Gynaecomastia in the Durban Breast Unit: A Comparison of HIV- and Non-HIV-Infected Individuals.

BACKGROUND: The clinical profile of gynaecomastia patients, both in human immunodeficiency virus (HIV)-positive and HIV-negative patients, in resource-limited settings remains largely undocumented. The aim of this study was to compare and contrast these groups with a view to developing an appropriate treatment algorithm for the South African population. METHODS: A retrospective chart review at the Durban Breast Unit for the period 2000-2015 was undertaken with ethics approval [BE012/16 (sub-study of BCA173/15)]. Statistical analysis was done with IBM SPSS version 25. A p value <0.05 indicated statistical significance. RESULTS: One hundred and four patients were documented. The mean age was 37 years. Gynaecomastia was most commonly attributed to puberty, HAART, other medications or an idiopathic aetiology. HIV status was known in 49 patients. There was a 97% prevalence of HAART use in the HIV-positive subgroup (n = 31). Efavirenz was the most common inciting drug. Incidence of gynaecomastia correlated with duration of HAART use. Age, late presentation, advanced Simon grade and bilateral disease appear to necessitate surgical intervention more frequently. CONCLUSION: Patients on HAART are advised to seek early advice upon noticing gynaecomastia. Drug cessation/change is likely to assist only upon early presentation resulting in static progression, and ultimate cure would still entail surgical excision. Extensive blood and imaging studies should be done only where clinically indicated and can be considered in cases of recurrence post-surgery. Management option must be discussed with patients, and surgeons are required to be familiar with the various surgical techniques necessary to treat gynaecomastia.

Global Disparities in Breast Cancer Genetics Testing, Counselling and Management.

Hereditary breast cancers, mainly due to BRCA1 and BRCA2 mutations, account for only 5-10% of this disease. The threshold for genetic testing is a 10% likelihood of detecting a mutation, as determined by validated models such as BOADICEA and Manchester Scoring System. A 90-95% reduction in breast cancer risk can be achieved with bilateral risk-reducing mastectomy in unaffected BRCA mutation carriers. In patients with BRCA-associated breast cancer, there is a 40% risk of contralateral breast cancer and hence risk-reducing contralateral mastectomy is recommended, which can be performed simultaneously with surgery for unilateral breast cancer. Other options for risk management include surveillance by mammogram and breast magnetic resonance imaging, and chemoprevention with hormonal agents. With the advent of next-generation sequencing and development of multigene panel testing, the cost and time taken for genetic testing have reduced, making it possible for treatment-focused genetic testing. There are also drugs such as the PARP inhibitors that specifically target the BRCA mutation. Risk management multidisciplinary clinics are designed to quantify risk, and offer advice on preventative strategies. However, such services are only possible in high-income settings. In low-resource settings, the prohibitive cost of testing and the lack of genetic counsellors are major barriers to setting up a breast cancer genetics service. Family history is often not well documented because of the stigma associated with cancer. Breast cancer genetics services remain an unmet need in low- and middle-income countries, where the priority is to optimise access to quality treatment.

Breast Cancer and HIV: a South African perspective and a critical review of the literature.

BACKGROUND: The diagnosis of breast cancer and concurrent HIV in South Africa is common. The limited current evidence on this subject suggests that the patients thus afflicted appear to be younger, have a more advanced stage of breast cancer, have a higher treatment related complications and poorer outcomes. This paper reviews the literature related to HIV and breast cancer, with a view to improving the standard and quality of care of HIV positive breast cancer patients. METHOD: Pubmed, EBSCOhost, Google scholar and Science Direct electronic databases were searched from 2001 and 2015. using the terms ('HIV' OR 'human immunodeficiency virus' OR 'AIDS' OR 'Acquired Immunodeficiency Syndrome') and 'breast cancer' or 'breast carcinoma' to identify all publications related to HIV and breast cancer. Titles and abstracts were evaluated for eligibility and appropriate full text articles obtained. The data extraction variables included the type of study, year of publication, study setting, participants, sample size, outcome measures and main findings. RESULTS: Only five studies fulfilled the criteria, in respect of the aforementioned maladies, with twenty or more participants in each study. Evidence suggested that breast cancers develop at a much younger age in the HIV positive patient compared to the HIV negative patients, with more aggressive appearing tumour biology. Overall, it appears that HIV positive patients experienced a higher cancer-specific mortality than HIV negative patients, and this is independent of the stage of the cancer or the cancer therapy received, further the relationship between the HIV syndrome and breast cancer is currently marginal and inconclusive, and hence requires further investigation. CONCLUSION: The prescription and administration of chemotherapy is a challenge, with potential complications impacting on the morbidity and mortality in HIV positive patients. Currently there are no reliable predictors of those at risk to complications from chemotherapy; however, being on ART appears to provide an acceptable safety profile. HIV positive patients are best managed in the context of a multi-disciplinary team in order to achieve favourable outcomes in the treatment of cancer. Well-designed prospective trials to assess the response to multimodal therapy, and the long-term outcomes of HIV positive patients with breast cancer are needed.

