up to 19% of patients. The failure to achieve adequate surgical margins is an important risk factor for local recurrence. This, however, is a common problem as PT are clinically similar to the more common fibro-adenoma and are therefore often locally excised without any gross surgical margins. It is still debatable as to whether it is necessary to subject the patient to repeat surgery to obtain pathologically negative margins after a diagnosis of a benign or borderline PT is made. Although the majority of recurrences are histologically similar to the initial tumour, a malignant recurrence is possible. Malignant tumours can metastasize through the haematogenous route and metastases are associated with a poor prognosis as they are poorly responsive to conventional chemotherapy. METHODS: We retrospectively reviewed 37 women who presented with local recurrence over a 10-year period to the Singapore General Hospital. Data, including age at the time of diagnosis, clinical presentation, histological features, type of surgery carried out, clinical progression and characteristics of locally recurrent disease, were analysed. Comparisons were made between those with benign, borderline and malignant tumours, as well as between those who developed a malignant recurrence and those who did not. RESULTS: The mean age at the time of diagnosis was 39.6 +/- 7.4 years and the mean tumour size was 6.0 +/- 5.1 cm. A total of 22 patients were classified as having benign tumour, 9 as having borderline tumour and 6 as having malignant tumour. Tumour grade did not influence the tumour size, the adequacy of surgical margins or the time interval to local recurrence or the number of recurrences. Local recurrence occurred after a median interval of 20 months. Although malignant tumours tended to recur earlier, this was not found to be statistically significant. The majority of recurrent tumours were histologically similar to the initial tumour; however, seven patients (19%) developed a malignant recurrence from an initially benign or borderline tumour. Although these tumours were larger, recurred more frequently and within a shorter interval, no significant predictive factor was found on multivariate analysis. Distant metastasis developed only in patients with malignant tumours and accounted for all three mortalities in the study. CONCLUSIONS: It may be acceptable to use an expectant management towards benign and borderline tumours that are excised without adequate surgical margins. However, surgery for locally recurrent tumours, as well as malignant tumours, should aim to achieve adequate surgical margins to reduce the risk of local recurrence, particularly that of a malignant recurrence.     

Phyllode tumours of the breast. A review of 21 cases

Twenty-one cases of phyllode tumours of the breast (9 malignant, 4 borderline and 8 benign) were reviewed. Three patients with malignant tumours developed metastases, and all died. Eight patients developed local recurrence, 6 in the malignant and borderline groups and 2 in the benign group. The classification into malignant, borderline and benign groups is a reliable guide for use when deciding on the extent of surgery. Malignant and borderline tumours require local mastectomy, while tumour excision suffices for benign disease. The customary pathological separation of malignant phyllode tumours from primary sarcoma of the breast is questioned.     

Primary pulmonary tumours of neurogenic origin.

Primary intrapulmonary neurogenic tumours are extremely rare. In a series of 1664 patients with pulmonary neoplasms observed during 1967-80 only four such tumours were identified (0.2%). All four patients underwent surgical excision. The histological diagnosis was benign neurilemmoma in three cases and malignant schwannoma in the fourth. The patients with neurilemmoma are alive and well four to 12 years after surgery, but the patient with malignant schwannoma died from metastatic spread of the tumour four months after surgery. No association with von Recklinghausen's disease was observed. Macroscopic and microscopic features generally lead to a correct diagnosis in benign types, but the histological diagnosis of malignant schwannoma may present some difficulties and requires the establishment of a definite origin in a nervous structure, identification of benign neurofibroma in different areas of the same tumour, and a high density of cells with appreciable pleomorphism, with mitosis and atypia. Benign tumours carry a good prognosis with little tendency to recur, but malignant schwannoma has a high invasive tendency and is associated with a low survival rate.     

Diagnosis, treatment and long-term outcome of solitary fibrous tumours of the pleura.

OBJECTIVE: Solitary fibrous tumours of the pleura (SFTP) are rare and can histologically be differentiated into benign and malignant forms. The aim of this study is to present new cases, and discuss up-to-date preoperative examinations, the role of video-assisted thoracic surgery and long-term outcome. METHODS: Between 1993 and 2006, 27 SFTPs were diagnosed (14 females, mean age+/-SD, 62.3+/-9.6 years) at our institution. Medical records were reviewed, and follow-up was obtained by repeated examinations or contact with general practitioners. RESULTS: SFTPs were associated with symptoms in 63% of all cases. In the six patients in which positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) was performed preoperatively, malignant lesions were all found to be positive. Complete resection was achieved by video-assisted thoracic surgery in 15 and anterolateral thoracotomy in 12 patients. Mean hospital stay was shorter for patients operated by video-assisted thoracic surgery compared to thoracotomy, 4.5 (range 3-6) versus 7.5 (range 4-25) days, respectively (p<0.01). Histology revealed 17 benign and 10 malignant SFTP. Mean+/-SD tumour diameter of malignant SFTPs was larger than in benign forms, 11.9+/-7.1 versus 6.1+/-3.5 cm, respectively (p<0.01). Tumour recurrence was recognised in four patients with malignant SFTPs at a median time interval after surgery of 38 (range 6-122) months, two late deaths occurred resulting from tumour recurrences. CONCLUSIONS: SFTPs can be treated minimally invasively by video-assisted thoracic surgery with short hospital stay. Large SFTPs with increased FDG-uptake have a high likelihood for malignancy. Long-term follow-up is mandatory in malignant SFTPs because of late recurrences associated with death.     

