Pioneering technique using Acellular Dermal Matrix in the rescue of a radiation ulcer

BACKGROUND

Radiotherapy as an adjuvant to mastectomy is integral to the treatment of breast cancer, but can result in skin ulceration. Skin ulceration following radiotherapy is traditionally managed by removing the implant and allowing the skin to heal by secondary intention.

CASE REPORT

A 42-year-old woman underwent radiotherapy following a breast reconstruction. She developed a 2 x 3cm radiation ulcer. The ulcer was managed by removing the implant and performing capsulectomy. A Beckers 50 expander was placed and reinforced with acellular dermal matrix inferolaterally. At follow-up the patient had a good cosmetic outcome.

CONCLUSION

Post-radiation skin ulcers present a challenge to treat with no current standardised management. The use of acellular dermal matrix may present a new technique to promote healing in these testing cases.

Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound

BACKGROUND

In patients with breast cancer, grey-scale ultrasound often fails to identify lymph node (LN) metastases. We aimed to validate the technique of contrast-enhanced ultrasound (CEUS) as a test to identify sentinel lymph node (SLN) metastases and reduce the numbers of patients requiring a completion axillary node clearance (ANC).

METHODS

371 patients with breast cancer and a normal axillary ultrasound were recruited. Patients received periareolar intra-dermal injection of microbubble contrast agent. Breast lymphatics were visualised by CEUS and followed to identify and biopsy axillary SLN. Patients then underwent standard tumour excision and either SLN excision (benign biopsy) or axillary clearance (malignant biopsy) with subsequent histopathological analysis.

RESULTS

The technique failed in 46 patients, 6 patients had indeterminate biopsy results and 24 patients were excluded. In 295 patients with a conclusive SLN biopsy, the sensitivity of the technique was 61% and specificity 100%. Given a benign SLN biopsy result, the post-test probability that a patient had SLN metastases was 8%. 35 patients were found to have SLN metastases and had a primary ANC (29 macrometastases and 6 micrometastases/ITC). There were 22 false negative results (10 macrometastases and 12 micrometastases). Macrometastases in core biopsy specimens correlated with LN macrometastases on surgical excision.

CONCLUSION

Pre-operative biopsy of SLN reduced the numbers of patients requiring completion ANC. Despite the low sensitivity, only 22 patients (8%) with a benign SLN biopsy were subsequently found to have LN metastases. Without the confirmation of macrometastases on core biopsy specimens, patients with micrometastases/ITC may be inadvertently selected for primary ANC.

HTERT mRNA expression correlates with matrix metalloproteinase-1 and vascular endothelial growth factor expression in human breast cancer: a correlative study using RT-PCR

BACKGROUND

Telomerase activity has been significantly associated with nodal metastasis and cellular proliferation in human breast cancer, indicating that its degree of expression has some form of vital control over the invasive nature of the malignancy concerned. Of the telomerase subunits, the reverse transcriptase (hTERT) is the main determinant of enzyme activity. Vascular endothelial growth factors (VEGF)-C and (VEGF)-D, matrix metalloprotease type 1 (MMP-1) and protease-activated receptors (PARs) have all been linked to promotion of tumour invasiveness and metastatic dissemination. This study aims to examine the association between hTERT transcription and that of VEGF-D, VEGF-C, MMP-1, PAR1a and PAR1b through a correlative analysis of the mRNA transcripts of these genes in human breast cancer.

MATERIALS AND METHODS

Breast cancer tissues (n = 116) and normal tissues (n-31) were collected immediately after surgery and stored at -80 degrees C until use. The level of hTERT transcripts from the prepared DNA from the above samples was determined using real time-quantitative PCR based on the Amplifluor technology. The levels of the transcript were generated from a standard that was simultaneously amplified with the samples. Normalisation against cytokeratin 19 (CK19) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was also carried out.

RESULTS

There was a positive correlation between hTERT mRNA expression (after CK19 normalisation) with both VEGF-D and MMP-1 in human breast cancer. PAR1 was seen to correlate with hTERT (after GAPDH normalisation) with a highly significant correlation with PAR1a alone. However there was no correlation between hTERT transcription and VEGF-C or with PAR1b alone.

CONCLUSION

Our findings suggest that hTERT is a potential up-regulator of MMP-1, PAR1 and VEGF-D expression and this may explain its apparent control over the invasiveness and metastasis of the malignancy concerned.

Post-caesarean incisional hernia or scar endometrioma?

Scar endometrioma is an uncommon condition following caesarean section. It presents as a lump on the caesarean scar and can often be painful. Endometrioma is referred to the general surgeon as an incisional hernia. We present six such patients referred to the general surgical department by either the general practitioner or the gynaecologist. Scar endometrioma is believed to arise due to implantation of endometrial tissue during caesarean section. Cyclical pain, as in endometriosis, is characteristic but uncommon. Local wide excision remains the treatment of choice.

