Does Prior Breast Irradiation Increase Complications of Subsequent Reduction Surgery in Breast Cancer Patients? A systematic Review and Meta-Analysis.

BACKGROUND: Reduction mammoplasty and mastopexy are potentially complicated by prior breast irradiation as part of breast conserving therapy. Associated tissue changes with therapeutic irradiation have led to surgeons deciding the risks may outweigh potential benefit for those patients. A systematic review of the existing literature was performed to explore surgical outcomes of patients undergoing delayed bilateral reduction mammoplasty or mastopexy following unilateral breast irradiation as part of breast conserving therapy. METHODS: Medline, PubMed and EMBASE were searched from 1990 to 2023 according to PRISMA guidelines. Studies were combined by the generic inverse variance method on the natural logarithms of rate ratios (RR) using a random effect model in Review manager 5.4.1. RESULTS: Fifteen studies reported outcomes in 188 patients who underwent breast reduction (BR) following unilateral breast conserving surgery and radiotherapy. The median age at BR was 51.5 years (range 39-60), and median time since radiotherapy was 48 months (range 11.7-86). We compared outcomes for irradiated breast (IB) versus non-irradiated breast (NIB). Pooled results showed higher rate of major complications in the IB (RR 2.52, 95%CI 0.96-6.63, p=0.06), but not statistically significant. However, rate of minor complications was significantly higher in the IB (RR 3.97 95%CI 1.86-8.50, p<0.0004). Incidence of fat necrosis as a discrete complication was 2× higher in IB (RR 2.14 95%CI 0.85-5.35, p-value 0.10) compared to the NIB, but not significant. CONCLUSION: We found breast reduction to be safe with acceptable risk of major complications. However, the overall complication rate remains higher in IB compared to NIB. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Cardiovascular Outcomes of Differentiated Thyroid Cancer Patients on Long Term TSH Suppression: A Systematic Review and Meta-Analysis.

We performed a systematic review and meta-analysis of the literature regarding cardiovascular outcomes of differentiated thyroid cancer (DTC) patients who are on long term thyroid stimulating hormone suppression. Searches were carried out using Prisma guidelines in Medline, Embase, CENTRAL, CINAHL and Scopus databases. Eligible papers were those which investigated discrete cardiovascular clinical outcomes in TSH suppressed patients and meta-analysis of selected studies was performed using Revman 5.4.1. We found a total of 195 879 DTC patients with median length to follow up of 8.6 years (range 5-18.8 years). Analysis showed DTC patients to be at higher risk of atrial fibrillation (HR 1.58, 95% CI 1.40, 1.77), stroke (HR 1.14, 95% CI 1.09, 1.20) and all-cause mortality (HR 2.04, 95% CI 1.02, 4.07). However, there was no difference in risk of heart failure, ischemic heart disease or cardiovascular mortality. These findings suggest that degree of TSH suppression must be titrated to accommodate risk of cancer recurrence and cardiovascular morbidity.

TSH receptor autoantibody levels post-total thyroidectomy in Graves' ophthalmopathy: a meta-analysis.

BACKGROUND: TSH receptor autoantibodies (TRAbs) are pathognomonic for Graves' disease and are thought to also underly the pathogenesis of Graves' ophthalmopathy (GO). A decline in TRAb levels has been documented post-total thyroidectomy (TTx) in GO, however with conflicting correlations with disease outcomes. The aim of the study was to compare the effectiveness of TTx to other treatment modalities of Graves' disease and examine whether the lowering of TRAbs is associated with GO improvements. METHOD: We searched electronic databases including Medline, Embase, Scopus, and Web of Science until 31 September 2022 using a broad range of keywords. Patients with GO undergoing TTx with measurements of both TRAbs and progression of the disease using a validated GO scoring system were included. Fourteen studies encompassing data from 1047 patients with GO met our eligibility criteria. The PRISMA guidelines were followed, and five studies had comparable data that were suitable for a meta-analysis. RESULTS: The Cochrane Risk of Bias tool for RCTs showed low risk of bias across most domains. The pooled odds ratio showed that more patients significantly had normalized TRAb levels post-TTx as compared to other interventions (OR: 1.36, 95% CI: 1.02-1.81, p = 0.035). But, there was no significant difference in GO improvement post-TTx as compared with other intervention groups. CONCLUSIONS: This meta-analysis shows that TRAb levels may decline largely post-TTx, but may not predict added improvements to the progression of GO. Thus, future studies with uniform designs are required to assess the minimal significant GO improvements.