When should surgeons retire?

Everyone ages, and so do surgeons. No one seemed to mind that Professor Michael DeBakey was 88 years old and still performing open heart surgery when he operated on the Russian President Boris Yeltsin.1 But is there a point beyond which the surgeon's age becomes a risk factor?

Improving outcomes in breast cancer for low and middle income countries.

Breast cancer is the most common cancer in women world-wide. Incidence rates in low- and middle-income countries (LMICs) are lower than in high income countries; however, the rates are increasing very rapidly in LMICs due to social changes that increase the risk of breast cancer. Breast cancer mortality rates in LMICs remain high due to late presentation and inadequate access to optimal care. Breast Surgery International brought together a group of breast surgeons from different parts of the world to address strategies for improving outcomes in breast cancer for LMICs at a symposium during International Surgical Week in Helsinki, Finland in August 2013. A key strategy for early detection is public health education and breast awareness. Sociocultural barriers to early detection and treatment need to be addressed. Optimal management of breast cancer requires a multidisciplinary team. Surgical treatment is often the only modality of treatment available in low-resource settings where modified radical mastectomy is the most common operation performed. Chemotherapy and radiotherapy require more resources. Endocrine therapy is available but requires accurate assessment of estrogen receptors status. Targeted therapy with trastuzumab is generally unavailable due to cost. The Breast Health Global Initiative guidelines for the early detection and appropriate treatment of breast cancer in LMICs have been specifically designed to improve breast cancer outcomes in these regions. Closing the cancer divide between rich and poor countries is a moral imperative and there is an urgent need to prevent breast cancer deaths with early detection and optimal access to treatment.

Blindness and ophthalmoplegia from metastatic breast carcinoma.

SUMMARY: We report a very rare complication from metastatic breast cancer of right-sided blindness and ophthalmoplegia in a 70-year-old female. Cavernous sinus syndrome, superior orbital fissure syndrome and complicated sinusitis were considered in the differential diagnosis but involvement of cranial nerves II, III, IV, VI and the ophthalmic division of V were consistent with an orbital apex syndrome. She had been diagnosed with breast carcinoma 10 years previously. This report highlights the correct clinical and diagnostic pathway with computed tomography (CT) scan of the brain and paranasal sinuses to evaluate for the presence and extent of pathology and biopsy route for any causative mass. In this patient, the mass in the right parasellar region and orbital apex with extension into the sphenoid sinus was amenable to transsphenoidal biopsy which showed features suggestive of metastatic breast carcinoma. She was treated with palliative whole brain radiotherapy without resolution of symptoms.

Oncoplastic surgery for breast carcinoma in South Africa - an audit of outcomes from a single breast unit.

BACKGROUND: Oncoplastic breast surgery permits tumours traditionally requiring total mastectomy to be excised with acceptable oncological and aesthetic outcomes. The purpose of this study was to evaluate outcomes following oncoplastic breast surgery in the breast unit at Inkosi Albert Luthuli Central Hospital in Durban. METHODS: This was a retrospective analysis of patient records. Patients who underwent oncoplastic breast surgery with curative intent from 2011 and 2012 were included in this study. Male patients, those with contraindications to breast conservation, and those with metastatic disease were excluded. Demographic and tumour-related data were collected and margin status, surgical site sepsis, recurrence and overall survival (OS) were recorded over a 5-year period starting from the date of presentation. RESULTS: Forty-five patients with 45 tumours were evaluated. The most prevalent tumour size at presentation was T2 (55.6%), and the most commonly performed procedure was a therapeutic mammoplasty. Twelve patients (27%) developed surgical site infection (SSI), eight of which were classified as deep SSI with wound breakdown. The resection margin was clear in 95.6%. Recurrence was noted in 8.9% of patients, with an OS of 91.1%. CONCLUSION: Breast-conserving surgery (BCS) using oncoplastic techniques results in favourable oncological outcomes in patients treated in a resource-constrained setting.

