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Schrier Global Burden of Hypertension Cardiovascular disease is the most common cause of death in economically developed countries and is rapidly evolving as a major cause of morbidity and mortality in economically developing nations as well (1). Certainly, hypertension is among the most important modifiable risk factors and the leading risk factor for disease burden worldwide (2). A majority of adults have hypertension by the sixth decade 541 and >70% have it by the seventh and eight decades of life. Among normotensive individuals in their sixth decade, the lifetime risk of developing hypertension approaches 90%. African American adults have an incidence and prevalence of hypertension that is 50% higher than their white or Mexican American counterparts. The prevalence of hypertension in many other countries is as high as or higher than that identified in the United States. In the last few decades, the prevalence of hypertension in economically developing countries appears to have risen; in 2008, 1 billion individuals had uncontrolled hypertension (7). Historical Perspective: the Link between Hypertension and Renal Dysfunction the occurrence of hypertension in the setting of renal disease and its impact on the progression of renal insufficiency has long been of interest to clinicians. The concept that hypertension is in some way related to renal dysfunction was first proposed by Bright in 1836 (10). He recognized the association between hypertrophy of the heart and contraction of the kidney and postulated that the cause was increased cardiac work required to force blood through a vascular tree constricted by irritating humoral substances 542 that accumulate in renal failure. The role of fluid retention in the genesis of renal hypertension was first outlined by Traube in 1871 (11), who proposed that with shrinkage of the renal parenchyma, a decreasing amount of fluid is removed from the arterial system by urinary secretion, thereby resulting in hypertension. Mahomed in 1879 (12) was the first to clearly describe hypertension of unknown cause, without evidence of underlying renal disease (now called essential hypertension). He emphasized that the most frequent complications in individuals with this type of hypertension were cardiovascular and most often occurred in the absence of significant renal dysfunction. However, in 1914, Volhard and Fahr (13) defined a subgroup of patients with essential hypertension who eventually developed severe renal involvement. They distinguished two types of hypertensive nephrosclerosis, benign and malignant. The benign type, characterized by hyaline arteriolosclerosis, was associated with a slowly progressive course with eventual complications caused by heart failure or stroke in the absence of clinically significant renal impairment. In contrast, malignant nephrosclerosis was characterized by arteriolar necrosis and endarteritis that resulted in rapidly progressive renal failure and death. Volhard (14) subsequently introduced the concept of the vicious circle in which renal disease causes hypertension, which in turn exacerbates renal injury. Over the years, it has been recognized that the kidney is both "villain and victim" in hypertension (15). The kidney, even when histologically normal, is felt to play a central role in the pathogenesis of essential hypertension.

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Excision with a clear margin of breast tissue is the treatment of choice for the vast majority of phyllodes tumors, even malignant ones as long as a margin greater than 1 cm is achievable. For larger, borderline and malignant lesions, mastectomy may be required, but this is not common (E). Borderline malignant and malignant forms of the disease are associated with high local recurrence rates and metastasis via a hematogenous route, most commonly to the lungs. Therefore, sentinel node biopsy and axillary dissection are not indicated, given that phyllodes tumors very rarely metastasize to lymph nodes (C). Radiotherapy is not generally used after lumpectomy (as it is in breast cancer) since phyllodes are most often benign and, even in malig- Breast 139 nant variants, radiotherapy has questionable benefit (D). Chemotherapy has not been proven effective with these tumors and is typically not recommended. Surgical treatment of phyllodes tumors of the breast: retrospective review of 172 cases. Distinction of phyllodes tumor from fibroadenoma: a reappraisal of an old problem. As such, they are associated with a mildly increased risk of subsequent breast cancer (1. These lesions can mimic carcinomas of the breast on mammography given their stellate appearance. However, presence of a translucent central area of fat within the lesion is the classical finding on imaging. Though biopsy rarely reveals atypia, carcinoma-in-situ or invasive cancer, upstaging is not uncommon after excision. It is notable that newer studies have suggested that excisional biopsy may not be necessary in cases where vacuum-assisted needle cores provide large volume biopsy specimens, atypical epithelial hyperplasia is absent, and when mammographic findings are consistent with histologic findings. Regardless, it is important for the radiologist and pathologist to alert the surgeon to the presence of a radial scar due to its increased risk of associated and subsequent malignancy. Fourteengauge needle core biopsy of mammographically evident radial scars: is excision necessary All radial scars/ complex sclerosing lesions seen on breast screening mammograms should be excised. Intraductal papilloma is a benign intraepithelial tumor of the breast ductal tissues.