The Utility of the Oncotype DX Test for Breast Cancer Patients in an Australian Multidisciplinary Setting.

Introduction: The Oncotype DX test is a genomic assay that generates a Recurrence Score (RS) predicting the 10-year risk of recurrence and response to adjuvant chemotherapy in ER+/HER2- breast cancer patients. The aims were to determine breast cancer distant recurrence and correlate with adjuvant chemoendocrine prescribing patterns based on the Oncotype DX recurrence score. Methods: We conducted a retrospective single-institution case series of 71 patients who had Oncotype DX assay testing after definitive surgery between 2012 and 2016. Both node-positive and node-negative patients were included. Patients were divided into Oncotype DX low risk (RS < 11) (n = 10, 14%), intermediate risk (RS 11-25) (n = 45, 63%), and high risk (RS > 25) (n = 16, 23%). Median follow-up was 6.1 years (range 4-8.9 years). Adjuvant treatment regimens and oncological outcomes were determined. Results. Mean age at diagnosis was 56 years (range, 33-77). Invasive ductal carcinoma (IDC) accounted for the majority (87%), with most tumors measuring between 10-20 mm (52%). 48% of the cohort were node positive. 15 of 16 high-risk patients (94%) received chemotherapy. 96% of intermediate-risk patients received endocrine therapy alone, one patient received chemoendocrine therapy (2%), and one declined systemic therapy (2%). In the low-risk group, 100% received endocrine therapy only. The high-risk group had the lowest mean ER% (P < 0.05), greatest mean mitotic rate (P < 0.05), and greatest proportion of Ki67% > 14. Five patients developed distant recurrence (7%): three from the intermediate-risk group (7%), one from the low-risk group (10%), and one from the high-risk group (6%). Conclusion: This is the first Australian study reporting the experience with medium-term recurrence outcomes of using the Oncotype DX assay in breast cancer. Chemotherapy was rarely given for patients with low-to-intermediate RS and always offered in high RS. This pattern of prescribing was associated with low rates of distant recurrence. National funding models should be considered.

Correlation between thyroidal and peripheral blood total T cells, CD8+ T cells, and CD8+ T- regulatory cells and T-cell reactivity to calsequestrin and collagen XIII in patients with Graves' ophthalmopathy.

Purpose/aim of the study: Graves' ophthalmopathy (GO) is closely related to the thyroid autoimmune disorder Graves' disease. Previous studies have suggested roles for thyroidal CD8+ T cells and autoimmunity against calsequestrin-1 (CASQ)-1 in the link between thyroidal and orbital autoimmune reactions in GO. A role for autoimmunity against CollXIII has also been suggested. In this study, we aimed to investigate correlations between some thyroidal and peripheral blood T-cell subsets and thyroidal T-cell reactivity against CASQ1 and CollXIII in patients with GO. MATERIALS AND METHODS: Fresh thyroid tissues were processed by enzyme digestion and density gradient to isolate mononuclear cells (MNCs). Peripheral blood MNCs were also isolated using density gradient. Flow-cytometric analysis was used to identify the various T-cell subsets. T -cell reactivity to CASQ1 and CollXIII was measured by a 5-day culture of the MNCs and BrdU uptake method. RESULTS: We found a positive correlation between thyroidal CD8+  T cells and CD8+ T-regulatory (T-reg) cells in patients with GO. Thyroidal T cells from two out of the three patients with GO tested (66.7%) showed a positive response to CASQ1, while thyroidal T cells from none of the six Graves' Disease patients without ophthalmopathy (GD) tested showed a positive response to this antigen. Thyroidal T cells from these patient groups however, showed no significant differences in their response to CollXIII. CONCLUSIONS: Our observations provide further evidence for a possible role of thyroidal CD8+ T cells, CD8+ T-reg cells and the autoantigen CASQ1 in the link between thyroidal and orbital autoimmune reactions of GO.

Is Sentinel Lymph Node Biopsy Necessary in Patients Undergoing Prophylactic Mastectomy? A Systematic Review and Meta-Analysis.