Surgery in South Africa - challenges and barriers.

BACKGROUND: Sustaining a surgical career can be challenging and there are numerous barriers to pursuing a career in surgery. These barriers and challenges are well reported in international literature, but there is a lack of knowledge on how this affects surgeons in South Africa. This study aimed to determine the barriers and challenges that South African surgeons face in their training and careers. METHODS: A 15-item questionnaire was designed and distributed via the Research Electronic Database Capturing software from 1 February-3 April 2020. Data were analysed in Stata 15 SE. All responses were anonymised. RESULTS: One hundred and twenty-nine participants responded to the questionnaire, 33 (26%) of whom were female. The majority were specialist surgeons (n = 87; 71%). One hundred and eleven participants (90%) reported they did not regret pursuing surgery. Barriers to pursuing surgery included limited personal time (n = 98; 76%), heavy surgical workload (n = 92; 71%), and difficulty taking leave of absence (n = 64; 50%), limited postgraduate training (n = 34; 26%), and verbal discouragement (n = 22; 17%). Challenges included difficulty maintaining work-life balance (n = 74; 56%), racial discrimination (n = 29; 23%) and gender discrimination (n = 15; 12%). Fifty-three per cent of participants experienced burnout. CONCLUSION: Despite high career satisfaction, South African surgeons face numerous barriers to pursuing and challenges in sustaining a career in surgery and often experience burnout. These barriers and challenges disproportionately affect female surgeons and can be mitigated through formalised mentorship programmes, flexible work schedules, funding for postgraduate training, and training in diversity and discrimination.

Surgery in South Africa - the attitudes toward mentorship in facilitating general surgical training.

BACKGROUND: There are many barriers to pursuing a surgical career in South Africa, some of which are unique to females. Mentorship has been proposed as a solution to mitigate these barriers. The value of mentorship has not been formally assessed among South African general surgeons and trainees. METHODS: The study was part of a larger study designed to assess barriers to pursuing a career in surgery, including the value of mentorship. A 15-item questionnaire was designed and distributed via the Research Electronic Database Capture from 1 February 2020-3 April 2020. Data were analysed using Stata 15 SE. All responses were anonymised. RESULTS: One hundred and twenty-nine (13.5%) of 955 potential participants responded to the survey of which 26% (33/129) were female. Sixty-seven per cent of respondents were specialist surgeons (87/129). Seventy per cent (90/129) of participants reported having a role model in surgery, however, 66% (86/129) reported they had no mentor in surgery. 107/129 (83%) participants reported the importance of mentorship. The need for a formalised mentorship programme to facilitate surgical training was recorded by 60% (78/129) of participants, while 18% (23/129) reported the need for a mentorship group specifically for females. CONCLUSION: Eighty-three per cent of participants reported the importance of mentorship however two-thirds lacked a mentor. Most participants advocated for a mentorship group to facilitate surgical training. Establishing formalised mentorship programmes could mitigate the barriers to pursuing a surgical career.

Is conservative management of fibroadenomas feasible? 5-year results from the Durban Breast Unit.

BACKGROUND: Fibroadenomas (FAs) usually present in young women and, despite being the commonest benign breast masses, are often excised. This study aimed to assess the results of a conservative management protocol in the setting of dedicated breast clinics to reassess the validity of this conservative approach. METHOD: A retrospective chart review of a prospectively maintained database of the index presentation of patients diagnosed with FAs on triple assessment at the breast clinics of Inkosi Albert Luthuli Central Hospital (IALCH) and Addington Hospital (ADH) was undertaken. Women under 35 years with FA less than 5 cm and agreeable to the 5-year conservative management strategy from 2008 to 2015 were included. Variables assessed over the 5-year study period included adherence to clinic visits and any change in size of the lesion(s). RESULTS: Three hundred and six women were studied. The mean age of presentation was 21.5 years (IQR 12-34), and the mean FA size was 2.43 cm (IQR 0.5-4.8). 72.9% were of African ethnicity. 76.5% had a single FA, and in 16.3%, they were bilateral. 50.7% of patients were lost to follow-up, and 9.6% (n = 25) had spontaneous resolution of their FA. Conservative management of FAs was feasible in only 26.1% of patients. CONCLUSION: Conservative management of FAs over 5 years is not practical in our local setting due to the high patient attrition rate. In those who completed the 5-year observation period, only 1 in 10 patients had complete resolution of their FA.

