A pilot study investigating feasibility of mainstreaming germline BRCA1 and BRCA2 testing in high-risk patients with breast and/or ovarian cancer in three tertiary Cancer Centres in Ireland.

In the Republic of Ireland (ROI), BRCA1/BRCA2 genetic testing has been traditionally undertaken in eligible individuals, after pre-test counselling by a Clinical Geneticist/Genetic Counsellor. Clinical Genetics services in ROI are poorly resourced, with routine waiting times for appointments at the time of this pilot often extending beyond a year. The consequent prolonged waiting times are unacceptable where therapeutic decision-making depends on the patient's BRCA status. "Mainstreaming" BRCA1/BRCA2 testing through routine oncology/surgical clinics has been implemented successfully in other centres in the UK and internationally. We aimed to pilot this pathway in three Irish tertiary centres. A service evaluation project was undertaken over a 6-month period between January and July 2017. Eligible patients, fulfilling pathology and age-based inclusion criteria defined by TGL clinical, were identified, and offered constitutional BRCA1/BRCA2 testing after pre-test counselling by treating clinicians. Tests were undertaken by TGL Clinical. Results were returned to clinicians by secure email. Onward referrals of patients with uncertain/pathogenic results, or suspicious family histories, to Clinical Genetics were made by the treating team. Surveys assessing patient and clinician satisfaction were sent to participating clinicians and a sample of participating patients. Data was collected with respect to diagnostic yield, turnaround time, onward referral rates, and patient and clinician feedback. A total of 101  patients underwent diagnostic germline BRCA1/BRCA2 tests through this pathway. Pathogenic variants were identified in 12 patients (12%). All patients in whom variants were identified were appropriately referred to Clinical Genetics. At least 12 additional patients with uninformative BRCA1/BRCA2 tests were also referred for formal assessment by Clinical Geneticist or Genetic Counsellor. Issues were noted in terms of time pressures and communication of results to patients. Results from a representative sample of participants completing the satisfaction survey indicated that the pathway was acceptable to patients and clinicians. Mainstreaming of constitutional BRCA1/BRCA2 testing guided by age- and pathology-based criteria is potentially feasible for patients with breast cancer as well as patients with ovarian cancer in Ireland.

Breast reconstruction post mastectomy- Let's Google it. Accessibility, readability and quality of online information.

INTRODUCTION: This study evaluated the readability, accessibility and quality of information pertaining to breast reconstruction post mastectomy on the Internet in the English language. METHODS: Using the Google© search engine the keywords "Breast reconstruction post mastectomy" were searched for. We analyzed the top 75 sites. The Flesch Reading Ease Score and Gunning Fog Index were calculated to assess readability. Web site quality was assessed objectively using the University of Michigan Consumer Health Web site Evaluation Checklist. Accessibility was determined using an automated accessibility tool. In addition, the country of origin, type of organisation producing the site and presence of Health on the Net (HoN) Certification status was recorded. RESULTS: The Web sites were difficult to read and comprehend. The mean Flesch Reading Ease scores were 55.5. The mean Gunning Fog Index scores was 8.6. The mean Michigan score was 34.8 indicating weak quality of websites. Websites with HoN certification ranked higher in the search results (p = 0.007). Website quality was influenced by organisation type (p < 0.0001) with academic/healthcare, not for profit and government sites having higher Michigan scores. 20% of sites met the minimum accessibility criteria. CONCLUSIONS: Internet information on breast reconstruction post mastectomy and procedures is poorly written and we suggest that Webpages providing information must be made more readable and accessible. We suggest that health professionals should recommend Web sites that are easy to read and contain high-quality surgical information. Medical information on the Internet should be readable, accessible, reliable and of a consistent quality.

The Value of Isosulfan Blue Dye in Addition to Isotope Scanning in the Identification of the Sentinel Lymph Node in Breast Cancer Patients With a Positive Lymphoscintigraphy: A Randomized Controlled Trial (ISRCTN98849733).

