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The National Institute for Clinical Excellence recommends the use of tumour profiling tests to guide adjuvant chemotherapy in breast cancer. The Oncotype DX™ score (Genomic Health) has superseded more traditional tools such as PREDICT in appropriate patients (ER + ve, HER2-ve, lymph node negative and with a Nottingham Prognostic Index [NPI] ≥ 3.4). The aim of this study was to see whether the introduction of Oncotype DX within our institution resulted in an overall reduction in rates of chemotherapy. Data was collected retrospectively using the Somerset Cancer Register, Pathology department databases and the institution’s own online medical records system. Two groups were compared: (1) pre-oncotype (Jan 2012–Dec 2014) and (2) post-oncotype (Jan 2016–July 2018). During the pre-oncotype period, 28/82 (34%) patients who would have been eligible for testing (patients who were ER + ve, HER2-ve, and a NPI ≥ 3.4) received chemotherapy compared to 34/135 (25%) who were sent for oncotype during the second study period (p = 0.157). For grade 3 cancers, and those aged under 50, the results were more marked: grade 3 pre-oncotype 23/43 (53%), post-oncotype 29/76 (38%) (p = 0.101), aged under 50 pre-oncotype 8/15 (53%), post-oncotype 10/31 (32%) (p = 0.197). Within our institution, overall rates of chemotherapy have reduced since the introduction of Oncotype DX with the results more marked in subgroups of traditional indicators of tumour aggression. As genomic assays provide a more accurate prediction of the benefit of chemotherapy, its overall reduction has potential cost saving implications as well as reducing risk in patients who will derive little benefit.

Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates.Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected.Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent).Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.Las recomendaciones para la mastectomía por equipos multidisciplinarios (multidisciplinary teams, MDTs) podrían contribuir a explicar la diferencia en las tasas de mastectomía. El objetivo primario de este estudio observacional prospectivo y multicéntrico fue describir la práctica actual en la toma de decisiones de los MDT para recomendar la mastectomía. El objetivo secundario fue determinar factores que contribuyen a la variación en las tasas de mastectomía. MÉTODOS: Se reclutaron pacientes consecutivas sometidas a mastectomía entre el 1 de junio de 2015 y el 29 de febrero de 2016 en las unidades participantes de todo el Reino Unido. Se recogieron datos del preoperatorio, tratamiento neoadyuvante sistémico (neoadjuvant systemic treatment, NST), quirúrgicos y oncológicos, así como la justificación de los MDT para recomendar la mastectomía.Un total de 1.776 pacientes fueron sometidas a 1.823 mastectomías en 68 unidades. La mastectomía fue recomendada por los MDTs en 1.402 (76,9%) de estas mujeres. Las razones más frecuentes para recomendar la mastectomía fueron la elevada proporción entre el tamaño del tumor y el de la mama (530; 29,1%) y la enfermedad multicéntrica (372; 20,4%). En total, a 202 mujeres postmenopáusicas con tumores unifocales positivos para receptores de estrógenos (ER+) se les recomendó la mastectomía y no se les ofreció NST; debido a una elevada proporción entre el tamaño del tumor y de la mama en 173 (86%) pacientes. A 75 mujeres de70 años con tumores positivos para el human epidermal growth factor receptor 2 (HER2+) se les recomendó la mastectomía y no se les ofreció NST; debido a una elevada proporción entre el tamaño del tumor y de la mama en 45 (60%) mujeres. CONCLUSIÓN: La mayoría de las mastectomías se recomendaron en casos con una elevada proporción entre el tamaño del tumor y el de la mama, pero existe una inconsistencia en la utilización de la NST para reducir el tamaño del tumor en pacientes con grandes cánceres ER+ o HER2+. La aplicación de recomendaciones estandarizadas para la NST podría reducir el número de mastectomía recomendadas por los MDT.

