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Introduction Oesophageal cancer is the 7th commonest cause of cancer death worldwide. Radiological staging of local oesophageal cancer is inaccurate. CT currently relies on attenuation of x-rays to generate contrast. Soft tissues have very similar attenuation properties so minimal contrast is generated. X-ray phase contrast imaging (XPCI) uses refraction of x-rays as they pass through tissue instead of attenuation and provides much higher soft tissue contrast. This technology can be tuned to a resolution of approximately 10 µm. This may allow for easy assessment of extent of disease infiltration. We aimed to use XPCI to image oesophagectomy specimens to assess pathological tumour and nodal stage for oesophageal cancer Methods Following ethical approval, 10 oesophagectomy specimens were obtained from patients having surgery for oesophageal cancers. These included both squamous and adenocarcinomas. Specimens were fixed in formalin for 12 hours. Sutures were placed through tissue to enable co-registration between CT slices and histology sections. For some scans, tissue was then dehydrated with graded ethanol for between 4.5 hours and 72 hours before being imaged. A Rigaku (MicroMax 007) xray source was used at 40 kV and 20 mA; a detector with 50µm pixel size; and sample and detector masks made of graphite substrate with gold overlay. Phase contrast was generated using edge illumination technique. We reconstructed the images using MATLAB® software. Specimens were returned for clinical histopathological assessment allowing correlation between H&E slides and CT images. Results We have performed 25 scans on 10 oesophagectomy samples and correlated them with histology Scans of samples in formalin failed to show adequate contrast between oesophageal layers to enable tumour visualisation and staging. Infiltrating the tissue with ethanol led to much better image contrast. We could easily identify mucosa, submucosa and both layers of muscle in reconstructed CT images. We also identified tumour infiltration through tissue layers and destruction of normal oesophageal morphology (figure 1). This was confirmed histologically and could be recognised by radiologists blinded to pathological staging This is the first time that XPCI has been used to image human oesophageal tissue. We have demonstrated the feasibility of the technique and the possibility of obtaining high resolution images which mimic histology with the extra benefit of demonstrating three dimensional structure.

Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus. A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment. Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively). We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.

Esophageal cancer has a poor prognosis, with little improvement in outcomes in recent years. Surgery maintains its pivotal role in cure, but this involves two or three compartment dissection with associated high risks. Chiefly, pulmonary complications following surgery are most common, and can be life-threatening. As a consequence, minimally invasive and robotic esophagectomy have been performed with improving efficacy and equivalent oncological outcomes. This is a review of the pertinent literature regarding these techniques. J. Surg. Oncol. 2016;114:731-735. © 2016 Wiley Periodicals, Inc.

Background Acquired aerodigestive fistulae (ADF) are rare, but associated with a high mortality rate. We present our experience of the diagnosis, management and outcomes of patients with ADFs treated at a tertiary centre. Utilising our findings, we propose an anatomical classification system, demonstrating how specific features of an ADF may determine management. Methods A clinical database was searched and 48 patients with an ADF were identified. A classification system was developed based on anatomical location of the ADF and differences in clinico-pathological features based on this categorisation were performed, with the chi-squared test used for inferential analyses and Kaplan-Meier curves with log-rank test to assess survival. Results Twenty (41.6%) patients developed an ADF secondary to malignancy, with previous radiotherapy (18.7%), post-operative anastomotic dehiscence and endotherapy (14.6% each) representing other causes. Thirty-one patients were managed with tracheal and/or oesophageal stents and eight underwent surgical repair. The classification system demonstrated benign causes of ADF were either proximally or distally sited, whilst a malignant cause resulted in mid-tracheal fistulae (p = 0.001), with the latter associated with poorer survival. ADFs over 20 mm in size were associated with poor survival (p = 0.011), as was the use of previous radiotherapy. Proximal and distal ADFs were associated with improved survival (p = 0.006), as were those patients managed surgically (p = 0.001). Conclusion By classifying ADFs, we have demonstrated that anatomical location correlates with the size, history of malignancy, previous radiotherapy and aetiology of ADF, which can affect management. The proposed classification system will aid in formulating multi-modality individualised treatment plans.

Esophageal cancer has a poor prognosis, with little improvement in outcomes in recent years. Surgery maintains its pivotal role in cure, but this involves two or three compartment dissection with associated high risks. Chiefly, pulmonary complications following surgery are most common, and can be life-threatening. As a consequence, minimally invasive and robotic esophagectomy have been performed with improving efficacy and equivalent oncological outcomes. This is a review of the pertinent literature regarding these techniques. J. Surg. Oncol. 2016;114:731-735. © 2016 Wiley Periodicals, Inc.

