The role of core needle biopsy in the diagnosis of suspected soft tissue tumours

BACKGROUND

Controversy surrounds the biopsy method of choice for the histological diagnosis of soft tissue sarcoma. The objective of this study was to evaluate the diagnostic accuracy of core needle biopsy (CNB) in patients referred with the suspicion of a soft tissue sarcoma.

METHODOLOGY

Previously undiagnosed patients (n = 530) with a suspected soft tissue tumour (STT) who underwent CNB at initial presentation were identified. Specific end-points were the ability to differentiate benign from malignant tumours, soft tissue from non-STT, and for sarcomas to define subtype and grade.

RESULTS

Of the 530 patients, 426 patients (80.4%) with soft tissue tumours were identified, of which 225 (52.8%) were malignant and 201 (47.2%) benign. In the remaining 104 patients, tumours masquerading as STT were diagnosed. CNB could differentiate soft tissue sarcomas from benign soft tissue tumours with an accuracy of 97.6%. High grade were differentiated from low grade sarcomas with an accuracy of 86.3%. Tumour subtype was accurately assigned in 89.5% of benign tumours and 88.0% of sarcomas.

CONCLUSION

CNB is simple, safe and can accurately diagnose benign and malignant soft tissue tumours. It can reliably identify other tumours masquerading as sarcoma. CNB should be the method of choice to obtain a histological diagnosis in suspected STT.

[How to avoid the inappropriate prescriptions in nursing homes?]

The inappropriate prescription is frequent in the Belgian nursing homes. Which are the better tools to control and improve our prescription? Is it relevant to start or continue medications for prevention in the context of moderate or severe dementia? STOPP-START seems to be a good screening tool for detecting the inappropriate prescriptions by the general practitioner.

Vertical and horizontal variations in the physiological diversity of the aerobic chemoheterotrophic bacterial microflora in deep southeast coastal plain subsurface sediments

Aerobic chemoheterotrophic bacteria were isolated from surface soils and coastal plain subsurface (including deep aquifer) sediments (depths to 265 m) at a study site near Aiken, S.C., by plating on concentrated and dilute media. Morphologically distinct colonies were purified, and their responses to 21 selected physiological tests were determined. These isolates were quite diverse; 626 physiologically distinct types (i.e., types with a unique pattern of responses to the 21 tests) were detected among the 1,112 isolates obtained. Physiologically distinct types were isolated on concentrated and dilute media (only 11% overlap between the groups); isolates from surface soils and subsurface sediments were also quite different (only 3% overlap). The surface soil isolates more readily utilized all but 1 of 12 carbon sources offered, and a significantly larger proportion of them hydrolyzed esculin and gelatin. Only 4% of the subsurface isolates fermented glucose, even though 82% of them could use it aerobically. l-Malate and d-gluconate were utilized by at least 75% of the subsurface isolates, and seven other carbon sources were used by at least 40% of them. Subsurface isolates from different geological formations (depths) and, to a lesser extent, from the same geological formation at different boreholes differed distinctly in their group responses to certain physiological tests. Moreover, sediments from different depths and boreholes contained physiologically distinct types of bacteria. Thus, considerable bacterial diversity was observed in coastal plain subsurface sediments, even within defined geological formations.

Surgical management of primary retroperitoneal sarcoma

BACKGROUND

Local recurrence after surgical resection is the main cause of disease-related mortality in patients with primary retroperitoneal sarcoma (RPS). This study analysed predictors of local recurrence and disease-specific survival.

METHODS

A prospective database was reviewed to identify patients who underwent surgery for primary RPS between 1990 and 2009. Patient demographics, operative outcomes and tumour variables were correlated with local recurrence and disease-specific survival. Multivariable analysis was performed to evaluate predictors for local recurrence and disease-free survival.

RESULTS

Macroscopic clearance was achieved in 170 of 200 patients. The median weight of tumours was 4.0 kg and median maximum diameter 27 cm. Resection of adjacent organs was required in 126 patients. The postoperative mortality rate was 3.0 per cent. Seventy-five patients developed local recurrence during follow-up. At 5 years the local recurrence-free survival rate was 54.6 per cent and the disease-specific survival rate 68.6 per cent. Inability to obtain macroscopic clearance at resection and high-grade tumours were significant predictors for local recurrence and disease-specific survival.