The gain by performing sentinel lymph node biopsy (SLNB) during prophylactic mastectomy (PM) is debatable, and we performed a meta-analysis of existing literature to evaluate that the role of SLNB in subjects undergoing PM. A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 11 relevant articles reporting on patients who underwent SLNB at the time of PM. Data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). We included 14 studies comprising of 2,708 prophylactic mastectomies. Among 2,708 prophylactic mastectomies, the frequency of occult invasive cancer (51 cases) was 1.8% and the rate of positive SLNs (33 cases) was 1.2%. In 25 invasive cancers at the time of PM were found to have negative SLNs which avoided axillary lymph node dissection (ALND). In seven cases with positive SLNBs were found not to have invasive cancer at the time of PM and needed a subsequent ALND. Most of the patients with positive SLNs had locally advanced disease in the contralateral breast. SLNB may be suitable for patients with ipsilateral, locally advanced breast cancer and is not recommend for all patients undergoing PM.

The association between breast cancer and thyroid cancer: a meta-analysis.

Previous studies have suggested an association between breast cancer and thyroid cancer; however, there has not been a formal meta-analysis which collates the existing evidence supporting the hypothesis that breast cancer or thyroid cancer predisposes an individual to developing the other. A systematic search was carried out using PubMed and Medline. We searched for articles containing epidemiological evidence of breast cancer following thyroid cancer and vice versa. Additionally, we searched for articles that included epidemiological data involving the incidence of all second primary malignancies (SPMs) following both breast cancer and thyroid cancer, and compared the datasets. The meta-analysis performed in a total of 18 studies showed that there is a significantly increased risk of developing thyroid cancer as a second primary malignancy of breast cancer (SIR = 1.59, 95 % confidence interval (CI) 1.28-1.99). Additionally, there was marginally increased risk of developing breast cancer as a second primary malignancy of thyroid cancer (SIR = 1.24, 95 % CI 1.16-1.33), compared to the general risk of developing a second primary malignancy following thyroid cancer. The findings suggest that the risk of developing thyroid cancer as a second primary malignancy of breast cancer and vice versa is increased compared to the background risk of developing other SPMs. The risk of developing thyroid cancer after a primary breast cancer was higher than the risk of developing breast cancer as a second primary malignancy of thyroid cancer. This suggests that the effects of treatment-related factors and specific pathological processes of each cancer may contribute to the increased risk rather than common risk factors including genetic factors. Elucidation of the common mechanisms between breast cancer and thyroid cancer will have important implications in both diagnostic and therapeutic management of these cancers. Benefit of thyroid ultrasound screening after breast cancer surgery needs to be assessed.

Survey of clinician perspective on management of papillary thyroid microcarcinoma in Australia and New Zealand.

Background: The incidence of thyroid cancer has been rapidly increasing in recent years largely due to improved diagnostic methods. There is evidence to suggest that in papillary thyroid microcarcinoma (PTMC), active surveillance (AS) is comparable in effectiveness compared to immediate surgery (IM). We conducted a survey of Clinicians and Surgeons from Australia and New Zealand to assess the role of AS in the management of PTMC. Methods: A short electronic survey was created on the platform Survey Monkey, separate links containing the survey were sent to various medical societies to be distributed to its members. The list of medical societies included: General Surgeons Australia, Endocrine Society of Australia, Australian and New Zealand Endocrine Surgeons, Australian and New Zealand Head and Neck Cancer Society and New Zealand Association of General Surgery. Results: We received 110 complete responses, which demonstrated that 63% of clinicians will discuss AS with patients diagnosed with PTMC. Surgeons are more likely to discuss AS compared to endocrinologists (P=0.03). Forty-eight percent of respondents report managing patients with AS in the past year, those who are able to perform thyroid ultrasounds are more likely to utilise AS (P=0.03). Common perceived barriers to AS include patient anxiety, lack of access to regular follow-up and lack of patient compliance. Conclusions: Our survey shows that Australian and New Zealand clinicians are generally aware of AS as a treatment option for PTMC, but there remain considerable barriers for common implementation.

Goldilocks mastectomy with immediate reconstruction: enhancing aesthetic outcomes and preserving nipple complex.

Despite significant advancements in early breast cancer detection, mastectomy remains a crucial treatment option for some patients. Immediate breast reconstruction post-mastectomy has emerged as an ideal procedure to minimize physical and psychosocial patient impacts, striving for improved cosmetic results. The "enhanced "Goldilocks mastectomy technique, characterized by nipple preservation or grafting and utilizing the fifth perforator anatomy, offers a sound approach to reconstruction in comorbid and large-breasted patients. This paper discusses the advantages, disadvantages, and real-world application of Goldilocks mastectomy in enhancing breast reconstruction outcomes and meeting patients' diverse needs.

