Routine histological examination of epidermoid cysts; to send or not to send?

BACKROUND: The diagnosis of epidermoid cyst is seldom in doubt, and associated malignancy extremely rare, yet it is commonplace for the lesion to be sent to the pathology laboratory for analysis. The aim of this study was to evaluate our current practice with regards to diagnostic accuracy among clinicians, and assess risk of not routinely sending suspected epidermoid cysts for histological examination. Potential cost savings were also estimated and calculated. METHODS: Retrospective analysis of clinical and pathology data on all suspected epidermoid cysts excised from a Scottish district general hospital over a 5-year period between January 2011 and October 2015. RESULTS: Five hundred and thirty-six suspected epidermoid cysts were excised during the study period. Three hundred and ninety-six were sent for histological examination which confirmed a diagnosis of epidermoid cyst in 303 (76.5%) cases. There was good agreement between preoperative suspicion and final histological diagnosis: 80.8% (257/318) among referring clinicians, 81.9% (289/353) among reviewing surgeons, and 88.4% (243/275) where there was preoperative agreement between both. There were no malignant lesions. An average of 80 clinically apparent epidermoid cysts were excised and sent for histology each year at a cost of £4800 per annum. CONCLUSION: There was close agreement between clinical and final histological diagnosis of epidermoid cyst. Where a characteristic, odorous, toothpaste-like material is present on transection intra-operatively, the diagnosis is confirmed and the lesion can be discarded. We argue that significant cost savings can be achieved by adopting this approach.

Margin width and local recurrence after breast conserving surgery for ductal carcinoma in situ.

INTRODUCTION: Ductal Carcinoma in situ (DCIS) represents 5% of symptomatic and 20-30% of screen detected cancers. Breast conserving surgery (BCS) ± radiotherapy is performed in over 70% of women with DCIS. What constitutes an adequate margin for BCS remains unclear. METHODS: A single institution follow up study has been conducted of 466 patients with pure DCIS treated by BCS between 2000 and 2010 of whom 292 received whole breast radiotherapy and 167 did not. Patients were selected for radiotherapy based on perceived risk of in breast tumour recurrence (IBTR). Distance to nearest radial margin was measured; 10 patients had a margin width of <1 mm, 94 had widths of 1-2 mm and 362 had widths of >2 mm. There was no association of margin width and the use of radiotherapy. RESULTS: At a median follow up of 7.2 years there were 44 IBTR (27 DCIS and 17 invasive). There was no evidence that margin widths >2 mm resulted in a lower rate of IBTR than margin widths of 1-2 mm. The actuarial IBTR rates at 5 and 10 years for margins of 1-2 mm were 9.0% (95% CI ± 5.9%) and 9.0% (95% CI ± 5.9%) respectively and for margins of >2 mm were 8.0% (95% CI ± 3.9%) and 13.0% (95% CI ± 3.9%) respectively. Odds Ratio for IBTR 1-2 mm vs >2 mm was 0.839 (95% CI 0.392-1.827) p = 0.846. In a multivariate analysis only DCIS size predicted for IBTR (HR 2.73 p < 0.0001). CONCLUSION: 1 mm appears a sufficient margin width for BCS in DCIS irrespective of whether patients receive radiotherapy.

Current treatment trends and the need for better predictive tools in the management of ductal carcinoma in situ of the breast.

Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.

Contemporary social media engagement by breast surgeons.

There continues to be a steady rise in the use of social media among healthcare professionals. We present an overview of social media use among breast surgeons within the United Kingdom including demographic variations and some of the factors that underpin these trends. The benefits and drawbacks of open social media platforms are also considered.