CONCLUSION

Complete macroscopic excision should be the goal of surgical resection. Ability to resect a RPS completely and tumour grade are the most important predictors of local recurrence and overall survival.

Risk markers for both chronic fatigue and irritable bowel syndromes: a prospective case-control study in primary care

BACKGROUND

Fatigue syndromes and irritable bowel syndrome (IBS) often occur together. Explanations include being different manifestations of the same condition and simply sharing some symptoms.

METHOD

A matched case-control study in UK primary care, using data collected prospectively in the General Practice Research Database (GPRD). The main outcome measures were: health-care utilization, specific symptoms and diagnoses. Risk markers were divided into distant (from 3 years to 1 year before diagnosis) and recent (1 year before diagnosis).

RESULTS

A total of 4388 patients with any fatigue syndrome were matched to two groups of patients: those attending for IBS and those attending for another reason. Infections were specific risk markers for both syndromes, with viral infections being a risk marker for a fatigue syndrome [odds ratios (ORs) 2.3-6.3], with a higher risk closer to onset, and gastroenteritis a risk for IBS (OR 1.47, compared to a fatigue syndrome). Chronic fatigue syndrome (CFS) shared more distant risk markers with IBS than other fatigue syndromes, particularly other symptom-based disorders (OR 3.8) and depressive disorders (OR 2.3), but depressive disorders were a greater risk for CFS than IBS (OR 2.4). Viral infections were more of a recent risk marker for CFS compared to IBS (OR 2.8), with gastroenteritis a greater risk for IBS (OR 2.4).

CONCLUSIONS

Both fatigue and irritable bowel syndromes share predisposing risk markers, but triggering risk markers differ. Fatigue syndromes are heterogeneous, with CFS sharing predisposing risks with IBS, suggesting a common predisposing pathophysiology.

Clinical outcomes of extra-thoracic solitary fibrous tumours

BACKGROUND

Extra-thoracic solitary fibrous tumours (ESFTs) have traditionally been regarded as indolent neoplasms similar to their intra-thoracic counterparts. However there has been some evidence that a subset of more aggressively malignant tumours exist. We examined our experience with these rare tumours in an effort to clarify their clinico-pathological behaviour and relate this to their histopathological findings.

PATIENTS/METHODS

All patients with a histopathological diagnosis of solitary fibrous tumour (SFT) who presented to the Royal Marsden Hospital between 1998 and 2006 were reviewed. Clinico-pathological data were recorded for all cases and subset analysis performed to compare rates of locoregional recurrence, distant metastases and death.

RESULTS

There were 33 cases included in the study. 18 cases had malignant features on histological examination. Locoregional recurrent disease was more common in those with malignant histopathological findings compared to those with benign histopathology (6/18 vs 0/15 p 0.021). Distant metastatic disease was more common in those with malignant histopathological findings (7/18 vs 1/15 p 0.046) and these patients were at increased risk of death (10/18 vs 0/15 p<0.01). The presence of malignant histopathology was the only factor to affect survival with no benign cases dying of disease and malignant cases having a median survival of 59 months (p 0.003).

CONCLUSION

In our experience ESFTs have a higher rate of malignant behaviour than that classically described. Those tumours with atypical or malignant features on histological examination have poor prognosis and should be managed and followed up in the same manner as other high-grade soft tissue tumours.

Treatment and outcome of radiation-induced soft-tissue sarcomas at a specialist institution

BACKGROUND

Radiation-induced sarcoma (RIS) is a rare late complication of therapeutic irradiation with a reputation for aggressive pathology and poor outcome.

METHODS

We retrospectively reviewed histopathological features, surgery and outcome in 67 patients with RIS treated between 1990 and 2005 at a single tertiary referral center.

RESULTS

Previous breast cancer was the most common indication for radiotherapy. The median interval from irradiation to development of RIS of was 11 years (3-36 years). Median tumour size was 7 cm with 56% classified as high grade, 31% intermediate grade and 13% low grade. The commonest histology was leiomyosarcoma. The only relationship for histology with site was for angiosarcoma (n=9), all of which developed on the chest wall/breast after irradiation for breast cancer. Of 67 patients, 34 underwent potentially curative surgery, and microscopically clear margins were achieved in 75% of cases. Pedicled or free tissue transfer was required in 12 patients and abdominal or chest wall mesh reconstructions were required in 8 patients. No patient received adjuvant radiotherapy but 7 received adjuvant/neoadjuvant chemotherapy. Median follow up is 53 months. Median sarcoma specific survival was 54 months (2- & 5-year survival: 75% & 45%). The local relapse rate was 65%. Negative histopathological margins were a significant predictor of sarcoma specific survival (HR 3.0 95% CI 1.1-8.6 p=0.04). Grade and size of tumour approached, but did not attain significance.