Otitis externa in UK general practice: a survey using the UK General Practice Research Database

BACKGROUND

Otitis externa is a common clinical problem in general practice and yet there are remarkably few data available on the demographic characteristics of patients with this condition and the approaches used by general practitioners (GPs) in the United Kingdom (UK) to manage it.

AIM

To define the descriptive epidemiology of otitis externa in the general population, to describe the first-line drug treatment used by UK GPs, and to determine factors related to second disease episodes.

DESIGN OF STUDY

Epidemiological data survey.

SETTING

All cases of otitis externa occurring in 1997 in practices contributing data to the UK General Practice Research Database.

METHOD

Data were extracted on age, sex, date of episode of otitis externa, treatment prescribed, co-existing diagnoses of eczema and diabetes, referral to ear, nose, and throat departments and occurrence of subsequent episodes of disease. Arbitrarily a second episode of disease was defined as persistence if it occurred at 28 days or fewer after the first episode and recurrence if it occurred at more than 28 days after the first episode.

RESULTS

A diagnosis of otitis externa was common in all age groups and, except in the elderly, was more common in females than males. There was an increase in disease episodes at the end of the summer in all age groups except the 60 years and over group. In the majority of cases GPs prescribed ear drops (85%), but a significant proportion of patients were also prescribed oral antibiotics (21%). Referral to secondary care was uncommon (3%). Among patients prescribed ear-drop formulations, those containing both steroid and antibiotic or steroid alone were used most commonly and were associated with the lower rates of disease persistence but not recurrence. Among patients prescribed antibiotics, penicillins were prescribed most commonly. Disease persistence rates, and to a lesser extent disease recurrence rates, were higher in patients prescribed oral antibiotics.

CONCLUSION

Otitis externa is a common condition and GPs can expect to see an excess of cases at the end of the summer. Topical ear drops are the most common treatment used in the UK. Patients prescribed steroid or steroid/antibiotic combination ear drops have fewer subsequent consultations for otitis externa over the following 28 days.

Preferential prescribing of type of combined oral contraceptive pill by general practitioners to teenagers with acne

OBJECTIVES

To determine the oral contraceptive prescribing patterns of general practitioners for teenagers in the UK and any preferential prescribing for those with acne.

METHOD

The General Practice Research Database was used in a retrospective observational study. Records of females aged 13-19 years were examined for the years 1994 and 1997.

RESULTS

In 1994, third-generation pills were widely prescribed, whereas, in 1997, levonorgestrel pills were most commonly prescribed. In those with a recent history of acne, the most commonly prescribed single product was one containing cyproterone acetate.

CONCLUSION

General practitioners appear to favor cyproterone acetate-containing pills for those with acne; this proclivity became more pronounced after the pill scare. General practitioners had all but ceased using third-generation pills in 1997, even when there was a therapeutic indication.

Use of the combined oral contraceptive pill by under 16s

The General Practice Research Database was used to examine prescribing of the combined oral contraceptive pill for females aged under 16 in England and Wales in 1997. From these data, calculations were made to estimate prevalence for these countries; family planning clinic return data were combined with the general practice estimates to give an overall figure of 4.2 per 100. This extent of use is low considering the amount of sexual activity now occurring. A weak effect of population density on prescribing was found, with higher rates in the more rural areas.

Repeated use of hormonal emergency contraception by younger women in the UK

A cohort of women aged 14-29 in 1993 was identified from the General Practice Research Database and followed up for a period of 4 years. Patient files were searched for evidence of use of emergency contraception and regular contraception. Of the 95 007 women, 15 105 (16%) had received emergency contraception during the study period (an average of 5% per annum). There was a small year on year increase in uptake of emergency contraception between 1994 and 1997. Only 4% of emergency contraception users received emergency contraception more than twice in any year. More than 70% of those who had no previous record of use of regular contraception had used regular contraception within 1 year of using emergency contraception. Teenagers were more likely than other age groups to use emergency contraception, to be repeat users of emergency contraception and to fail to start regular contraception after first use of emergency contraception until later in the study period. These results disprove the notion of widespread repeated use of emergency contraception. They show that provision of an emergency contraception service does not result in failure to initiate regular contraception or abandonment of regular contraception; rather they show many women using regular contraception for the first time after use of emergency contraception.

Pseudomyxoma peritoneii

A middle aged male patient presented with gradual distension of the abdomen. Imaging modalities showed classical features of pseudomyxoma peritoneii which was confirmed by aspiration cytology. Details of the case are described and relevant literature is reviewed.