Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland.

INTRODUCTION: There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS: A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS: A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION: There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

Shortness of breath, fever and abdominal pain in a 21-year-old student.

A 21-year-old patient presented with a 3-day history of shortness of breath, productive cough, fatigue, fevers and night sweats, associated with right upper quadrant pain. He had an appendicectomy 3 months previously. The CT images showed a right subphrenic collection, which was indenting the right lobe of the liver, with an appendicolith in the middle. He underwent laparoscopic surgery where the abscess was drained and the appendicolith was retrieved. The patient had an uncomplicated postoperative period and was discharged soon afterwards. Complications from spilled appendicoliths have been reported previously. Retained appendicoliths and gallstones can act as niduses for infection, and thus cause symptoms at a later stage. Surgical notes should include the findings of appendicoliths, and in the event where retrieval is not possible, a clear record of this must be made, and the patient along with the general practitioner need to be informed.

Anthropometric characteristics and mammographic parenchymal patterns in post-menopausal women: a population-based study in Northern Greece.

OBJECTIVE: To examine the effects of various anthropometric determinants on mammographic patterns at postmenopausal ages, accounting for reproductive differences. METHODS: Mammograms from 900 post-menopausal women classified into high- (P2/DY) versus low-density (N1/P1) groups using the Wolfe criteria were associated with changes in body figure, reported and measured height and weight, body mass index, hip, waist and chest circumferences, chest/hip ratio, waist/hip ratio (WHR), breast size, and leg length. Reproductive factors included ages at menarche, first pregnancy and menopause, years since menopause, parity, and breast feeding duration. The study was nested within a large cross-sectional survey of a population-based breast cancer screening program in Northern Greece. RESULTS: Increasing chest circumference (p = 0.002), change in body build during adulthood to a heavier profile (p = 0.04), and heavy somatotype at age 18 (p = 0.007) were the anthropometric determinants significantly associated with low-density mammographic patterns. CONCLUSIONS: Chest circumference as a measure of upper body fat adiposity appears to be a stronger determinant of mammographic patterns than body fat distribution (measured as WHR). A heavy body build in adulthood is associated with decreased mammographic density. Further studies are necessary to confirm our results, ideally prospective cohorts, looking at the effect of anthropometric determinants on mammographic pattern changes over time and breast cancer risk.

Correlates of high-density mammographic parenchymal patterns by menopausal status in a rural population in Northern Greece.

Reproductive factors affect breast cancer risk, but less is known of their associations with mammographic density and whether these differ by menopausal status. We report on a cross-sectional study of 1946 pre- and 3047 post-menopausal women who joined a breast screening programme in Northern Greece during 1993-1997. The odds of having a high-density Wolfe pattern (P2/DY) was inversely associated with age (P for linear trend <0.001) in both pre- and post-menopausal women and, for post-menopausal women, with years since menopause (P < 0.001). The odds of a P2/DY pattern declined with higher parity (P < 0.001) and younger age at first pregnancy (P = 0.05) in both pre- and post-menopausal women. They also decreased with the duration of breast-feeding in pre-menopausal women (P = 0.03 in pre- and P = 0.69 in post-menopausal women; test for interaction with menopausal status: P = 0.07). Age at menarche, age at menopause and the number of miscarriages/abortions were not associated with mammographic density. Age at first pregnancy and parity were strong correlates of mammographic density in pre- and post-menopausal women while duration of breast-feeding appeared to be particularly important in pre-menopausal women.

Doctors' confusion over ratios and percentages in drug solutions: the case for standard labelling.

The different ways of expressing concentrations of drugs in solution, as ratios or percentages or mass per unit volume, are a potential cause of confusion that may contribute to dose errors. To assess doctors' understanding of what they signify, all active subscribers to doctors.net.uk, an online community exclusively for UK doctors, were invited to complete a brief web-based multiple-choice questionnaire that explored their familiarity with solutions of adrenaline (expressed as a ratio), lidocaine (expressed as a percentage) and atropine (expressed in mg per mL), and their ability to calculate the correct volume to administer in clinical scenarios relevant to all specialties. 2974 (24.6%) replied. The mean score achieved was 4.80 out of 6 (SD 1.38). Only 85.2% and 65.8% correctly identified the mass of drug in the adrenaline and lidocaine solutions, respectively, whilst 93.1% identified the correct concentration of atropine. More would have administered the correct volume of adrenaline and lidocaine in clinical scenarios (89.4% and 81.0%, respectively) but only 65.5% identified the correct volume of atropine. The labelling of drug solutions as ratios or percentages is antiquated and confusing. Labelling should be standardized to mass per unit volume.