CONCLUSION

RIS is a biologically aggressive tumour with high rates of local relapse despite aggressive attempts at curative surgery.

[Risk factors of osteoporosis]

Osteoporosis constitutes an important public health problem. The diagnosis is based only upon osteodensitometry. The risk of fracture depends also from factors independent from the bone mass. Scales of risks are developed to better evaluate the risk fracture of the patients.

Pancreatic islet isolation variables in non-human primates (rhesus macaques)

BACKGROUND

Non-human primates (NHPs) are important preclinical models for pancreatic islet transplantation (PIT) because of their close phylogenetic and immunological relationship with humans. However, low availability of NHP tissue, long learning curves and prohibitive expenses constrain the consistency of isolated NHP islets for PIT studies. To advance preclinical studies, we attempted to identify key variables that consistently influence the quantity and quality of NHP islets.

METHODS

Seventy-two consecutive pancreatic islet isolations from rhesus macaques were reviewed retrospectively. A scaled down, semi-automated islet isolation method was used, and monkeys with streptozotocin-induced diabetes, weighing 3-7 kg, served as recipients for allotransplantation. We analysed the effects of 22 independent variables grouped as donor factors, surgical factors and isolation technique factors. Islet yields, success of isolation and transplantation results were used as quantitative and qualitative outcomes.

RESULTS

In the multivariate analysis, variables that significantly affected islet yield were the type of monkey, pancreas preservation, enzyme lot and volume of enzyme delivered. The variables associated with successful isolation were the enzyme lot and volume delivered. The transplant result was correlated with pancreas preservation, enzyme lot, endotoxin levels and COBE collection method.

CONCLUSIONS

Islet quantity and quality are highly variable between isolations. The data reviewed suggest that future NHP isolations should use bilayer preservation, infuse more than 80 ml of Liberase into the pancreas, collect non-fractioned tissue from the COBE, and strictly monitor for infection.

Melanoma recurrence confined to a free flap after isolated limb perfusion

We present the case of a 72-year-old female presenting to our unit with locally recurrent malignant melanoma of the lower limb almost entirely confined to a fasciocutaneous free flap. The flap (lateral arm donor site) had been used several years previously to reconstruct a wide local excision defect following the excision of recurrent disease. The striking difference about this case is that the recurrence observed after isolated limb perfusion (ILP) was almost entirely confined to the flap rather than the affected limb. Several possible explanations for this phenomenon are discussed--considering factors such as altered flap lymphatics, neuronal factors, and differential flap-versus-normal tissue response to the tumour necrosis factor used in ILP. The case highlights interesting questions about the mechanism of action of ILP--especially with regard to free flap tissue--and unknowns regarding tumour spread across wound scar boundaries.

Positron emission tomography and pathological evidence of response to neoadjuvant therapy in adenocarcinoma of the esophagus

Our aim was to determine if fluorodeoxyglucose positron emission tomography (FDG-PET) could be correlated with a pathological response in patients with esophageal adenocarcinoma receiving neoadjuvant chemotherapy and/or chemoradiation therapy. Patients with resectable, histologically proven adenocarcinoma of the esophagus were entered in the study. Preoperative chemotherapy comprised two cycles of cisplatin and 5-fluorouracil. Radiation therapy commenced with the second cycle on day 22. FDG-PET images were obtained pre-treatment and on completion of intended neo-adjuvant treatment. Quantification was achieved by the calculation of both standardized uptake values (SUV) and tumor/liver ratios (TLR). Evidence of histopathological response was identified according to the Mandard tumor regression scoring system. There were 45 patients, 22 receiving neoadjuvant chemotherapy and 23 chemoradiation therapy. Forty patients underwent surgical resection. Seven patients (16%) had a histopathological response. The mean percentage change in SUV in the histological responders group was -56.8% (SD 29) and in the non-responders -27.8% (SD 32.1) (P = 0.035). The mean percentage change in TLR was -49.1% (SD 44.8) in the responders and in the non-responders -27.3% (SD 31.3) (P = 0.128). There was no difference between the two methods of assessment, however there was less variation with SUV. There was no correlation between the FDG-PET response and the histopathological response. Presently an FDG-PET scan performed 3-6 weeks after neoadjuvant therapy for adenocarcinoma of the esophagus should not be used as a marker of the potential result of the treatment. The optimal timing of a second FDG-PET remains unclear.

