Evolving indications and long-term oncological outcomes of risk-reducing bilateral nipple-sparing mastectomy.

Background: Bilateral nipple-sparing mastectomy (NSM) is a technically feasible operation and is associated with excellent cosmetic outcomes. The aim of this study was to evaluate trends in patient characteristics, indications for surgery and long-term outcomes of bilateral NSM for breast cancer risk reduction over time. Methods: A review of a single-centre experience with bilateral NSM performed between 2001 and 2017 for breast cancer risk reduction in patients without breast cancer was performed. Trends in patient characteristics and indications for surgery were evaluated over four time intervals: 2001-2005, 2006-2009, 2010-2013 and 2014-2017. Statistical analysis was performed using χ2 tests. Results: Over the study period, 272 NSMs were performed in 136 patients; their median age was 41 years. The number of bilateral NSMs performed increased over time. The most common indication was a mutation in breast cancer-associated genes (104 patients, 76·5 per cent), which included BRCA1 (62 patients), BRCA2 (35), PTEN (2), TP53 (3) and ATM (2). Other indications were family history of breast cancer (19 patients, 14·0 per cent), lobular carcinoma in situ (10, 7·4 per cent) and a history of mantle irradiation (3, 2·2 per cent). The proportion of patients having a bilateral NSM for mutation in a breast cancer-associated gene increased over time (2001-2005: 2 of 12; 2006-2009: 9 of 17; 2010-2013: 34 of 41; 2014-2017: 61 of 66; P < 0·001). Mean follow-up was 53 months; no breast cancers were found during follow-up. Conclusion: The use of bilateral NSM for breast cancer risk reduction is increasing and the indications have evolved over the past 16 years. These excellent long-term oncological results suggest that bilateral NSM is a good option for surgical breast cancer risk reduction.

Long-term outcomes in patients with multiple endocrine neoplasia type 1 and pancreaticoduodenal neuroendocrine tumours.

BACKGROUND: In patients with multiple endocrine neoplasia type 1 (MEN-1), pancreaticoduodenal (PD) neuroendocrine tumours (NETs) are associated with early mortality, yet the best treatment strategy remains uncertain. AIM: To assess patient important outcomes (mortality and metastasis) of PD-NETs and predictors of outcomes in patients with MEN-1. METHODS: Retrospective cohort of patients with MEN-1 who attended the Mayo Clinic, Rochester, MN from 1997 to 2014. RESULTS: We identified 287 patients with MEN-1; 199 (69%) patients had 217 PD-NETs. Among those with a PD-NETs, 129 (65%) had surgery of which 90 (70%) had their primary surgery performed at Mayo Clinic. The median postoperative follow-up was 8 years during which 13 (14%) patients died. The mean (±standard deviation) age of death was 51 (±9) years. Tumour size, metastasis at surgery or tumour type were not predictive of mortality, but for every year older at surgery, the odds of metastasis increased by 6%. Surgery was not performed in 70 (35%) patients. Among those who were observed/medically managed without known metastatic disease, mean tumour growth was 0·02 cm/year (range, -0·13-0·4 cm/year). Four patients (7%) died at a median age of 77 (range, 51-89) years. CONCLUSION: PD-NETs are common in patients with MEN-1 and are associated with early mortality even after surgical intervention. Active surveillance is a viable option in nonaggressive PD-NETs, although definitive factors identifying such patients are lacking. Therefore, counselling regarding risks and benefits of current treatment options remains integral to the care of patients with MEN-1.

Breaking Barriers to Successful Implementation of Day Case Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is a common procedure performed in both emergency and elective settings. Our aim was to analyse the trends in laparoscopic surgery in Ireland in the public and private healthcare systems. In particular we studied the trend in day case laparoscopic cholecystectomy. National HIPE data for the years 2010-2012 was obtained. Similar datasets were obtained from the three main health insurers. 19,214 laparoscopic cholecystectomies were carried out in Ireland over the 3-year period. More procedures were performed in the public system than the private system from 2010-2012. There was a steady increase in surgeries performed in the public sector, while the private sector remained static. Although the ALOS was significantly higher in the public sector, there was an increase in the rate of day case procedures from 416 (13%) to 762 (21.9%). The day case rates in private hospitals increased only slightly from 29 (5.1%) in 2010 to 40 (5.9%) in 2012. Day case laparoscopic cholecystectomy has been shown to be a safe procedure, however significant barriers remain in place to the implementation of successful day case units nationwide.

An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions.

BACKGROUND: Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary. METHODS: A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata. RESULTS: A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer. CONCLUSIONS: This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.

A comparison of clinical-pathological characteristics between symptomatic and interval breast cancer.

