A UK prospective multicentre decision impact, decision conflict and economic evaluation of the 21-gene assay in women with node+ve, hormone receptor+ve, HER2-ve breast cancer.

BACKGROUND: For a tumour profiling test to be of value, it needs to demonstrate that it is changing clinical decisions, improving clinical confidence, and of economic benefit. This trial evaluated the use of the Oncotype DX Breast Recurrence Score® assay against these criteria in 680 women with hormone receptor-positive (HR+), HER2-negative early breast cancer with 1-3 lymph nodes positive (LN+) in the UK National Health Service (NHS). METHODS: Prior to receipt of the Recurrence Score (RS) result, both the physician and the patient were asked to state their preference for or against chemotherapy and their level of confidence on a scale of 1-5. Following receipt of the RS result, the physician and patient were asked to make a final decision regarding chemotherapy and record their post-test level of confidence. RESULTS: Receipt of the RS result led to a 51.5% (95% CI, 47.2-55.8%) reduction in chemotherapy, significantly increased the relative and absolute confidence for both physicians and patients and led to an estimated saving to the NHS of £787 per patient. CONCLUSION: The use of the Oncotype DX assay fulfils the criteria of changing clinical decisions, improving confidence and saving money.

Pneumomastia: a rare cause of breast swelling.

BACKGROUND: Pneumomastia is air within the breast parenchyma. A number of causes have been reported for this condition. This case report describes a new cause and details of the management strategy applied, together with a review of the literature. CASE REPORT: We describe a case of acute breast swelling in a 40-year-old woman and its subsequent successful conservative management. CONCLUSION: Bronchopleural fistula after thoracotomy is a risk, and can cause pneumomastia. This is more likely to occur after redo thoracic surgery. Pneumomastia after repeat thoracotomy can be managed conservatively, even in the presence of a bronchopleural fistula.

Chyle Leak Following Axillary Lymph Node Clearance - a Benign Complication: Review of the Literature.

SUMMARY: CASE REPORT: An 82-year-old patient underwent a mastectomy and axillary lymph node clearance for a large multicentric lobular cancer of the left breast. On day 11 after her operation, white viscous fluid was noted in her axillary drain. METHODS: We analysed case reports in the literature, noting the interval between surgery and diagnosis of chyle, the duration of the chyle leak, the volume of chyle during the first 24 h, the median volume and the administered treatment. RESULTS: 25 cases were reported in 13 publications. Our case was unusual in that chyle was noted 11 days after surgery. In most cases, chyle leakage subsides spontaneously by simply leaving the drain in situ. CONCLUSIONS: A conservative observant approach appears appropriate in most cases. Only for persistent and large-volume leaks, dietary intervention (medium-chain lipid diet, nil by mouth, total parenteral nutrition) is justified. Surgery with re-exploration of the axilla and oversewing of the chyle duct can be used as the last reserve for persistent chyle leaks.

Metastasis of Primary Colon Cancer to the Breast - Leave Well Alone.

BACKGROUND: Metastasis to the breast is rare. Its management differs from that of primary breast cancer, as illustrated by this case of a colonic metastasis to the breast. CASE REPORT: A 78-year-old woman presented with a breast lump 16 months after a palliative colonic resection for an obstructing colon cancer (T4 N0 M1). Core biopsy of the breast lump revealed morphological features identical to the original bowel cancer. In view of her progressive metastatic disease, the breast lump was simply observed. She passed away 4 months later from advanced intra-abdominal carcinomatosis. DISCUSSION: There are 19 cases of colonic metastasis to the breast in the literature. In the literature, colonic metastases to the breast are usually excised. CONCLUSION: Excision of a colonic metastasis to the breast can be avoided if the patient's life expectancy is short.

Liver cell adenoma and liver cell adenomatosis.

During the last three decades liver cell adenoma and liver cell adenomatosis have emerged as new clinical entities in hepato-logical practice due to the widespread use of oral contraceptives and increased imaging of the liver. On review of published series there is evidence that 10% of liver cell adenomas progress to hepatocellular carcinoma, diagnosis is best made by open or laparoscopic excision biopsy, and the preferred treatment modality is resection of the liver cell adenoma to prevent bleeding and malignant transformation. In liver cell adenomatosis, the association with oral contraceptive use is not as high as in solitary liver cell adenomas. The risk of malignant transformation is not increased compared with solitary liver cell adenomas. Treatment consists of close monitoring and imaging, resection of superficially located, large (>4 cm) or growing liver cell adenomas. Liver transplantation is the last resort in case of substantive concern about malignant transformation or for large, painful adenomas in liver cell adenomatosis after treatment attempts by liver resection.