Patients treated by APR have a higher rate of CRM involvement, a higher LR, and poorer prognosis than AR. The frequency of CRM involvement for APR has not diminished with TME. CRM involvement in the APR specimens is related to the removal of less tissue at the level of the tumor in an APR. Where possible, a more radical operation should be considered for all low rectal cancer tumors.

No standardised, comprehensive approach to rapid on‐site evaluation (ROSE) of cytology samples currently exists. Recent meta‐analysis indicates variation in the effectiveness of ROSE, however, reviews commonly omit the details of how ROSE is conducted. This review demonstrates the clinical effectiveness of single slide assessment (SSA) for ROSE of cytology samples, providing a highly effective, standardised methodology, maximising cell yield and the diagnostic potential of samples obtained via endobronchial or endoscopic ultrasound. Advances in molecular testing and immunotherapy now allow patients to access sophisticated, targeted cancer treatments and, consequently, obtaining diagnostic material alone is no longer sufficient. SSA uses specific criteria, based on the morphological presentation, to ensure sufficient material is obtained through one procedure, allowing for all the molecular profiling and tumour expression testing required to provide the patient and clinicians with the optimal treatment options. In total, 450 endobronchial or endoscopic ultrasound procedures were conducted with ROSE SSA performed by a biomedical scientist between 2010 and 2017. In 97% of cases, ROSE SSA matched the final report (inadequate vs adequate—benign material vs malignancy). ROSE SSA provided sufficient material for immunocytochemistry in 200/208 cases (96%) and for additional molecular testing/tumour profiling in 92% (85/92) of cases. The median number of needle passes was three. ROSE SSA streamlines diagnostic pathways; minimising risk of complications to patients, reducing cost and delays to treatment associated with repeat or more invasive procedures. Using SSA, sufficient material for a comprehensive diagnosis can be obtained in one procedure.

DescriptionA 69-year-old man with known, stable atypical meningioma of the brain diagnosed 5 years previously presented with severe shortness of breath. The patient had previously been treated with surgery and radiotherapy to the brain. Chest X-ray revealed bulky mediastinal lymphadenopathy (figure 1). CT (figure 2) confirmed mediastinal and upper abdominal lymphadenopathy in addition to multiple pulmonary emboli. The patient underwent an endoscopic ultrasound and fine-needle aspiration (EUS-FNA), an established technique that enables prompt cytological sampling and assessment. 1The EUS-FNA preparations showed sheets and clusters of bland, polygonal epithelioid cells ( figure 3). These demonstrated strong immunohistochemical positivity (figure 4) for epithelial membrane antigen. The final immunopanel was strongly supportive of metastatic meningioma.Meningiomas are common intracranial tumours, classified by WHO into three grades based on mitotic activity and tumour differentiation.2 Atypical (grade 2) and anaplastic (grade 3) meningiomas account for less than 5% of all meningiomas, and metastases from these lesions are rare (0.1%). 3Due to the small number of patients with a diagnosis of metastastic meningioma, there are no established treatment pathways and the prognosis is unknown. 3 The patient in our case report completed radiotherapy to the mediastinum at a dose of 30 Gy in 10 fractions over 10 days, which improved his respiratory symptoms alongside a reducing dose of steroids. Following clinic discussion, he declined systemic treatment options and opted for palliative care.Metastatic meningioma: a rare cause of mediastinal lymphadenopathy. Figure 1 Chest X-ray.

Lymph Node Study (a multi-institutional prospective observational study) has made major contributions to our knowledge about the feasibility, indications, technique, and learning curve for sentinel lymph node (SLN) biopsy in breast cancer. Its particular strength is its breadth; by drawing on the experience of more than 300 surgeons performing more than 4000 SLN biopsy procedures in practice setting ranging from university teaching institutions to rural hospitals, it has been preeminent in establishing that SLN biopsy works in the "real world." SLN biopsy is falsely negative (FN) in about 5% of node-positive and (depending on the proportion of node-positive cases) in about 2% of all patients. A very large study is therefore required to identify with statistical significance those factors that might contribute to FN results. In a recent report, 1 the Louisville group have addressed this issue and in the process have raised as many questions as answers.As they have shown before, FN were significantly more frequent when only 1 SLN was removed, 2 a strong argument for removal of all blue and hot SLN, not just the first one. As they have also shown before, FN were more frequent for inexperienced surgeons, and their present data interestingly suggest that the "learning curve" may constitute as few as 4 cases, compared with their earlier estimate of 20 cases.3 This result matches the experience of others 4 and is consistent with a gradual maturation of the SLN biopsy technique.Their observation that FN were more frequent for smaller tumors is harder to explain, and is discordant with their earlier finding that the FN rate was unrelated to tumor size. 5 It is equally unclear why FN were more frequent with upper outer quadrant tumors. Finally, their observation that FN were more frequent with the use of immunohistochemical (IHC) staining makes no sense at all; increased pathologic scrutiny of the SLN can only act to increase the sensitivity of the examination (thereby decreasing the FN rate). This is confirmed by a detailed collective review of the SLN literature, comparing 27 studies using hematoxylin and eosin staining alone with 8 studies using hematoxylin and eosin plus IHC, with FN rates of 8% and 3%, respectively (P Ͻ 0.006). 6Since the Louisville study did not require a standardized pathology technique, it would be interesting to see a direct comparison of all clinicopathologic features for the IHC versus no-IHC cases to see if some other variable could explain this counterintuitive result.The larger problem may lie elsewhere. Cases with incomplete data automatically "drop out" of multivariate analyses, and this may explain some of the perplexing results above. While their study purports to involve 4116 patients and 3869 successful SLN biopsy procedures by more than 300 surgeons, examination of the data tables indicates that while SLN and axillary node status were known in all cases, tumor size was missing in 33%, and all of the other clinicopathologic features were missing in 65% of cases. This pattern of missin...