BACKGROUND: An association between interval breast cancers (cancer detected after a normal mammogram and before the next scheduled mammogram) and tumour aggressiveness has been postulated which may reflect their relatively poor overall prognosis. The aim of this study was to evaluate known prognostic features of screen detected breast cancers compared to interval breast cancers. METHODS: Patients diagnosed with breast cancer between January 2010 and 2013 at a single unit of the National Breast Screening Program (NBSP) in Ireland and those between the ages of 50 and 65 diagnosed at a symptomatic breast clinic were included in the study. Patients who had not had a screening mammogram within the proceeding two years or had a previous history of breast cancer were excluded. Data were retrospectively collected on patient demographics, tumour type, grade, hormone receptor status and stage of disease at presentation. RESULTS: There were 915 patients included in the study, with 92% (n = 844) diagnosed through the NBSP. Ductal carcinoma in-situ accounted for 19% (n = 160) of screen-detected breast cancers but only 2.8% of interval cancers (p < 0.05). The most common type of invasive cancer was invasive ductal carcinoma. Tumour grade was significantly higher in interval breast cancers (p < 0.05). Interval cancers were identified at a significantly higher stage (Stage 1 versus 2; p < 0.001) than screen-detected cancers. Interval breast cancers were less likely to be ER positive (76% versus 81%; p < 0.05) and significantly more likely to over-express HER2 (20% vs 10%, p < 0.05) than screen-detected cancers. CONCLUSION: This study highlights the fact that interval cancers appear to have a number of adverse prognostic markers for overall breast cancer survival when compared to women with screen-detected breast cancers. Interval cancers were more likely to be invasive, of a higher grade and stage and with a greater predominance of HER2 and triple negative molecular subtypes. Therefore this heterogeneous group of tumours may be biologically more aggressive and account disproportionately to overall breast cancer mortality.

Malignant melanoma: factors affecting the surgical interval from excision biopsy to definitive surgical management.

INTRODUCTION: Surgery remains the mainstay of treatment for malignant melanoma. Despite previous studies examining the surgical interval (SI) between the diagnostic excision biopsy (DEB) and definitive surgical management there remains few guidelines regarding an optimal time interval. The aim of this study was to determine the SI between DEB and definitive surgery and elucidate factors associated with delays in management of malignant melanoma. METHODS: A retrospective study of 107 consecutive patients who had a DEB and subsequent wide local excision between January 2011 and June 2012 was performed. Mode of referral and dates of diagnostic biopsy/definitive surgery were documented. Patient demographics and tumour characteristics were reviewed. RESULTS: The mean age was 59.6 years, and male:female ratio was 1:1.3. Median duration of the SI was 41 ± 27 days (range 6-137 days). The SI was increased when dermatologists performed the DEB as opposed to general surgeons (p = 0.035). The anatomic location of the lesion predicted the SI, with lesions of the head/neck undergoing definitive excision 48 ± 32.3 days after DEB vs. 37.5 ± 22.6 days for all other sites (p = 0.001). Neither demographic factors nor histopathological prognostic features affected the SI. Reasons for a prolonged SI included referrals to different services and time for pre-operative planning. CONCLUSIONS: Significant variations were noted in the SI predominantly accounted for by mode of referral and location of the malignant melanoma. Further investigation is required to elucidate factors affecting the SI and its subsequent effect on patient outcomes.

Flank hernia secondary to phenol nerve block.

BACKGROUND: The management of patients with chronic pain is challenging. The aim of treatment is alleviation of symptoms in an attempt to increase functional capacity. Interventional procedures, such as chemical neurolysis are adopted when other techniques fail to provide adequate pain control. RESULTS: An 82-year-old man presented with a history of chronic left sided abdominal pain. This was initially treated with central nerve blockade. His symptoms persisted and he was scheduled for an intercostal neurolytic block with 6% aqueous phenol. Following the procedure, he experienced further abdominal pain and developed a painful left flank swelling. CT scan, ultrasound scan, and colonoscopy excluded the presence of an organic cause, such as intra-abdominal pathology. A left flank hernia was subsequently diagnosed. Conservative management was employed. Surgical repair will be implemented should conservative measures fail to control symptoms. CONCLUSION: This case raises our awareness of a complication that may occur with phenol intercostal neurolysis.

Emergency appendicectomy in the era of laparoscopy: a one-year audit.

BACKGROUND: Appendicectomy for acute appendicitis is the commonest emergency surgical operation. With widespread acceptance of minimal access surgery most appendicectomies are now performed laparoscopically. AIMS: The aim of this study was to assess whether the rate of normal appendicectomy has changed following the introduction of laparoscopic techniques in our institution. METHODS: A retrospective study of patients having emergency appendicectomies over a 1-year period (2005) in a large teaching hospital was undertaken. RESULTS: A comparison of data was made from a prior study performed at the same hospital in 1988. 196 adult patients underwent appendectomies during this period. The normal appendectomy rate was 10.2% compared to 22.8% in the previous study. This rate was twice as high in women of reproductive age as compared to men. CONCLUSION: There has been widespread uptake of laparoscopic appendectomy in our hospital. This technique has reduced the rate of histologically normal appendicectomies due to intra-operative visualization of the appendix.

Isolated limb infusion for melanoma.

Isolated limb infusion involves administrating cytotoxic drugs in a patient with malignant melanoma confined to one limb, and which is not surgically resectable. It provides palliation in cases where cutaneous disease is extensive.

Nicorandil related anal ulcer.

BACKGROUND: Anal ulceration is uncommon. Patients are typically referred because of severe anal pain, bleeding, discharge, and ulceration. It is important to exclude anal carcinoma, and to consider more unusual causes. METHODS: A 74-year-old lady presented with severe anal pain and ulceration. This was subsequently noted to be related to nicorandil, a potassium channel activator used in the treatment of angina. Discontinuation of nicorandil and faecal diversion allowed symptom relief and ulcer healing. CONCLUSION: Knowledge of the association between nicorandil and anal ulceration is essential in order to appropriately diagnose and manage this condition.