Inflammation of the residual appendix stump: a systematic review

AIM

A systematic review of the literature was undertaken to examine reported cases of stump appendicitis (SA) to determine the relationship between SA and the original operative strategy (open vs laparoscopic), and to evaluate the clinical features and diagnosis.

METHOD

A Pub-med search was conducted to identify cases of appendicitis of a residual stump following appendicectomy. Two original cases of SA following laparoscopic appendicectomy treated in our own hospitals are also included in the analysis. Sixty cases of SA reported in the English medical literature were analysed.

RESULTS

The interval from the original appendicectomy ranged from 4 days to 50 years. SA followed appendicectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation or gastroenteritis, with a significant delay to surgery. Computerized tomography diagnosed SA in 46.6% of cases. Perforation with gangrene of the stump occurred in 40%.

CONCLUSION

Stump appendicitis is rare. It may complicate open or laparoscopic appendicectomy. A high level of suspicion should be maintained in any patient with right sided abdominal pain and a history of prior appendicectomy.

Core Biopsy Following Neoadjuvant Chemotherapy Predicts Tumour Response and Aids in Breast Preservation

Back groundAdvancement in chemotherapy regimens has improved pathological tumour response following neoadjuvant chemotherapy (NAC). This has subsequently helped in increasing incidence of breast preservation. Here we report how core biopsy of the tumour bed following NAC is useful in predicting tumour response and aids in breast preservation.Materials and MethodsData were collected retrospectively from consecutive newly diagnosed breast cancer patients at West Middlesex University Hospital between January 2002 and December 2008 who underwent NAC. Patients were assessed with clinical examination, mammogram, ultrasound (USS) and Magnetic Resonance Imaging (MRI). NAC consisted of 6-8 cycles of FEC or had FEC followed by Taxanes. The tumour response was assessed by USS and MRI. In addition, multiple cores were performed both in the central and periphery of the tumour bed. Patients subsequently underwent either mastectomy or wide local Excision (WLE) with axillary clearance. The extent of resection was determined by the presence of tumour in the peripheries.Results43 patients received neo-adjuvant chemotherapy and the median age was 49 years (range 24-72). The median size of tumour by MRI scan was 4.5 cm (range 2.5-10). One patient declined surgery and 8 patients did not have core biopsy following neoadjuvant chemotherapy so all the nine cases were excluded from analysis.The sensitivity of USS, MRI and core biopsy in predicting residual disease in our series was 84%, 84% and 68% respectively. The specificity and the positive predictive value (PPV) of imaging was 25% and 75% whereas the specificity and PPV of core biopsy was both 100%.Our overall initial breast conservation rate was 88% (30 of 34) and 4 of them had subsequent mastectomy following breast conservation surgery (BCS) due to positive margins following BCS reducing it to 76% (26/34).The mean size of the T2 tumour was 2.9 cm and 90% had BCS (9/10) including re excision of margins in one case. The average size of the T3 tumour was 6.0 cm and 76% (13/17) had BCS. Re excision of positive margins was done twice in one case. The mean size of T4 tumour in our series was 6.3 cm and 57% had BCS (4/7).DiscussionThe tumour response following NAC is traditionally assessed by imaging and further surgery is determined by the extent of response. The low specificity and PPV of imaging is due to overestimation of the presence of residual tumour. Absence of enhancement in MRI means either there is necrosis or fragmentation. This is especially true when the tumour mass has completely resolved. The presence of architectural distortion in these cases can complicate MRI interpretation. It is interesting to note that MRI has a high negative predictive value in diagnosing primary tumour as well as recurrence. However this ability is lost following chemotherapy for above mentioned reasons. So core biopsy is an extremely useful tool here when it is positive irrespective of what the imaging indicates. The rate of breast conservation is also increased by assessing tumour response to decide the extent of resection. Extensive sampling of the central and periphery of the tumour following chemotherapy increases the negative surgical margins when breast conservation is considered.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4121.

Typing of drug resistant isolates of Mycobacterium tuberculosis from India using the IS6110 element reveals substantive polymorphism

We investigated IS6110 polymorphism in clinical isolates of Mycobacterium tuberculosis from patients attending the outpatient department at various hospitals in northern India. DNA fingerprinting of 126 clinical isolates of M. tuberculosis was carried out using restriction fragment length polymorphism (RFLP) associated with the IS6110 element in M. tuberculosis genomes. A substantive degree of polymorphism was evident in the MDR M. tuberculosis isolates. The number of bands in the fingerprints varied from 0 to 19. However, the lack of common bands made it difficult to cluster the majority of these isolates. We were also unable to associate drug resistance with IS6110 copy number. Specific regions of the gyrA and katG genes from a representative number of these isolates were sequenced to determine the genotype. The majority of the isolates analyzed were found to belong to Group 1, indicating that these strains were evolutionarily older. We find no evidence of the W strain, prevalent in the US, in our study. The epidemiological patterns of the various strains in India seem to be very complex, as reflected by the presence of a large number of different strains (types) within north India.