Diagnostic, II.

The authors have indicated no significant interest with commercial supporters.O ver a 6-year period, we collected data from 256 keloid lesions from 192 patients. The patients were collected from the Barts and The London National Health Service Trust catchment area in East London and the City of London, United Kingdom, and all 192 patients were referred from hospital-based surgical specialties and dermatology to our specialist keloid clinic. In our keloid clinic, we treat patients only aged 16 and older who have keloids that have been referred for intralesional steroid therapy administered by one keloid nurse specialist 1 .The data were studied on the basis of the size of the keloids, the site of the keloids, low-dose steroid therapy, high-dose steroid therapy, and three types of combination steroid therapy. 3Of the 256 keloids studied, earlobe and sternal keloids were by far the most common sites affected, but the back of the head and the occipital area had keloids with the largest mean surface area (422 cm 2 ) (Figure 1).The nonbearded area of the face had a mean dose of steroid injection of 8.75 mg by the end of treatment with no recurrence. Likewise, the bearded area had a mean dose of 20.37 mg, with a 33% chance of recurrence, the upper limbs 21.91 mg with 20% recurrence, the earlobes 16.38 mg with 10% recurrence, the occipital area of the head 18.29 mg with 0% recurrence, and the sternum 35.77 mg with a 16% recurrence rate ( Figure 2).After treatment in our keloid clinic, 43% of patients were discharged with no recurrence, 7.3% returned for further injections, 5% went on to have excision surgery, 8% went on to have camouflage treatment, 2 28% were partially treated and declined further treatment after steroid therapy, 3% were discharged fully treated with pressure earrings, 1 6 2 4 E a r l o b e S t e r n u m / c h e s t / b r e a s t U p p e r l i m b / s h o u l d e r / a x i l l a B e a r d a r e a O t h e r s B a c k o f h e a d F a c e n o n b e a r d a r e a 0 1.3 8.4 7.7 4.6 Site Mean size vs Keloid Mean surface area (cm2) 7.8 22.2 1.5 5 10 15 20 25 Figure 1. Mean size and site of the keloids.

Rectal leiomyosarcomas are very rare mesenchymal tumours. This is a case report of a rectal leiomyosarcoma diagnosed initially as a leiomyoma in a patient who had undergone pelvic radiotherapy several years previously. In addition to its pathological rarity, this case is of particular interest because it reinforces the association between pelvic irradiation and rectal leiomyosarcomas and it highlights the importance of treating suspicious cases aggressively in spite of favourable preoperative radiological and histological assessment.Rectal leiomyosarcomas are rare and constitute less than 0.1% of colorectal malignancies.1 Approximately 290 leiomyosarcomas arising from the rectum have been reported in the literature to date. Although other colorectal malignancies have been associated with irradiation, no firm association exists between rectal leiomyosarcomas and pelvic irradiation. We present the third case of rectal leiomyosarcoma following pelvic irradiation. Case historyA 79-year-old woman presented to clinic with a history of rectal bleeding, weight loss and altered bowel motions. Clinical examination and rigid sigmoidoscopy were normal. The patient had a past history of endometrial and cervical carcinoma, for which she had undergone an abdominal hysterectomy and received pelvic irradiation 26 years previously. Further investigation with colonoscopy was arranged.During colonoscopy, a polypoidal rectal tumour with surrounding erythema originating 13cm from the anal margin was identified and biopsied (Fig 1). Histological analysis of the primary biopsy specimens gave no evidence of malignancy. However, due to the suspicious nature of the lesion, the patient was booked for staging computed tomography (CT) and magnetic resonance imaging (MRI) and a repeat sigmoidoscopy, during which further biopsies could be taken.Imaging revealed the mass to be a 3cm lesion originating 15cm from the anal verge with no clear breach of the muscularis propria and no signs of distant metastases. Histology from the repeat biopsy specimens identified spindle cells demonstrating nuclear pleomorphism. Immunostaining was positive for smooth muscle markers desmin and smooth muscle actin (SMA) but S100 protein, CD34 and CD117 were found to be negative. These findings were in keeping with a benign leiomyoma of the rectum.Due to the history of previous malignancy, an elective anterior resection was performed rather than the typical Figure 1 Caecum (A), transverse colon (B), rectal images demonstrating mass (C) and descending colon (D)