BACKGROUND: Sentinel lymph node biopsy (SLNB) has become the gold standard for axillary staging. Debate remains as to the optimal method of SLN detection. OBJECTIVES: Determine whether patients undergoing an SLNB required the addition of isosulfan blue dye to radioisotope when an SLN was identified on a preoperative lymphoscintigram. METHODS: A prospective randomized controlled trial comparing the combination of radioisotope and blue dye versus radioisotope alone was performed between March 2010 and September 2012. The trial protocol was registered with Current Controlled Trials. Women with clinically and radiologically node-negative breast cancer with a positive preoperative lymphoscintigram were eligible for inclusion. RESULTS: A total of 667 patients were included in the analysis with 342 patients receiving the combination (blue dye and radioisotope) and 325 patients receiving radioisotope alone. The groups were evenly matched both demographically and pathologically. The mean age was 48 years (48.3 vs 47.7 years; P = 0.47), the mean tumour size was 24.2 mm (24.3 mm vs 24.1 mm; P = 0.7) and there was no statistically significant difference in the grade of the tumors between the 2 groups (P = 0.58). There was no difference in the identification rate, nor was that in the number of nodes retrieved between the 2 groups (P = 0.30). There was no difference in the number of positive lymph nodes that were identified between the 2 groups (23.8% vs 22.1%; P = 0.64). CONCLUSIONS: This study failed to demonstrate an advantage with the addition of isosulfan blue dye to radioisotope in the identification of the SLN in the presence of a positive preoperative lymphoscintigram.

Sentinel node biopsy in breast cancer revisited.

The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced. The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.

Use of incentive spirometry in portable chest radiography.

PURPOSE: The degree of lung inflation seen on a chest radiograph is dependent on the point during the patient's respiratory cycle at which the radiographer exposes the image receptor. Exposing the image receptor at the exact peak of inflation can be difficult because of the limited time available in which to capture the inspiratory pause. An incentive spirometer can indicate the moment of peak inhalation. This study tested whether images taken with and without an incentive spirometer display different levels of image quality. METHODS: This is a paired, prospective, single-blinded study of 30 patients undergoing portable chest radiography. The radiographs were acquired with and without the use of an incentive spirometer. Visual grading analysis was performed using the 1996 European Guidelines on Quality Criteria for Diagnostic Radiographic Images. RESULTS: The mean patient age was 53 years. Sixty images were acquired, 30 with the use of incentive spirometry and 30 without. The most common indication for portable chest radiography was "postlung lobectomy." DISCUSSION: Scoring on the radiologist's ability to see the sixth rib, spine, trachea, and cardiac border was not affected significantly by the use of incentive spirometry. Use of an incentive spirometer was associated with significant improvement in ability to see the 10th rib (P ≤ .004), vascular pattern (P ≤ .001), retrocardiac lung (P ≤ .013), and the costophrenic angles (P ≤ .005). CONCLUSION: This study introduces a technique to improve the quality of portable chest radiographs. The use of incentive spirometry improved inspiratory depth and image quality for portable chest radiographs.

Assessing the impact of neoadjuvant chemotherapy on the management of the breast and axilla in breast cancer.

BACKGROUND: Nodal status is a sensitive prognostic indicator in breast cancer. Axillary metastases may be an indication for neoadjuvant systemic therapy. The aims of this study were to compare pathologic response rates to neoadjuvant chemotherapy (NAC) in the breast and axilla across different molecular subtypes of breast cancer and to compare the predictive value of axillary assessment before and after chemotherapy in determining final nodal status in this cohort of patients. PATIENTS AND METHODS: The cohort comprised patients undergoing NAC from 2003 to November 2012. Data regarding patient and tumor characteristics, management, and outcomes were obtained from a prospectively maintained database and analyzed using PASW Statistics, version 18 (SPSS Inc, Chicago, IL). RESULTS: Two hundred two cancers were identified in 196 patients. One hundred thirty-one (65%) diagnostic axillary procedures were performed, 105 (80%) before NAC, of which 93 (89%) were positive. In 28 (30%), downstaging was noted before NAC. Human epidermal growth factor receptor 2 (HER2) subtypes had the highest rate of complete pathologic response (n = 11 [61%]) and negative axillary clearance (AXCn) (n = 11 [69%]). Of 177 AXCns, 68 (38%) were negative before NAC. CONCLUSION: AXCn in patients undergoing NAC remains controversial. HER2 subtypes are less likely to have axillary involvement after NAC and may demand different management.