Hypothyroidism after hemithyroidectomy: a systematic review and meta-analysis.

BACKGROUND: The incidence of hypothyroidism following hemithyroidectomy and risk factors associated with its occurrence are not completely understood. This systematic review investigated the incidence and risk factors for hypothyroidism, thyroxine supplementation following hemithyroidectomy as well as the course of post-operative hypothyroidism, including the time to hypothyroidism and incidence of transient hypothyroidism. METHODS: Searches were conducted in MEDLINE, EMBASE, Scopus, and Cochrane library for studies reporting the incidence of hypothyroidism or thyroxine supplementation following hemithyroidectomy. RESULTS: Sixty-six studies were eligible for inclusion: 36 reported risk factors, and 27 reported post-operative course of hypothyroidism. Median follow-up was 25.2 months. The pooled incidence of hypothyroidism was 29% (95% CI, 25-34%; P<0.001). Transient hypothyroidism occurred in 34% of patients (95% CI, 21-47%; P<0.001). The pooled incidence of thyroxine supplementation was 23% (95% CI, 19-27%; P<0.001), overt hypothyroidism 4% (95% CI, 2-6%, P<0.001). Risk factors for development of hypothyroidism included pre-operative thyroid stimulating hormone (TSH) (WMD, 0.87; 95% CI, 0.75-0.98; P<0.001), TSH ≥ 2 mIU/L (RR, 2.87; 95% CI, 2.43-3.40; P<0.001), female sex (RR, 1.19; 95% CI, 1.08-1.32; P=0.007), age (WMD, 2.29; 95% CI, 1.20-3.38; P<0.001), right sided hemithyroidectomy (RR, 1.35; 95% CI, 1.10-1.65, P=0.003), the presence of autoantibodies anti-TPO (RR, 1.92; 95% CI, 1.49-2.48; P<0.001), anti-Tg (RR, 1.53; 95% CI, 1.40-1.88; P<0.001), and Hashimoto's thyroiditis (RR, 2.05; 95% CI, 1.57-2.68; P=0.001). CONCLUSION: A significant number of patients will develop hypothyroidism or require thyroxine following hemithyroidectomy. An awareness of patient risk factors and postoperative thyroid function course will assist in counselling patients on their risk profile and guiding management.

Oncoplastic breast surgery - a pictorial classification system for surgeons and radiation oncologists (OPSURGE).

INTRODUCTION: Changes to the tumour bed following oncoplastic breast surgery complicate the administration of adjuvant radiotherapy. Consensus guidelines have called for improved interdisciplinary communication to aid adjuvant boost radiotherapy. We propose a framework of tumour bed classification following oncoplastic surgery to enhance understanding and communication between the multidisciplinary breast cancer team and facilitate effective and more precise delivery of adjuvant boost radiotherapy. METHODS: A classification system was devised by grouping oncoplastic procedures based on skin incision, tissue mobilization, tumour bed distortion, seroma formation and flap reconstruction. The system is supplemented by a colour-coded pictorial guide to tumour bed rearrangement with common oncoplastic procedures. RESULTS: A 5-tier framework was developed. Representative images were produced to describe tumour bed alterations. CONCLUSION: The proposed framework (OPSURGE) improves the identification of the primary tumour bed after initial breast-conserving surgery, which is imperative to both the surgeon in planning re-excision and the radiation oncologist in planning boost radiotherapy.

Bidirectional association between breast cancer and meningioma: a systematic review and meta-analysis.

BACKGROUND: An association between breast cancer and meningioma has been suggested in cohort studies. We aimed to perform a systematic review and meta-analysis to determine whether there is an association between initial breast cancer and subsequent meningioma diagnosis and vice versa. METHODS: A systematic literature search was performed on Medline, Embase, Scopus and Google scholar from inception up to April 2023. A meta-analysis of selected studies was performed using Review Manager 5.4. RESULTS: There were eight studies included in the systematic review. Seven had reported Standardized Incidence Ratio (SIR) for female patients and were suitable for the meta-analysis. Only one study reported SIR for male patients. For the association between initial breast cancer and subsequent meningioma, in 795 000 female patients with follow-up ranging from 7 to 13 years, the SIR was 1.27 (95% CI: 1.20-1.34, P-value <0.00001). For the association between initial meningioma and subsequent breast cancer, in 28 000 female patients with follow-up ranging from 6 to 15 years, the SIR was 1.32 (95% CI: 1.21-1.45, P-value <0.00001). There were low heterogeneity and no significant publication bias. CONCLUSION: There was a small but significant association between initial breast cancer and subsequent meningioma as well as initial meningioma and subsequent breast cancer in female patients. The potential underlying mechanisms and risk factors were unclear from current literature and would be a potential area for future research.

