Fifty women aged 70 years and older with newly diagnosed carcinoma of the breast were prospectively studied after being offered a choice of four treatment options. Thirty-four of 38 patients who chose their own treatment had breast conservation; four opted for mastectomy. At 12-month follow-up only two women were unhappy with their choice of treatment. It is concluded that elderly women should be involved in deciding the treatment of their breast cancer.

The small amount of normally spliced mRNA detected may be sufficient to explain the relatively mild clinical features in our patient.

BackgroundAcute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.MethodsPatients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.ResultsOf 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.ConclusionA surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

An 80-year-old female presented with an incidental finding of a retrosternal mass on magnetic resonance imaging. Ultrasound demonstrated a mediastinal lesion adjacent to but separate from the inferior pole of the right thyroid lobe. Fine needle aspiration cytology demonstrated colloid and follicular cells. At surgery, the right thyroid lobe was found to be normal. A discrete 5 cm nodule was found in the anterior mediastinum separate from the thyroid and just anterior and to the right of the trachea and thymus. The nodule had a vascular pedicle arising from the mediastinum. The differential diagnosis included metastatic thyroid carcinoma. Histology was consistent with a benign ectopic sequestered thyroid nodule. Extensive investigations demonstrated no sign of a thyroid malignancy.

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In the last 20--30 years the availability of effective chemotherapy and more accurate clinical staging has greatly improved the prognosis for patients with testicular germ cell tumours. Initially, such treatment appeared to diminish the role of histopathology to the distinction between seminoma and nonseminomatous germ cell tumour (NSGCT) in the primary specimen. However, histopathology has evolved as a prognostic tool indicating the risk of relapse in various defined clinical contexts thereby facilitating therapeutic decisions. The clinical emphasis has been on quality of life and reduction of therapy both in terms of the number of patients treated and the number of chemotherapy courses given to each patient. The treatment of adult testicular germ cell tumours may differ between countries but protocols are established. Therefore it is appropriate to discuss the role of histopathology during this era of relative therapeutic stability.

Primary malignant tumours of the aorta are rare. They present with aneurysm formation, arterial occlusion, and embolic phenomenon. We report the case of a 56-year-old man whose initial presentation and investigations lead to emergency endovascular stenting of a descending thoracic aneurysm with a contained leak. Initial response was favourable, yet the patient presented again with worsening symptoms. The circum-aortic haematoma expanded by 50% on subsequent imaging, but no endoleak was identified. When altered bone marrow signal was identified on magnetic resonance imaging, the possibility of malignancy was considered. A metastatic skin lesion was then biopsied, which demonstrated morphological and immunohistochemical features consistent with metastases from a pleomorphic sarcoma of the aorta.

This study was a 4-year prospective audit of abdominal aortic aneurysm surgery including 222 aneurysm repairs: 106 elective, 76 urgent and 40 emergency. Twenty-five patients died: four who underwent elective surgery, seven urgent and 14 emergency. The two major causes of death, multiple organ failure and colonic ischaemia, were responsible for 11 of the 25 deaths. The three deaths from myocardial infarction all occurred in patients with a leaking aneurysm. Blood loss was significantly higher in patients with multiple organ failure and in those with colonic ischaemia. Methods to identify patients at high risk of massive blood loss and colonic ischaemia may be a way to reduce mortality.