Cystosarcoma phyllodes: the Western Australian experience.

BACKGROUND: Cystosarcoma phyllodes is a rare breast tumour whose behaviour is not well understood by many clinicians. METHODS: In 1998 a retrospective study was undertaken of women diagnosed with phyllodes tumour of the breast who had their initial surgery between 1983 and 1994 in Western Australian public hospitals. RESULTS: Forty women were diagnosed and treated over this period; however, only 28 received ongoing follow-up (70%). Follow-up was obtained on 26 of these. The median age at diagnosis in this group was 46 years. Cases were predominantly Caucasian (85.5%). Postmenopausal women were affected in 26.9% of cases. Four patients had recurrences after surgery (one malignant and three benign). No patient had a recurrence with primary tumours with a diameter of < or = 2 cm. Mean time to recurrence was 35.8 months. CONCLUSIONS: Breast-conserving surgery was used in almost all cases (96.2% of first operations).     

Prepubertal testicular tumours and efficacy of testicular preserving surgery

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Testicular tumours in childhood are very rare. Historically, most of these tumours have been considered malignant, but more recent studies indicate that benign lesions, particularly teratoma, are much more frequent than previously thought. Testicular tumours in this age group have traditionally been treated with inguinal radical orchiectomy, but more conservative management has been proposed in view of the higher frequency of benign tumours. In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers.

OBJECTIVE

? To report our experience of testicular tumours in children aged ≤13 years, including our experience with testis‐sparing surgery.

PATIENTS AND METHODS

? A retrospective study was performed of 15 patients with testicular tumours aged ≤13 years who presented at our centre between 1984 and 2008. The use of testis‐preserving surgery according to indication was investigated and outcomes were recorded.

RESULTS

? The clinical presentation was increased testicular size with a palpable mass in 80% of the cases. All 15 patients underwent surgery. The tumour was benign in 12 (80%) patients and malignant in three (20%) patients. ? Organ‐preserving surgery was planned and achieved in 11 patients (73%). ? Pathology of the tumourectomy specimens disclosed benign tumours in all cases: four epidermoid cysts, two teratomas, one juvenile granulosa cell tumour, one haemangioma, one lipoma, one fibrous hamartoma and one splenogonadal fusion. ? In four patients who underwent radical orchiectomy, pathology identified one yolk sac tumour (stage I), two mixed germ cell tumours and one gonadoblastoma.

CONCLUSIONS

? In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers. ? The lesion, however, should be thoroughly excised to avoid recurrences.     

Benign mesenchymal tumours of the lung including sclerosing haemangiomas

Clinical aspects of twelve patients with benign mesenchymal lung tumours including four so-called sclerosing haemangiomas were studied. The age of the patients varied from 17 to 62 years (mean 40 years). Seven patients were female and five were male. The benign tumour was enucleated in five cases and excised by segmentectomy in one case. Three tumours were removed by lobectomy, and one by bilobectomy including bronchial resection and bronchoplasty. Two tumours (an endobronchial leiomyoma and fibroma) were removed by bronchial resection. Two patients who had previous hysterectomy for uterine leiomyomas had intraparenchymal pulmonary leiomyomas with histologically benign appearance. Although these tumours might represent metastases from uterine tumours, the follow-up of 5 and 8 years did not reveal clinically malignant features. None of the patients in this series showed tumour recurrences. Our results confirm earlier observations suggesting that the so-called sclerosing haemangioma is actually an epithelial, not a mesenchymal tumour.     