Pathological and clinical outcomes following neoadjuvant dual HER2 therapy for early-stage breast cancer: An Australian institutional real-world experience.

AIM: There has been significant progress made in developing novel targeted therapies in the neoadjuvant setting for non-metastatic HER2-positive breast cancer, which may be used in combination with conventional chemotherapy to optimise pathological responses at surgery. However, these therapies, particularly the chemotherapeutic components, may portend significant and long-lasting toxicity. Hence, de-escalation of treatment intensity has been an area of interest and was evaluated in the phase II NeoSphere study. Herein, we report the real-world pathological and survival outcomes from neoadjuvant taxane and dual HER2 blockade recorded at our centre. METHODS: This was a retrospective cohort study of patients receiving neoadjuvant pertuzumab, trastuzumab and taxane chemotherapy for non-metastatic HER2-positive breast cancer at a single centre in Sydney, Australia. We collected data pertaining to baseline demographic characteristics, pathological response rates, post-surgical prescribing patterns and also undertook survival analyses for invasive disease-free survival (iDFS) as well as exploratory analyses for correlations between pre-specified clinicopathologic factors and pathological response at surgery. RESULTS: Our population was largely similar at baseline to the NeoSphere study. 71 patients were included in the final analysis. 61% achieved a pathological complete response (pCR). Three patients received conventional chemotherapy in the adjuvant setting. 92% of included patients were alive and disease-free at 3 years of follow-up. Only 3 events of recurrence or death were recorded at a median follow-up of 32 months. No significant difference in iDFS was noted between patients achieving pCR and those with residual disease at surgery. CONCLUSION: This study demonstrates that de-escalated adjuvant treatment for HER2-positive early breast cancer achieved favourable pathological and long-term outcomes comparable to large trials, some utilising more intensive chemotherapeutic components.

Breast Cancer Survival Outcomes and Tumor-Associated Macrophage Markers: A Systematic Review and Meta-Analysis.

INTRODUCTION: Tumor-associated macrophages (TAMs) in breast cancer are associated with a poor prognosis. Early studies of TAMs were largely limited to the pan-macrophage marker CD68, however, more recently, an increasing number of studies have used CD163, a marker expressed by alternatively activated M2 macrophages and TAM subsets. We hypothesized that CD163-positive (CD163+) TAMs would be a better predictor of survival outcomes in breast cancer compared to CD68+ TAMs. METHODS: We performed a systematic literature search of trials (from 1900 to August 2020) reporting overall survival (OS) or progression-free survival (PFS), breast cancer-specific survival (BCSS), TAM phenotype, and density. Thirty-two studies with 8446 patients were included. Meta-analyses were carried out on hazard ratios (HRs) for survival outcomes of breast cancer patients with a high density of TAMs (CD68+ and/or CD163+) compared to a low density of TAMs. RESULTS: A high density of TAMs (CD68+ and/or CD163+) was associated with decreased OS (HR 1.69, 95% CI 1.37-2.07) and reduced PFS (HR 1.64; 95% CI 1.35-1.99). Subgrouping by CD marker type showed a lower OS for high density of CD163+ TAMs (HR 2.24; 95% CI 1.71-2.92) compared to a high density of CD68+ TAMs (HR 1.5; 95% CI 1.12-2). A high density of TAMs (CD68+ and/or CD163+) in triple-negative breast cancer (TNBC) cases was associated with lower OS (HR 2.81, 95% CI 1.35-5.84). CONCLUSION: Compared to CD68+ TAMs, a high density of CD163+ TAMs that express a similar phenotype to M2 macrophages are a better predictor of poor survival outcomes in breast cancer.

Parasitization of the pedicle: a rare form of TRAM flap recurrence.