Long-term engraftment following transplantation of pig pancreatic primordia into non-immunosuppressed diabetic rhesus macaques

BACKGROUND

Transplantation therapy for human diabetes is limited by a shortage of donor organs, and transplant function diminished over time by cell death and limited potential for expansion of beta cells in pancreas or islets. Outcomes are complicated by immunosuppression. A way to overcome supply and expansion problems is to xenotransplant embryonic tissue. Previously, we have shown that beta cells originating from embryonic day (E) 28 (E28) pig pancreatic primordia transplanted into the mesentery of streptozotocin (STZ)-diabetic (type 1) Lewis rats or Zucker Diabetic Fatty (ZDF) diabetic (type 2) rats engraft and normalize glucose tolerance without the need for host immune-suppression.

METHODS

In this study, we transplant E28 pig pancreatic primordia in the mesentery of STZ-diabetic rhesus macaques.

RESULTS

Long-term engraftment of pig beta cells within liver, pancreas and mesenteric lymph nodes post-transplantation of E28 pig pancreatic primordia into STZ-diabetic rhesus macaques is demonstrated by electron microscopy, positive immune-histochemistry for insulin, and positive RT-PCR and in situ hybridization for porcine proinsulin mRNA. Insulin requirements were reduced in one macaque followed over 22 months post-transplantation and porcine insulin detected in plasma using sequential affinity chromatography, HPLC and mass spectrometry. Of potential importance for application of this transplantation technology to treatment of diabetes in humans and confirmatory of our previous findings in Lewis and ZDF rats, no host immunosuppression is required.

CONCLUSIONS

Under selected circumstances, pancreatic primordia elicit a muted immune response relative to more differentiated tissue, such that engraftment occurs in non-immunosuppressed hosts. Our findings that pig pancreatic primordia engraft long-term in non-immunosuppressed STZ-diabetic rhesus macaques establishes the potential for their use in human diabetics.

Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy

Chemoradiotherapy (CRT) as a definitive treatment for esophageal cancer, is being used with increasing frequency and as a result, surgeons will be required to assess more patients who have residual or recurrent local malignancy. This article aimed to assess outcomes after esophagectomy following definitive CRT (dCRT) and compare any difference between them and patients who had preoperative neoadjuvant CRT (nCRT) using a similar regimen of chemotherapy. From a prospective database the details of patients who had a resection following nCRT and dCRT were analyzed. The main therapeutic difference between the groups was the dose of radiotherapy (35 vs 60 Gy) and the timing of the resection following completion of the CRT (median 4 vs 28 weeks). Fourteen patients had an esophagectomy following a dCRT and 53 had one following a nCRT. Preoperatively, the dCRT group had worse respiratory function and more ECG abnormalities. Preoperative tumor length, pathological TNM staging and R0 resection rates were the same in both groups. Post resection, the dCRT group had greater morbidity than the nCRT group, spending longer in the intensive care unit (median 48 vs 24 h), more days in hospital (median 31 vs 13) and having more severe respiratory complications (37%vs 6%). The operative mortality was higher in the dCRT group (7%vs 0%). The three-year survival was 24% after dCRT. Patients selected for salvage esophagectomy following dCRT are a major challenge in postoperative care. However, some patients survive for a reasonable period of time, making resection a worthwhile option.

Clear cell sarcoma (melanoma of soft parts): The Royal Marsden Hospital experience

INTRODUCTION

Clear cell sarcoma (CCS) is a rare tumour with a propensity for local recurrence and nodal metastasis. About 300 cases have been reported, thus further clarification regarding the course and outcome of the disease is required.

METHODS

Patients with a histopathologic diagnosis of CCS were identified from prospective histopathology and sarcoma databases and supplemented with a retrospective analysis of the patients' hospital records.