Parathyroid carcinomas are very rare tumors and may arise in the normally located or ectopic gland. The latter present certain diagnostic difficulties, and there are no specific guidelines on their management. We present a case of parathyroid carcinoma arising within an ectopically located intrathyroid gland and discuss the diagnosis, management, and difficulties encountered. Furthermore, we review all six previously reported cases of this rare event and demonstrate the patterns in presentation, as well as the differences in management.A 39-yr-old male presented with a right neck mass with biochemical derangement suggestive of a parathyroid lesion. However, radiological investigations were inconclusive as to the true nature of this lesion because they demonstrated a mass within the right thyroid lobe. A sestamibi (99m)technetium subtraction study was performed, which suggested an intrathyroid parathyroid carcinoma. The patient underwent successful surgical intervention.Although rare, ectopically located parathyroid glands can harbor malignant disease. Those located within the thyroid gland can be difficult to diagnose, and thus a combination of radiological modalities, including sestamibi (99m)technetium studies, need to be utilized. Although surgical resection is the most effective treatment, there are no specific guidelines as to the radicality of such treatment.

Background We describe the presentation, diagnostic pathway, and management of 28 patients with benign retroperitoneal schwannomas. Methods A prospectively kept soft-tissue tumor database was reviewed to identify patients who presented to the Royal Marsden Hospital with retroperitoneal schwannomas. Results From 2001 to 2009, 28 patients presented with retroperitoneal schwannomas. In 13 patients, tumors were identified incidentally, 8 patients presented with pelvic or abdominal symptoms and 7 patients presented with a palpable mass. Seventeen occurred in the pelvis and 11 occurred in the abdominal retroperitoneal space. The median age was 47 years and 21 patients were women; the mean follow-up period was 39 months. Twenty patients underwent resection and 8 patients were managed conservatively with radiologic surveillance. An initial histologic diagnosis was accomplished in 19 of 28 patients. Complete resection was achieved in 17 of 20 patients and 3 patients with pelvic schwannomas underwent a subtotal resection. Resected tumor size ranged from 5 to 23 cm (median, 9 cm), and weighed between 64 and 2,300 g (median, 500 g). There was no surgical mortality. In the 3 subtotal resected tumors, no progression of residual disease or malignant transformation has been noted on follow-up imaging. All 8 patients in the surveillance group had a histologic diagnosis and typical radiologic findings. Conclusions An accurate preoperative diagnosis is important because the risks of complicated surgery in the retroperitoneum and pelvis for what is a benign lesion should be considered carefully. Cross-sectional imaging combined with a needle biopsy should in all cases provide the correct diagnosis. Management options include radiologic surveillance in asymptomatic patients or surgical resection in symptomatic patients.

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 In soft tissue from non-STT and for sat comas 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 tirade 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 J Surg. Oncol 2010, 102.523-529 (C) 2010 Wiley-Liss, Inc

Background: Angiosarcomas comprise less than 1% of all sarcomas, arising from endothelial cells of blood or lymph vessels. Chronic immunosuppression increases the risk of many malignancies and an association between the development of angiosarcoma with an immunosuppressed state is established. A few cases have been reported of angiosarcomas arising in the post-renal transplant patient. Specifically, there have been six cases of an angiosarcoma arising in arteriovenous (AV) fistulae in this patient population. We describe a further case and review the relevant literature with specific emphasis on a possible mechanism for the development of angiosarcoma in the post-transplant patient. Case Presentation: We report the case of a 48-year-old male who developed an angiosarcoma in a ligated native AV fistula. The lesion arose on the background of immunosuppression following a successful ABO-incompatible renal transplant for chronic renal failure. Conclusion: Angiosarcomas are extremely rare tumours but should be considered as a differential diagnosis for an evolving mass near the site of an AV fistula. Diagnosis relies on an index of suspicion and obtaining a definitive histological diagnosis. Both clinicians and patients should be aware that an evolving mass within or around an AV fistula should prompt urgent biopsy. J. Surg. Oncol. 2010;101:520-523. (C) 2010 Wiley-Liss, Inc.

Fraud is an important issue that affects research of both scientific and clinical fields because of its potential to adversely affect patient care. Fraud can take many forms, each with varying prevalence and implications. A number of ethical institutions have been created to investigate and regulate this malpractice. Using case examples, we describe the various forms of fraud and their potential implications. The increasing importance of editorial responsibility is highlighted and discussed. Finally, we suggest solutions for how to effectively regulate and eradicate this practise.

