Multi-study randomised controlled trial to develop, implement and evaluate bra prescription to reduce breast pain and improve quality of life.

BACKGROUND: and Purpose: Breast pain is a common condition presented at breast care clinics and bras are often recommended to reduce symptoms, although criteria and pathways for obtaining appropriate bras are limited. This multi-study, randomised controlled trial (RCT) aimed to establish criteria and performance variables to prescribe bras for breast pain patients, to implement this bra prescription, and evaluate whether, compared to standard care alone, the bra prescription improves breast pain and quality of life (QoL). MATERIALS AND METHODS: Eighteen breast pain patients from a UK hospital were assigned to standard care or bra prescription groups and completed the study. Bra prescription patients were prescribed a bra to wear every day for eight weeks. Patient Global Impression of Change (PGIC), breast pain intensity, QoL, and adherence were assessed. RESULTS: Between-groups there were no differences in baseline breast pain or QoL and no differences in PGIC or breast pain following the intervention. Within-groups, improvements in QoL within bra prescription patients were identified. CONCLUSION: This study developed a framework for bra prescription for breast pain patients and the intervention demonstrated improvements in QoL.

Human herpes virus 8-positive germinotropic lymphoproliferative disorder: first case diagnosed in the UK, literature review and discussion of treatment options.

We present this case of human herpes virus 8-positive germinotropic lymphoproliferative disorder in a 20-year-old woman seen in the surgical oncology clinic for localised lymphadenopathy. This is the first case to be reported in the UK, and we discuss it along with a literature review including investigations and treatment options. This will demonstrate the importance of preoperative workup and multidisciplinary teamwork in deciding management plans and serve as a guide for future encounters of this rare condition in clinical practice.

Is Elective Cancer Surgery Safe During the COVID-19 Pandemic?

BACKGROUND: The COVID-19 pandemic has resulted in a significant decrease in the number of elective cancer operations performed. Cancer patients are felt to be a high-risk group for COVID-19, and therefore, concerns have been raised regarding the safety of operating during this time; however, the potential risk of cancer progression if untreated must also be considered. The aim of this study was therefore to identify the incidence of COVID-19 post-operatively in patients undergoing elective cancer surgery of all types. METHODS: Data were collected on all patients who had an elective therapeutic cancer operation in a single large district general hospital, where standard COVID-19 precautions were in place, between 01/02/2020 and 27/4/2020, Follow-up was for a minimum of 2 weeks post-discharge. The primary outcome was the incidence of COVID-19 during the follow-up period. RESULTS: A total of 621 elective cancer surgeries, from a range of specialities, were performed during the study period, with 55% (n = 341) being done as day cases. None of the patients were positive for COVID-19 post-operatively using reverse transcriptase polymerase chain reaction testing. CONCLUSIONS: The risk of COVID-19 following elective cancer surgery in this group of high-risk patients appears to be minimal in this study. With further precautions being introduced to reduce the risk of transmission of COVID-19, an increase in the rate of elective cancer surgery should be a current priority for all hospitals where possible.

A practical approach to the management of breast cancer in the COVID-19 era and beyond.

The COVID-19 pandemic has resulted in a major shift in how breast services are being utilised and managed. The guidelines relating to this have been published by recognised medical associations from the UK, Europe and the USA, addressing many aspects of breast cancer care. There is an awareness that there may be limitations in resources during this time, and therefore, prioritisation strategies have been identified to ensure that breast cancer patients are appropriately treated, whilst reducing the risk of infection from COVID-19 to both patients and staff. Equally important is the consideration of how breast cancer services can be safely re-introduced, as infection rates from COVID-19 decline. However, until there is a definite management strategy for COVID-19, such as a vaccine being developed, it is likely that there will still be a significant impact from COVID-19 on breast cancer care. This paper, therefore, aims to highlight the current guidance and evidence regarding breast cancer management in the era of COVID-19, and also aims to look at future management strategies in this period of uncertainty.

Mastectomy skin flap necrosis: challenges and solutions.

INTRODUCTION: Mastectomy skin flap necrosis (MSFN) has a reported incidence of 5%-30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions. METHODS: A MEDLINE search was performed using the search term "mastectomy skin flap necrosis". Titles and abstracts from peer-reviewed publications were screened for relevance. RESULTS: MSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited. CONCLUSION: MSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

A multicentre validation of Metasin: a molecular assay for the intraoperative assessment of sentinel lymph nodes from breast cancer patients.