RESULTS

Between 1990 and 2005, a total of 72 patients with a diagnosis of CCS were identified, 35 having been referred for management and 37 having been referred for histopathologic opinion. The median age was 39 years (range 5-90 years). Of the 35 patients referred to the Royal Marsden Hospital for management, 23% developed local recurrence or in-transit metastases at a median of 9 months (2-79 months) after resection of the primary, and nodal or distant metastatic disease was seen in 63% after 14 months (range 0-177 months). Five- and 10-year survival were 52% and 25%, respectively.

CONCLUSIONS

CCS has a number of similarities with melanoma, particularly in its peripheral distribution and propensity for nodal disease. Wide excision with clear margins offers the best chance of cure. Local recurrence and regional metastases are common, and are almost always followed by distant metastases and death.

Cloning and characterization of recombinant rhesus macaque IL-10/Fc(ala-ala) fusion protein: a potential adjunct for tolerance induction strategies

The powerful anti-inflammatory and immunosuppressive activities of IL-10 make it attractive for supplemental therapy in translational tolerance induction protocols. This is bolstered by reports of IL-10-mediated inhibition of innate immunity, association of human stem cell and nonhuman primate (NHP) islet allograft tolerance with elevated serum IL-10, and evidence that systemic IL-10 therapy enhanced pig islets survival in mice. IL-10 has not been examined as adjunctive immunosuppression in NHP. To enable such studies, we cloned and expressed rhesus macaque (RM) IL-10 fused to a mutated hinge region of human IgG1 Fc to generate IL-10/Fc(ala-ala). RM IL-10/Fc(ala-ala) was purified to approximately 98% homogeneity by affinity chromatography and shown to be endotoxin-free (<0.008 EU/microg protein). The biological activity of IL-10/Fc(ala-ala) was demonstrated by (1) costimulation of the mouse mast cell line, MC/9 proliferation in a dose-dependent fashion, (2) suppression of LPS-induced septic shock in mice and (3) abrogation of LPS-induced secretion of proinflammatory cytokines/chemokines in vitro and in vivo in NHP. Notably, RM IL-10/Fc(ala-ala) had significantly greater potency than human IL-10/Fc(ala-ala) and exhibited a circulating half-life of approximately 14 days. The availability of this reagent will facilitate definitive studies to determine whether supplemental therapy with RM IL-10/Fc(ala-ala) can influence tolerance outcomes in NHP.

Insulin secretion from pancreatic islets in fibrin glue clots at different fibrinogen and thrombin concentrations

BACKGROUND

Fibrin glue has proven to be a good delivery system for cell transplantation but the factors that influence the fibrin-cell relationships are not well understood. The purpose of this study was to assess the effect of different concentrations of fibrin glue components (thrombin and fibrinogen) on the function of pancreatic islets.

METHOD

Islets were isolated from rat pancreata and combined with 6 different fibrin glue formulations. Each islet sample was incubated sequentially with RPMI containing low and high glucose, and culture supernatants were harvested for insulin determination using enzyme-linked immunosorbent assay (ELISA).

RESULTS

The control group (no fibrin glue) and group 3 (with thrombin 50 U/mL and fibrinogen 10 mg/mL) had the highest insulin secretion in response to glucose stimulation. These were followed by groups 5 and 4 with 2.6 and 1.8 stimulation indexes, respectively. Group 2 (with thrombin 50 U/mL and fibrinogen 5 mg/mL) and group 6 (commercial kit with thrombin 250 U/mL and fibrinogen 75-115 mg/mL) had the lowest insulin response after glucose stimulation.

CONCLUSION

This study demonstrates that different fibrin glue formulations significantly impact pancreatic islets function. In the future, when using fibrin glue as a carrier for pancreatic islet transplantation, lower concentrations of fibrinogen and thrombin are recommended to obtain more viable and functional grafts.

Retroperitoneal sarcoma

Poor prognosis and difficult to treat

Nutritional status and length of stay in patients admitted to an Acute Assessment Unit

BACKGROUND

The Redesigning Care initiative at Flinders Medical Centre aimed to improve access to timely, consistent, quality care. This led to the creation of an Acute Assessment Unit (AAU) where all patients are assessed by the Allied Health team on admission. This study aimed to: (i) determine the nutritional status of patients admitted to the AAU using the scored Patient Generated-Subjective Global Assessment (PG-SGA); and (ii) determine the association between nutritional status and length of stay (LOS).

METHODS

A prospective, observational study was conducted in 64 patients (mean age 79.9 +/- 11 years, 76% female). Nutritional status was assessed within 48 h of admission and LOS data were collected prospectively.