Assessing the impact of an ageing population on complication rates and in-patient length of stay.

BACKGROUND: Ireland has an ageing population; with the proportion of people aged over 80 years estimated to increase over the next 20 years from 1.1% to 2.1%. AIMS: The aim of this study was to examine the demographics of the population served by the surgical department in a tertiary referral centre in the west of Ireland and to examine whether increasing age had an influence on morbidity, mortality and length of stay. METHODS: Data pertaining to all surgical admissions over a 6-month period between was collected prospectively using an ACS-NSQIP based proforma. Data collected included patient age, gender, operative intervention, in-patient length of stay, mode of admission and complications related to their admission. RESULTS: A total of 2209 patients were admitted under the care of the general, vascular and breast services in our centre over a 6-month period between August and January. Two thousand and nineteen patients had complete data collected. The average age was 50.37 years (± 23.62), with 24.12% (n = 533) older than 70 years. Only 12.31% of patients aged younger than 70 years experienced morbidity, compared to 25.10% of older patients. It was shown that there was a stepwise increase with complication rates and hospital in-patient stay across each decade of increasing age. Multivariate analysis showed those factors most predictive of a complication to include emergency admission, major or complex major surgical intervention, female gender and age. Length of stay was also found to have a positive correlation with increasing age (Spearman's Rho, p < 0.001). CONCLUSION: Increasing age is associated with increased complication rates and increased hospital length of stay.

Endocrine surgeon-performed US guided thyroid FNAC is accurate and efficient.

BACKGROUND: Ultrasound guided fine needle aspiration cytology (US-FNAC) is a key diagnostic technique used to assess thyroid nodules. This procedure has been the domain of radiologists, but it is increasingly performed by endocrine surgeons. In the present study we aimed to assess the accuracy and clinical efficiency of US-FNAC performed by endocrine surgeons. PATIENTS AND METHODS: This study was a retrospective review of consecutive patients in a 3-year period who underwent US-FNAC performed by endocrine surgeons and radiologists. Medical records, cytology results, and surgical pathology results were collected and analyzed. RESULTS: A total of 576 US-FNAC were performed on 402 patients during the study period. The endocrine surgeons and radiologists performed 299 and 277 US-FNAC, respectively. The FNAC inadequacy rate was 5.3 % for the endocrine surgeons and 9.3 % for the radiologists (p = 0.05). For thyroid cancer, the sensitivity, specificity, and false negatives of the US-FNAC for the endocrine surgeons was 87 %, 98 %, and 3 %, respectively while that for the radiologists was 88 %, 95 %, and 3.5 %, respectively. Patients with thyroid cancer had a shorter time to surgery in the endocrine surgeons' group (mean 15.3 days) compared to the radiologists' group (mean: 53.3 days; p = 0.01). CONCLUSIONS: US-FNAC performed by an experienced endocrine surgeon is accurate and allows efficient surgical management for patients with thyroid cancer.

Ultrasound-guided core biopsy: an effective method of detecting axillary nodal metastases.