AIMS: Treatment strategies for breast cancer continue to evolve. No uniformity exists in the UK for the management of node-positive breast cancer patients. Most centres continue to use conventional histopathology of sampled sentinel lymph nodes (SLNs), which requires delayed axillary clearance in up to 25% of patients. Some use touch imprint cytology or frozen section for intraoperative testing, although both have inherent sensitivity issues. An intraoperative molecular diagnostic approach helps to overcome some of these limitations. The aim of this study was to assess the clinical effectiveness of Metasin, a molecular method for the intraoperative evaluation of SLNs. METHODS AND RESULTS: RNA from 3296 lymph nodes from 1836 patients undergoing SLN assessment was analysed with Metasin. Alternate slices of tissue were examined in parallel by histology. Cases deemed to be discordant were analysed by protein gel electrophoresis. There was concordance between Metasin and histology in 94.1% of cases, with a sensitivity of 92% [95% confidence interval (CI) 88-94%] and a specificity of 97% (95% CI 95-97%). Positive and negative predictive values were 88% and 98%, respectively. Over half of the discordant cases (4.4%) were ascribed to tissue allocation bias (TAB). CONCLUSIONS: Clinical validation of the Metasin assay suggests that it is sufficiently sensitive and specific to make it fit for purpose in the intraoperative setting.

BRAF V600 co-testing in thyroid FNA cytology: short-term experience in a large cancer centre in the UK.

AIMS: To ascertain whether BRAF V600 mutational analysis is useful for diagnosis of thyroid cancer in thyroid fine needle aspirate (FNA). METHODS: Over 8 months thyroid FNAs reported as Thy 3F (neoplasm possible/suggestive of follicular neoplasm), Thy4 (suspicious of malignancy) and Thy 5 (malignant) were tested for BRAF V600 mutation and managed as malignant if mutations were present. RESULTS: Of 207 FNAs from 176 patients, 5 were Thy 5, 19 Thy 4, 36 Thy 3f, 13 Thy 3a, 84 Thy 2 and 50 Thy 1. 11 Thy 3f, 15 Thy 4 and 3 Thy 5 FNAs were tested for BRAF V600 mutation. 0 Thy 3F cases, 6 Thy 4 and 1 Thy 5 (24% of the total tested) showed evidence of mutation. Four patients with BRAF V600 mutation underwent surgery to remove all thyroid tissue, two patients received a lobectomy and one patient is awaiting thyroidectomy. All patients with BRAF V600 mutation were found to have malignancy on final histology, with a diagnostic sensitivity for malignancy excluding coincidental microcarcinoma of 43% and specificity of 100%. CONCLUSIONS: BRAF V600 mutational analysis can enable single-stage total thyroidectomy for carcinoma if gene mutation is present in preoperative FNA. BRAF V600 co-testing may reduce the need for completion thyroidectomy with implied cost savings and lower patient morbidity associated with completion thyroidectomy when the cytology is inconclusive but where BRAF V600 mutation is identified in preoperative thyroid FNA.

Oncoplastic breast conserving surgery.

Oncoplastic breast conserving surgery is a fundamental component of the repertoire for the management of breast cancer. It facilitates removal of large volumes of breast tissue, and can improve cosmetic outcomes and patient satisfaction whilst maintaining good oncological principles, reducing re-excision and mastectomy rates and assisting in adjuvant radiotherapy planning. We review the various techniques for oncoplastic breast conserving surgery that have emerged over recent years and describe their utilisation in excising tumours from various locations within the breast, and the pertinent patient specific factors that must be considered in technique selection. Finally complications and the evidence for the oncological safety specific to this type of surgery are discussed.

Isoflurane hepatitis-induced liver failure: a case report.

A case of fulminant hepatic failure two days following an uneventful operation during isoflurane anesthesia is presented. Investigations included elevated bilirubin and serum transaminases in the absence of any other cause of hepatic dysfunction. The patient died on the fourth postoperative day. Subsequent postmortem examination showed centrilobular coagulative necrosis consistent with drug toxicity, with isoflurane as the most likely toxic agent.

Ileocolic Intussusception - A rare cause of acute intestinal obstruction in adults; Case report and literature review.

Colonic Intussusception although common in children, is a rare cause of acute intestinal obstruction in adults. The etiology, clinical presentation and management of this condition is different in adults as compared to children. Pre-operative diagnosis is usually difficult due to the non specific and intermittent nature of the symptoms. CT scan can be a helpful adjunct in establishing the diagnosis. We present a case report of adult ileocolic intussusception with classical radiological signs and operative findings. A brief literature review is also presented with emphasis on the controversy of reduction of the intussusception before resection.