The surgical burden of breast disease in KwaZulu-Natal province.

BACKGROUND: The current surgical workload assessments in KwaZulu-Natal (KZN) are inadequate to inform strategies to improve surgical services. Breast diseases have a well-defined spectrum and surgical treatment options, analysis of which could guide health policy in the field. This project aimed to quantify and analyse the operative workload for breast pathology in KZN. METHODS: A retrospective review of breast-related operations conducted at public sector hospitals in KwaZulu-Natal province between 1 July and 31 December 2015 was undertaken. Data was collected from theatre operative registers and manually categorised as follows: sepsis, benign pathology, malignant pathology, and by hospital, according to geographic location, and complexity of care to determine factors to improve the service for breast care in the province. RESULTS: In the 6-month study period, 13 282 general surgical procedures were performed of which 776 (5.8%) were breast-related operations. There were 372 (47.9%) operations for breast sepsis, 140 (18%) for benign breast lesions, 17 (2.2%) for cosmetic indications and 27 (3.5%) for diagnostic procedures. There were 223 (28.7%) procedures for nonbenign disease: 21 (2.6%) wide local excisions (WLE), 203 (26.2%) mastectomies of which 161 (72.2%) mastectomies had an axillary lymph node dissection and 26 (11.7%) were performed as onco-plastic procedures. Hospitals in the Durban and Pietermaritzburg metropolitan areas performed 75% of the breast-related procedures. The majority (69.6%) of sepsis-related procedures were performed at secondary/regional facilities, while 58.3% of non-benign breast surgeries were performed at tertiary and quaternary centres. CONCLUSION: Breast sepsis accounts for almost 50% of the surgery and is mainly dealt with at hospitals above district level. One-third of breast surgery in KZN province is for non-benign disease. There is a paucity of breast-conserving surgery. Elucidation of these observations can guide improvement in the provincial breast care service.

HIV and breast cancer - a mammographic analysis: An observational study to identify the mammographic pattern of breast cancer in HIV-positive patients.

BACKGROUND: Data on the association between HIV and breast cancer mammographic patterns and histological subtypes are limited. OBJECTIVES: To determine whether specific mammographic findings, histological features and patient profiles were unique to a cohort of HIV-positive patients who developed breast cancer, by comparing them with a HIV-negative cohort. METHODS: This was a descriptive study in which we conducted a retrospective chart review and mammographic and pathology analysis of newly diagnosed breast cancer patients referred to the Addington Hospital breast clinic between August 2008 and June 2012 and entered into a prospective database. RESULTS: Thirty-eight HIV-positive and 38 HIV-negative patients were included in the study. HIV-positive patients were more likely to have multifocal breast cancer (p=0.007), but not multicentric disease (p=0.05). The presence of grouped and fine pleomorphic microcalcifications and positive HIV status demonstrated statistical significance (p=0.000). A statistically significant relationship between grouped and fine pleomorphic microcalcifications with biopsies confirming high-grade ductal carcinoma in situ (HGDCIS) and HIV status was demonstrated (p=0.001). The mean age of the HIV-positive patients was 42.5 years (p=0.000). CONCLUSIONS: We demonstrated a statistically significant relationship between HIV status, the presence of multifocal breast cancer, and mammographically detected grouped and fine pleomorphic microcalcifications. A statistically significant relationship between HGDCIS and HIV status, and the presence of grouped and fine pleomorphic microcalcifications in HIV-positive patients with biopsies confirming HGDCIS, was demonstrated. Our study also showed that there is a relationship between age of presentation and HIV status.

Changes in surgical practice in 85 South African hospitals during COVID-19 hard lockdown.