BACKGROUND: Axillary nodal status is an important prognostic predictor in patients with breast cancer. This study evaluated the sensitivity and specificity of ultrasound-guided core biopsy (Ax US-CB) at detecting axillary nodal metastases in patients with primary breast cancer, thereby determining how often sentinel lymph node biopsy could be avoided in node positive patients. STUDY DESIGN: Records of patients presenting to a breast unit between January 2007 and June 2010 were reviewed retrospectively. Patients who underwent axillary ultrasonography with or without preoperative core biopsy were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography and percutaneous biopsy were evaluated. RESULTS: Records of 718 patients were reviewed, with 445 fulfilling inclusion criteria. Forty-seven percent (n = 210/445) had nodal metastases, with 110 detected by Ax US-CB (sensitivity 52.4%, specificity 100%, positive predictive value 100%, negative predictive value 70.1%). Axillary ultrasonography without biopsy had sensitivity and specificity of 54.3% and 97%, respectively. Lymphovascular invasion was an independent predictor of nodal metastases (sensitivity 60.8%, specificity 80%). Ultrasound-guided core biopsy detected more than half of all nodal metastases, sparing more than one-quarter of all breast cancer patients an unnecessary sentinel lymph node biopsy. CONCLUSIONS: Axillary ultrasonography, when combined with core biopsy, is a valuable component of the management of patients with primary breast cancer. Its ability to definitively identify nodal metastases before surgical intervention can greatly facilitate a patient's preoperative integrated treatment plan. In this regard, we believe our study adds considerably to the increasing data, which indicate the benefit of Ax US-CB in the preoperative detection of nodal metastases.

HER-2 positive and p53 negative breast cancers are associated with poor prognosis.

p53 and HER-2 coexpression in breast cancer has been controversial. These markers were tested using immunohistochemistry and HercepTest. HER-2 expression is related to reduced breast cancer survival (p = .02) . p53 expression relates to HER-2 expression (p = .029). Coexpression between p53 and HER-2 has no relation to prognosis. On univariate and multivariate analysis, combination of HER-2 positive and p53 negative expression was associated with a poor prognosis (p = .018 and p = .027, respectively), while the combination of HER-2 negative and p53 positive expression was associated with a favorable prognosis (p = .022 and p = .010, respectively). Therefore the expression of these markers should be considered collectively.

Referral patterns of patients with liver metastases due to colorectal cancer for resection.

INTRODUCTION: Colorectal carcinoma accounts for 10% of cancer deaths in the Western World, with the liver being the most common site of distant metastases. Resection of liver metastases is the treatment of choice, with a 5-year survival rate of 35%. However, only 5-10% of patients are suitable for resection at presentation. AIMS: To examine the referral pattern of patients with liver metastases to a specialist hepatic unit for resection. METHODOLOGY: Retrospective review of patient's charts diagnosed with colorectal liver metastases over a 10-year period. RESULTS: One hundred nine (38 women, 71 men) patients with liver metastases were included, mean age 61 years; 79 and 30 patients had synchronous and metachronus metastases, respectively. Ten criteria for referral were identified; the referral rate was 8.25%, with a resection rate of 0.9%. Forty two percent of the patients had palliative chemotherapy; 42% had symptomatic treatment. CONCLUSION: This study highlights the advanced stage of colorectal cancer at presentation; in light of modern evidence-based, centre-oriented therapy of liver metastasis, we conclude that criteria of referral for resection should be based on the availability of treatment modalities.

Totally extraperitoneal laparoscopic inguinal hernia repair is a safe option in patients with previous lower abdominal surgery.

BACKGROUND: History of inguinal hernia repair changed over the decades from repair by tissue approximation to the insertion of synthetic mesh and the introduction of laparoscopic repair. Despite accounting for 15-20% of hernia operations worldwide, many surgeons considered previous lower abdominal surgery as a contraindication to performing totally extraperitoneal (TEP) repair. AIM: The aim of this study was to assess the feasibility of TEP in primary and recurrent inguinal hernias in patients with previous lower abdominal surgery. PATIENTS AND METHODS: This study was a retrospective review of patients who underwent TEP inguinal hernia repair from January 2001 to July 2005. Variables studied included patient demographics, type of hernia, type of previous surgery, conversion to open repair, postoperative complications, and overnight admission. RESULTS: One hundred eight patients (107 males, 1 female), with a median age of 55 years (range 87-24), underwent TEP repair. Ninety-four patients had primary inguinal hernias, and 13 patients had recurrent inguinal hernias. Seventeen patients had a previous lower abdominal surgery (13 primary and 4 recurrent inguinal hernias). There was 1 conversion to open repair and 1 case of postoperative bleeding that required an exploration-both in the group with no previous surgery. Postoperative complications were minimal. All cases were performed as day cases; however, patients with recurrent hernia stayed longer in the hospital than those with primary hernia (P = 0.006). CONCLUSION: TEP repair is feasible in patients with previous lower abdominal surgery. TEP was planned as a day-case procedure; however, patients with recurrent hernias needed a planned admission, as an overnight stay was required.