Transanal excision of early rectal carcinoma—review of a personal series

Transanal excision of small rectal tumours is a relatively minor procedure that is potentially curable and can be employed in selected cases of rectal cancer. The outcome of 22 cases treated by local excision was reviewed. This represented 9% of patients treated for rectal cancer over the study period. All patients had a transanal excision with curative intent and included three patients who were medically unfit for a major procedure. Follow up was for a minimum of 5 years or until death if this was earlier. The mean age was 65.7 years with 10 males and 12 females. The 5‐year recurrence rate was 27% (five of 22). The crude 5‐year survival for curative resection was 77%. Of the 22 local excisions, 10 were T1 and 12 were T2. The size of tumour varied from 0.5 cm to 3.5 cm. Eight were well differentiated, 10 moderate and two poorly differentiated. Two of the earlier cases in the series were unclassified. There were six recurrences, all of which were extraluminal. Three recurrences were in less than 3 years (early recurrence) and three beyond this time. Of the recurrences, one presented with liver metastases within 2 months of surgery, one was unfit for a major procedure and subsequently died of a myocardial infarction. The remaining patients with recurrences had salvage surgery. Three are still alive and one died over 5 years after a local excision, with the presence of recurrence. All recurrences were of T2 stage, with moderate (n=5) or poor differentiation (n=1). Three of the six tumours measuring > 3 cm recurred compared with three of the 16 tumours between 0.5 cm and 3 cm. Analysis of these cases demonstrates that local resection of small rectal tumours can give good results and salvage operation is possible in the event of recurrence. Long term follow up is recommended because of risks of late recurrence. The best prognosis group appears to be with the well‐differentiated T1 tumours with no involved margins.     

CYSTOSARCOMA PHYLLODES: THE WESTERN AUSTRALIAN EXPERIENCE

Background : Cystosarcoma phyllodes is a rare breast tumour whose behaviour is not well understood by many clinicians. Methods : In 1998 a retrospective study was undertaken of women diagnosed with phyllodes tumour of the breast who had their initial surgery between 1983 and 1994 in Western Australian public hospitals. Results : Forty women were diagnosed and treated over this period; however, only 28 received ongoing follow-up (70%). Follow-up was obtained on 26 of these. The median age at diagnosis in this group was 46 years. Cases were predominantly Caucasian (85.5%). Postmenopausal women were affected in 26.9% of cases. Four patients had recurrences after surgery (one malignant and three benign). No patient had a recurrence with primary tumours with a diameter of ≤ 2 cm. Mean time to recurrence was 35.8 months. Conclusions : Breast-conserving surgery was used in almost all cases (96.2% of first operations).     

PHYLLODES TUMOURS: A CLINICOPATHOLOGICAL REVIEW OF 30 CASES

Thirty cases of phyllodes tumour (cystosarcoma phyllodes) of the breast that presented to the Clinical Oncology Unit at Guy's Hospital were reviewed. Tumours were classified as benign, malignant or borderline according to the following histological criteria: mitotic rate, nuclear pleomorphism, stromal overgrowth and tumour margins. In 14 (46.5%) cases the tumours were considered histologically benign, in 11 (36.5%) malignant, and in five (17%) borderline. Recurrence was seen in a similar proportion of patients with tumours classified as benign (21 %) and malignant (18 %) according to histological criteria. Malignant lesions tended to recur earlier. Infiltrating tumour margins were noted in all patients and stromal overgrowth in all hut one in whom recurrence was observed. Risk of recurrence also appeared to he related to tumour size. Only one patient developed distant metastases and died of her disease. Because of treatment variation no conclusion can he made regarding optimal therapy but the importance of adequate clearance, either through wide excision or mastectomy, is emphasized for all phyllodes tumours irrespective of histological features.     

Management of incidental impalpable intratesticular masses of < or = 5 mm in diameter

OBJECTIVE: To gain more insight into the histology of small incidental intratesticular lesions and evaluate the need for surgical management, as exploratory surgery is the only way to exclude malignancy in testicular tumours. PATIENTS AND METHODS: Between September 2000 and April 2005, incidental intratesticular masses of < or = 5 mm in diameter were found in 20 men undergoing scrotal ultrasonography for reasons other than suspected testicular tumour. After staging, an organ-sparing approach including frozen-section analysis was used to obtain histological data. RESULTS: The mean diameter of the detected tumour masses was 3.5 mm, and the mean (range) age of the patients was 36.4 (26-58) years. Four men (20%) had orchidectomy because the tumours were found to be malignant; the resected specimens yielded multifocal testicular intraepithelial neoplasia (TIN) in all patients and additional seminomatous tumour cells elsewhere in the testis in one. Frozen-section results were false-negative in one patient and he had orchidectomy after having established the definitive histological diagnosis. The 16 patients with benign lesions were correctly diagnosed and their testicles were not removed. CONCLUSIONS: Advanced and innovative ultrasonography technology allows the detection of increasingly small testicular masses. In the present series, most incidental intratesticular lesions were benign. In patients with malignant lesions, multifocal TIN and/or distant seminomatous foci were present despite the tumour being small. Therefore, it is essential to perform exploratory surgery as it is the only way to obtain accurate histological findings, thus providing oncological efficacy and precluding removal of a testicle bearing a benign lesion.