Trefoil factor family (TFF) peptides promote wound healing in the gut. Recent evidence has suggested that TFF3 may be a pancreatic mitogen, an unusual role for TFF peptides. We sought to clarify human pancreatic TFF and mucin expression and performed in vitro experiments to see how pancreatic cell lines respond to TFF3 in particular.Samples of normal and diseased pancreas (chronic pancreatitis, pancreatic intraepithelial neoplasia, neuroendocrine tumors, and pancreatic ductal adenocarcinoma [PDAC]) were studied by immunohistochemistry and in situ hybridization. Pancreatic cell lines were challenged with TFF2 and TFF3 in wound and migration assays.In normal islets, colocalization of insulin or glucagon with TFF3 was common. All TFF messenger RNAs were seen in ductal epithelium. Adenocarcinomas expressed all TFF messenger RNAs. Normal ducts were mucin free; MUC5AC was strongest in pancreatic intraepithelial neoplasia and chronic pancreatitis but was reduced in PDAC. TFF2 induced Panc-1 migration and accelerated wound closure in Capan-2 and COLO-357. Double immunohistochemistry for insulin or TFF3 and Ki67 colabeled only very rare islet cells. TFF3-positive PDAC ducts showed some Ki67 colocalization.No correlation between TFF3 or insulin and Ki67 was seen without ductal hyperplasia. TFF2 may assist pancreatic tumor cell movement, but TFF3 may not be a pancreatic mitogen.

Unplanned excision of soft tissue sarcoma (STS) accounts for up to 40% of all initial operations for STS and is undertaken when the mass is presumed to be benign. The effect this has on outcome has never been fully established. Patients with extremity or trunk STS between 2001 and 2005 who were treated by an initial inadvertent operation and then referred immediately to our unit were identified. Outcomes were compared with a control group of patients with STS who were stage-matched and had been treated conventionally by core biopsy and definitive surgery. Endpoints were local recurrence, distant metastases and sarcoma-specific survival. 134 patients who had undergone unplanned excision of STS were identified. One hundred twenty-one underwent further re-excision, and 51 (48%) of these patients had residual tumour identified after surgical re-excision. Two hundred nine stage-matched controls were identified who were treated conventionally. Median follow-up was 51.6 months. Local recurrence rates were considerably higher in the study group (23.8 vs. 11%, p = 0.0016), despite the control group having more stage 3 tumours. When the tumours were matched by stage, an increase in local recurrence was seen across all stages but was most pronounced for stage 3 tumours (37.5 vs. 14.2%, p = 0.005). Metastasis-free and sarcoma-specific survival were also significantly increased for stage 3 tumours. Unplanned initial excision of extremity soft tissue sarcoma may compromise long-term local control of extremity STS despite full further oncological management.

Angiosarcomas comprise less than 1% of all sarcomas, arising from endothelial cells of blood or lymph vessels. Chronic immunosuppression increases the risk of many malignancies and an association between the development of angiosarcoma with an immunosuppressed state is established. A few cases have been reported of angiosarcomas arising in the post-renal transplant patient. Specifically, there have been six cases of an angiosarcoma arising in arteriovenous (AV) fistulae in this patient population. We describe a further case and review the relevant literature with specific emphasis on a possible mechanism for the development of angiosarcoma in the post-transplant patient.We report the case of a 48-year-old male who developed an angiosarcoma in a ligated native AV fistula. The lesion arose on the background of immunosuppression following a successful ABO-incompatible renal transplant for chronic renal failure.Angiosarcomas are extremely rare tumours but should be considered as a differential diagnosis for an evolving mass near the site of an AV fistula. Diagnosis relies on an index of suspicion and obtaining a definitive histological diagnosis. Both clinicians and patients should be aware that an evolving mass within or around an AV fistula should prompt urgent biopsy.

Background Myxoid liposarcoma is the second most commonly occurring sub-type of liposarcomas. In contrast to other soft tissue sarcomas, it is known to have a tendency to spread toward extrapulmonary sites, such as soft tissues, retroperitoneum, and the peritoneal surface. Bony spread, however, is not as common. Case presentation We report an unusual case of diffuse skeletal metastases from myxoid liposarcoma occurring 13 years after treatment of the primary tumour in the left lower limb. The skeletal spread of the disease was demonstrated on MRI only after other imaging modalities (plain radiography, CT and TC99 bone scans) had failed to detect these metastases. Conclusion MRI is an extremely sensitive and specific screening tool in the detection of skeletal involvement in these types of sarcomas, and therefore, should be a part of the staging process.