BACKGROUND: In preparation for the COVID-19 pandemic, South Africa (SA) began a national lockdown on 27 March 2020, and many hospitals implemented measures to prepare for a potential COVID-19 surge. OBJECTIVES: To report changes in SA hospital surgical practices in response to COVID-19 preparedness. METHODS: In this cross-sectional study, surgeons working in SA hospitals were recruited through surgical professional associations via an online survey. The main outcome measures were changes in hospital practice around surgical decision-making, operating theatres, surgical services and surgical trainees, and the potential long-term effect of these changes. RESULTS: A total of 133 surgeons from 85 hospitals representing public and private hospitals nationwide responded. In 59 hospitals (69.4%), surgeons were involved in the decision to de-escalate surgical care. Access was cancelled or reduced for non-cancer elective (n=84; 99.0%), cancer (n=24; 28.1%) and emergency operations (n=46; 54.1%), and 26 hospitals (30.6%) repurposed at least one operating room as a ventilated critical care bed. Routine postoperative visits were cancelled in 33 hospitals (36.5%) and conducted by telephone or video in 15 (16.6%), 74 hospitals (87.1%) cancelled or reduced new outpatient visits, 64 (75.3%) reallocated some surgical inpatient beds to COVID-19 cases, and 29 (34.1%) deployed some surgical staff (including trainees) to other hospital services such as COVID-19 testing, medical/COVID-19 wards, the emergency department and the intensive care unit. CONCLUSIONS: Hospital surgical de-escalation in response to COVID-19 has greatly reduced access to surgical care in SA, which could result in a backlog of surgical needs and an excess of morbidity and mortality.

Dyslipidaemic pancreatitis clinical assessment and analysis of disease severity and outcomes.

INTRODUCTION: The relationship between pancreatitis and dyslipidaemia is unclear. PATIENTS AND METHODS: Admissions with acute pancreatitis were prospectively evaluated. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths was made in relationship to the lipid profiles. RESULTS: From June 2001 to May 2005, there were 230 admissions. The pancreatitis was associated with alcohol (63%), gallstones (18%), idiopathic (9%) and isolated dyslipidaemia (10%). Dyslipidaemia was significantly different between the two predominant race groups: Indian 50.5% and African 17.9% (p < 0.000017). Seventy-eight (34%) had associated dyslipidaemia and 152 (66%) were normolipaemic at admission. The average body mass index was higher in the dyslipidaemic group (27 +/- 6) than in the normolipaemic group (24.5 +/- 6.20; p = 0.004). The mortality rate was similar between the dyslipidaemic and normolipaemic patients (10 and 8%, respectively) and unrelated to race (p = 0.58). The 9 deaths in the dyslipidaemic group occurred in those with persistent hypertriglyceridaemia irrespective of its level (p = 0.003). CONCLUSION: Dyslipidaemic pancreatitis was more common in the Indian ethnic group. Adverse outcomes in those with dyslipidaemia were predominantly associated with hypertriglyceridaemia.

A comparison of colo-colic and ileo-colic intussusception.

There are many differences in the clinical features of intussusception between African and temperate countries. The records of 192 patients with intussusception who presented to the Pediatric Surgical Service at King Edward VIII Hospital, Durban, South Africa during a 10-year period were reviewed. Compared with temperate countries, the patients were older (median, 1 year 7 months), presented later (median, 4.2 days), had a higher proportion of colo-colic lesions (17%), had absence of primary bowel pathology, and had a high surgical rate (82%). To define clinically important differences, the clinical and pathological features of 158 cases of ileo-colic intussusceptions were compared with 34 colo-colic cases. Compared with the ileo-colic group, colo-colic lesions occurred in older children (median, 3.8 years) (v 1.5 years; P < .001). In the colo-colic group, there were fewer shocked and pyrexial patients, and the rate of successful nonoperative reduction was higher. The groups had a similar incidence of surgical intervention (82%). In the ileo-colic group, there was a higher mortality rate and more complications, but only the higher resection rate (P < .001) was statistically significant.

Congenital alimentary tract abnormalities presenting in adolescence and young adulthood.

Intestinal atresias and duplications of the alimentary tract commonly present in the neonatal period or early infancy, but in rare cases they can persist and present de novo during adolescence. We report on these two abdominal congenital anomalies, the clinical presentations of which in adolescence and young adulthood are unique.

The challenges of managing breast cancer in the developing world - a perspective from sub-Saharan Africa.

Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer,and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.