Early discharge policy of patients with acute colonic diverticulitis following initial CT scan.

INTRODUCTION: Diverticulitis develops in 15-20% of individuals with diverticulosis. Severity ranges from mild to severe. Mild diverticulitis is uncomplicated confined per colonic inflammation commonly treated conservatively. Recent literature suggests it could be managed in an outpatient setup. AIMS: To determine if patients with mild acute colonic diverticulitis (ACD) on early CT scan can be treated and discharged at an early time. METHODOLOGY: Retrospective review of patient's charts admitted during 2005 with ACD confirmed by CT scan performed within 24 h of admission. Severity of ACD was determined according to CT classification. RESULTS: Forty-two (31 women, 11 men) patients included, mean age 66 years, CT severity classification: 61.9% mild, 7.1% moderate, and 31.0% severe diverticulitis. Patients with mild ACD were discharged safely, had no recurrence of their symptoms, and needed no readmission within 6 months of follow-up. CONCLUSION: Patients with mild ACD on CT scan performed within 24 h could be safely discharged and treated according to protocols of outpatient management of diverticulitis.

Three-port versus four-port laparoscopic cholecystectomy in acute and chronic cholecystitis.

BACKGROUND: Several modifications have been introduced to laparoscopic cholecystectomy (LC). The three-port technique has been practiced on a limited scale. Our aim was to compare the three-port and four-port LC in acute (AC) and chronic cholecystitis (CC). METHODS: The medical records of 495 patients who underwent LC between September 1999 and September 2003 were reviewed. Variables such as complications, operating time, conversion to open procedure, hospital stay, and analgesia requirements were compared. RESULTS: Two hundred and eighty-three patients underwent three-port LC and 212 patients underwent four-port LC. In total, 163 (32.9%) patients were diagnosed with AC and 332 (67.1%) with CC by histology. There was no statistical difference between the three and four-port groups in terms of complications, conversion to open procedure (p = 0.6), and operating time (p = 0.4). Patients who underwent three-port LC required less opiate analgesia (pethidine) than those who underwent four-port LC (p = 0.0001). The hospital stay was found to be related to the amount of opiates consumed (p = 0.0001) and was significantly shorter in the three-port LC group (p = 0.005). CONCLUSION: Three-port LC is a safe procedure for AC and CC in expert hands. The procedure offers considerable advantages over the traditional four-port technique in the reduction of analgesia requirements and length of hospital stay.

The diagnosis of acute cholecystitis in patients undergoing early laparoscopic cholecystectomy in a community hospital.

BACKGROUND: Early laparoscopic cholesyctectomy is the procedure of choice for acute cholecystitis; however, the diagnosis of acute cholecystitis in a community hospital setting is not always a simple matter. METHODS: A retrospective review of 70 patients who have been admitted through the A&E department with the symptomatic gall bladder stones between July 2002 and May 2003. RESULTS: To diagnose acute cholecystitis, as a single test, the sensitivity and the predictive value of the clinical-based diagnosis were 72.72% and 57.1%, respectively, higher than ultrasonography-based diagnosis 27.2% and 42.8%, respectively. The diagnosis of acute cholecystitis was 100% correct in 5 patients when the clinical diagnosis, ultrasound, and abnormal liver function test suggested the diagnosis of acute cholecystitis. The same was true for the diagnosis of chronic cholecystitis in 15 patients when the clinical picture and the ultrasound together with a normal liver function test supported the diagnosis. CONCLUSIONS: A detailed history and clinical examination are superior to ultrasonography for the diagnosis of acute cholecystitis. In a community hospital setting, a combination of clinical, radiologic, and laboratory tests are needed to accurately diagnose or exclude acute cholecystitis.