Local recurrence after mastectomy and autologous breast reconstruction is uncommon and tends to occur predictably within the superficial tissues or at the chest wall. We present a unique case of breast cancer recurrence involving the superficial and deep tissues. By parasitizing the pedicle of a free transverse rectus abdominis myocutaneous flap pedicle, the tumour was seen to extend through the chest wall to the right pleura.

Does Immediate Breast Reconstruction Lead to a Delay in Adjuvant Chemotherapy for Breast Cancer? A Meta-Analysis and Systematic Review.

Timely delivery of adjuvant chemotherapy is crucial. With an increasing frequency of immediate breast reconstructions (IBR) following mastectomy (MAS), concerns have arisen regarding its complication rates and effects on time to chemotherapy. The aim was to conduct a systematic review and meta-analysis to determine if there is a prolonged time to chemotherapy (TTC) after IBR and MAS. Electronic databases, reference lists and relevant articles were searched systematically. Eligibility criteria included women receiving adjuvant chemotherapy who underwent either MAS only or MAS and IBR. Random-effects models were used in the analysis. A total of 29 studies were included in qualitative analysis, comprising of 156,000 patients (IBR: 57,159; MAS: 98,841). But 23 studies had sufficient data to be included in the meta-analysis. Sixteen papers concluded there was no difference in TTC compared to MAS. There was a difference of 3.50 days between TTC in IBR versus MAS (95% CI [0.42, 6.57], P value = .0256; IBR = 43.56 days, MAS = 40.38 days). The rate of patients being delayed past 90 days was not significantly higher in IBR (OR = 1.34, 95% CI [0.76, 2.38], P = .310). IBR patients were more likely to have complications compared to the MAS group (OR = 2.04, 95% CI [1.04-4.01], P < .01). We concluded that there is a statistically significant longer time to chemotherapy following IBR of 3.50 days, yet there is no difference in delays past 90 days. Therefore, the longer TTC in IBR is unlikely to be of any clinical significance.

Benign thyroid disease is associated with breast cancer: a meta-analysis.

The controversial relationship between benign thyroid diseases and breast cancer (BC) has been investigated for over 50 years. Despite extensive population studies, the results as a whole have been inconsistent. The purpose of this study was to collate and analyse available data, calculating a pooled odds ratio (OR) of the risk of BC in patients diagnosed with benign thyroid diseases. Studies were obtained from a database search of MEDLINE, EMBASE, PubMed, Current Contents Connect and Google Scholar with additional cross checking of reference lists. Inclusion criteria required a confirmed diagnosis of a benign thyroid disease, reporting of an OR or data to calculate an OR (and 95% confidence interval, CI) and the use of an internal control group as the comparator. Collated data was assessed for heterogeneity and a pooled OR calculated. 28 studies were included in the meta-analysis. There was significant evidence of an increased risk of BC in patients with autoimmune thyroiditis, evident in a pooled OR 2.92 (95% CI 2.13-4.01). In addition, the results supported an increased risk associated with the presence of anti-thyroid antibodies (OR 2.02, 95% CI 1.63-2.50) and goitre (OR 2.26, 95% CI 1.39-3.69). Subgroup analysis of antibody presence revealed increased risk associated with both anti-TPO (OR 2.64, 95% CI 1.82-3.83) and anti-TG (2.71, 95% CI 1.58-4.69). Quantitative analysis of hypothyroidism and hyperthyroidism was not significant. While these results indicate an association between thyroid auto-immunity and BC, further prospective studies are required to definitively prove causality.

A new variation of duplicated extrahepatic bile duct encountered intraoperatively on cholangiogram.

A potentially devastating complication of laparoscopic cholecystectomy (LC) includes iatrogenic bile duct injury, the incidence of which has remained stable at 0.3% over the past three decades. Although there are several relative risks such as surgeon experience and patient factors (male sex, obesity, older age), misinterpretation of biliary tree anatomy contributes towards 80% of iatrogenic common bile duct (CBD) injuries. Although extremely rare, an isolated duplicated common hepatic duct anomaly with a normal CBD remains a potential variation to encounter during biliary surgery. With only one similar variation published worldwide, we report the second case encountered during LC and confirmed on cholangiogram. Given these anomalies are asymptomatic and perpetuate iatrogenic CBD injuries, awareness of this variation is crucial. Preoperative diagnosis is possible with the use of magnetic resonance cholangiopancreatography; however, such imaging is not routinely used prior to LC in Australia due to factors including expense and availability.