RESULTS

According to PG-SGA global rating, 53% (n = 34) of patients were malnourished. There was a weak association between PG-SGA score and LOS (r = 0.250, P = 0.046). The malnourished patients had a longer LOS by 1 day compared to well-nourished patients, and while this did not reach statistical significance (Z = -0.988, P = 0.323), it has implications for health care costs. LOS overall was short at a median of 4.5 days (range 1-24).

CONCLUSIONS

A significant proportion of patients admitted to the AAU is malnourished. There was a trend for these patients to have a longer LOS, indicating a critical need for nutritional management; however LOS as a whole was short. While nutrition support in hospital is useful in reinforcing dietary education, the short LOS emphasized the importance of discharge education and follow-up.

Islet yield after different methods of pancreatic Liberase delivery

OBJECTIVE

Enzymatic digestion of the pancreas is a fundamental step in islet isolation and there are many ways to administer the enzyme during procurement. The aim of this study was to evaluate the influence of different methods of Liberase delivery during pancreas harvest on the quality and quantity of islets.

METHODS

Depending on the type of Liberase delivery, 4 groups were created. Group 1 was intraductal, Group 2 was interstitial, Group 3 was intragallbladder, and Group 4 was no infusion of enzyme. After injection, the pancreata were harvested, digested in Liberase solution, mechanically disrupted, and purified using discontinuous gradient centrifugation. After 24-hour culture, the number, purity, and viability of the isolated islets were determined.

RESULTS

Intraductal injection of the enzyme yielded statistically significantly more islets per mouse when compared with interstitial, intragallbladder, and no injection administration. Although there was a trend toward better islet purity and viability for Group 1, this was not statistically significant.

CONCLUSION

Intraductal administration is the best enzyme delivery method for pancreatic islet isolation. The pancreatic ducts are the most anatomic and physiological way to transport the enzyme uniformly inside the pancreas, determining an adequate digestion and better islet quantity and quality when compared with other delivery methods.

Subcutaneous pancreatic islet transplantation using fibrin glue as a carrier

BACKGROUND

Pancreatic islet grafts are difficult to manipulate and implant in the recipient site mainly because they are formed by a group of cells suspended in a solution. This physical property determines various characteristics that are unique for pancreatic islet transplantation. The purpose of this study was to evaluate the role of fibrin glue as a delivery method for islet transplantation.

METHODS

C3H mouse islets were syngeneically transplanted into streptozotocin-diabetic recipients using fibrin glue in a subcutaneous pocket (Group 1) and using liquid islets injected under the kidney capsule (Group 2). Blood glucose levels were measured during 4 weeks of follow-up and compared against normal (Group 3) and diabetic levels (Group 4).

RESULTS

No statistical differences were observed between the normal, kidney capsule, and fibrin glue groups. Only the diabetic group had a statistical difference when compared with the normal control group (P < .01). At the beginning, levels in Group 1 (fibrin glue) were higher than in Group 2 (kidney capsule), but turned into similar values after time and no statistical differences were observed between them during follow-up.

CONCLUSIONS

Islet/fibrin glue grafts placed in a subcutaneous pocket obtained the same results as liquid grafts placed under the kidney capsule, proving to be an adequate delivery method for islet transplantation and solving some of the engraftment problems we find with liquid grafts.

Surgical management of soft tissue sarcoma in patients over 80 years

AIMS

To report outcome on patients over 80years of age with soft tissue sarcoma (STS), with respect to surgical treatment, co-morbidity, complications and survival.

METHODS

From a prospective database of 3400 patients with STS presenting over a 13-year period, all patients over 80years of age were identified and reviewed, with respect to tumour characteristics morbidity, mortality and outcome.

RESULTS

128 patients over 80years were treated for STS with 63 referred for treatment of primary disease, of whom 50 underwent resectional surgery. The remaining 65 patients were treated for recurrent or incompletely excised disease. Of the 50 patients treated primarily with surgery, 56% of tumours where high grade and 56% were greater than 10cm in diameter. The overall complication rate was 34%, with a 30-day mortality of 4%. Two- and 5-year survival rates were 56% and 46%, with a local recurrence rate of 22% at a mean follow-up of 22months.

CONCLUSION

This patient group presented with poor prognosis tumours that were associated with poor outcomes in the medium to long term. Age need not be considered a contra-indication to radical surgery with curative intent.