CA 15-3 is predictive of response and disease recurrence following treatment in locally advanced breast cancer.

BACKGROUND: Primary chemotherapy (PC) is used for down-staging locally advanced breast cancer (LABC). CA 15-3 measures the protein product of the MUC1 gene and is the most widely used serum marker in breast cancer. METHODS: We retrospectively investigated the role of CA 15-3 in conjunction with other clinico-pathological variables as a predictor of response and time to disease recurrence following treatment in LABC. Pre and post primary chemotherapy serum concentrations of CA 15-3 together with other variables were reviewed and related to four outcomes following primary chemotherapy (clinical response, pathological response, time to recurrence and time to progression). Persistently elevated CA 15-3 after PC was considered as consecutively high levels above the cut off point during and after PC. RESULTS: 73 patients were included in this study. Patients received PC (AC or AC-T regimen) for locally advanced breast cancer. 54 patients underwent surgery. The median follow up was 790 days. Patients with high concentrations of CA 15-3 before PC treatment had a poor clinical (p = 0.013) and pathological (p = 0.044) response. Together with Her-2/neu expression (p = 0.009) and tumour lympho-vascular space invasion (LVI) (p = 0.001), a persistently elevated CA 15-3 post PC (p = 0.007) was an independent predictive factor of recurrence following treatment in LABC. CONCLUSION: Elevated CA 15-3 level is predictive of a poor response to chemotherapy. In addition, persistently elevated CA 15-3 levels post chemotherapy in conjunction with lympho-vascular invasion and HER2 status predict a reduced disease free survival following treatment in locally advanced breast cancer.

Esophagogastroduodenoscopy prior to laparoscopic cholecystectomy.

BACKGROUND: Peptic ulcer disease and gallstones are common causes of upper abdominal pain. The benefits of routine gastrostroscopy before laparoscopic cholecystectomy have been controversial. Some cases of persistent abdominal pain after laparoscopic cholecystectomy have been attributed to peptic ulcer disease. MATERIALS AND METHODS: We reviewed the significance of preoperative esophagogastroduodenoscopy in patients scheduled for laparoscopic cholecystectomy. We compared a group of patients who underwent esophagogastroduodenoscopy before laparoscopic cholecystectomy and a group of patients who underwent laparoscopic cholecystectomy with no preoperative esophagogastroduodenoscopy. Postoperative residual abdominal pain, esophagogastroduodenoscopy findings, hospital stay, and other variables were examined. RESULTS: There were 400 patients in this study: 218 (54.5%) patients underwent esophagogastroduodenoscopy while 182 (45.5%) did not. The mean age was 49.8 years, 311 were female and 89 were male patients. One hundred and twenty seven (31.7%) patients were diagnosed with acute cholecystitis and 273 (68.2%) were nonacute. In the esophagogastroduodenoscopy group, there were normal findings in 98 (45%) patients. Disorders such as hiatus hernia (21%), acute duodenal ulcers (3.6%), esophagitis (3.6%), gastric ulcer (0.4%), and Barrett's esophagus (0.4%) were among the findings. Laparoscopic cholecystectomy was avoided in six patients with chronic cholecystitis. Preoperative esophagogastroduodenoscopy did not reduce the incidence of postoperative residual abdominal pain; in fact, patients who underwent esophagogastroduodenoscopy had longer hospital stays (P = 0.02). Unlike chronic cholecystitis, esophagogastroduodenoscopy did not change the course of the planned surgery in acute cholecystitis. CONCLUSION: Esophagogastroduodenoscopy prior to laparoscopic cholecystectomy does not have an impact on postoperative residual abdominal pain; however, it can disclose other gastroesophageal disorders with similar symptoms to gallstones and may change the course of the planned surgery in chronic cholecystitis.