Magnetic resonance imaging (MRI) is highly sensitive in detecting invasive lobular carcinoma (ILC) of the breast. In our institution, patients who are deemed to be suitable for breast conserving surgery (BCS) with unifocal small ILC on standard imaging are offered breast MRI to exclude multifocal and larger ILC. Our study investigates the usefulness of breast MRI in ILC. A prospective cohort study over a 58-month period, including all consecutive patients with ILC having breast MRI. Primary objective was to find out the proportion of ILC patients where preoperative MRI caused a change in the surgical treatment. Secondary objectives included finding mastectomy rate (initial & final), re-operation rate, cancer size correlation with different imaging modalities and final histopathology, loco-regional recurrence and disease-free survival. A total of 334 bilateral breast MRI were performed including 72 (21.5%) MRI for ILC patients. All these MRI were carried out within 2 week of patients given the diagnosis (median 5.5 days). Age range was 24-83 (median 56.5) years. Nineteen of 72 ILC patients (26.4%) had a change in their planned operation from BCS to a different operation owing to MRI findings (seven patients with multifocal cancers, 10 with significantly larger size of the cancer and two with contralateral malignancy). Initial mastectomy rate was 31.9%, final mastectomy rate was 36.1% and re-operation rate in BCS group was 18.3%. MRI correlated better with ILC histopathology cancer size than mammogram and ultrasound scans. There was no statistically significant difference (p = 0.999) between the cancer size on histology (median 23 mm) and MRI (median 25 mm). However, mammogram (median 17 mm) and ultrasound (median 14.5 mm) scans showed cancer sizes significantly different to final histology cancer size (p = 0.0008 and p = 0.0021 respectively). Over a 44 months median follow-up (range 27-85), 95.8% disease-free survival and 98.6% overall survival have been observed. One out of every four patients (26.4%) with ILC had a change in their planned operation due to MRI findings. A relatively high disease-free survival over a medium-term follow-up proves the oncological safety of MRI in ILC. Our study provides evidence in support of the targeted use of preoperative breast MRI among patients with ILC to improve surgical planning.

The role of cavity shaves in reducing re-excision rates in breast conserving surgery (BCS) remains unclear. We compared rates of close margins and re-excision following cavity shaves based on either intraoperative radiology or systematic cavity shaves. Data was recorded prospectively from 1999 to 2003 for 217 patients undergoing BCS. For the first 106 cases, cavity shaves were performed when intraoperative radiological margins appeared close (10 mm). The remaining 111 cases had systematic superior and inferior cavity shaves (SSICS). Close margins and re-excision rates were compared between groups. The median weight of excised tissue was less in group two: 82.8 g versus 100.5 g, P=0.001. SSICS reduced close margins by 83% (18/106 versus 8/111), OR 0.17, 95% CI 0.08-0.48, P=0.001. Multivariate analysis showed SSICS also reduced re-excision rates (15 versus 8 cases), OR 0.26, 95% CI 0.09-0.74, P=0.012. SSICS reduces close margins and re-excision rates. This approach has additional cosmetic benefits because less tissue is excised.

We report a highly unusual case of a pregnant woman presenting with induration and subsequent skin ulceration of the breast. A wedge biopsy led to the definitive diagnosis of a rare type of primary systemic anaplastic large cell lymphoma of T-cell phenotype involving the skin.

Objective Recent changes in postgraduate medical training in the UK collectively organized under the auspices of Modernising Medical Careers (MMC) have created new labels for junior doctors in training. It would appear that many nurses and other health workers do not understand the new terminology. We aimed to investigate the knowledge of nursing staff about new junior doctor titles in a district general hospital. As far as we are aware, this is the first survey to determine the views and knowledge of the new terms among staff working in the NHS. Design Questionnaire study. Setting District general hospital. West Midlands, UK. Participants Fifty-five randomly selected staff nurses working in the surgical directorate. Main outcome measure Questions were asked about their views and knowledge of the current nomenclature. To objectively assess knowledge of the new titles respondents were asked to match equivalent positions with those based on the old system. Results Only 22% ( n = 12) of respondents felt that they fully understand current terms in usage. Seventy-six percent ( n = 42) felt that it was ‘very important’ that titles accurately convey role and seniority of the doctor. The most common titles correctly matched were FY1 and House Officer ( n = 45, 81%) and FY2 and First Year Senior House Officer ( n = 35, 64%). Only 9% ( n = 5) of staff nurses correctly matched ST3 to Junior Registrar and 13% ( n = 7) correctly matched ST7 to Senior Registrar. Ward-based staff nurses demonstrated greater familiarity with titles when compared to nurses who work mainly in the outpatient clinic and theatre setting (p = 0.017). We did not identify a statistically significant association with demographic characteristics (age, gender, experience) and knowledge of the new terms (p > 0.05). Approximately 98% ( n = 54) of the staff surveyed felt that terms are confusing to nurses and need to be simplified. Conclusions Our survey revealed that nursing staff lacked knowledge of the current terminology to describe doctors in training. This may have implications for staff expectations regarding specific role of junior doctor in terms of clinical decision-making, working relationships and communication between team members, and ultimately patient care.

Introduction: Breast magnetic resonance imaging (MRI) is highly sensitive in detecting invasive lobular carcinoma (ILC) of the breast. We investigate the use of breast MRI in ILC and in what proportion of patients it influences a change in the management. Methods: A prospective cohort study over a 58-months period, including all consecutive patients with ILC having breast MRI scans. Results: A total of 334 bilateral breast MRI scans were performed. 72 (21.5%) of these were for the assessment of histologically confirmed ILC and were eligible for evaluation. All these MRI scans were carried out within 2 week of patients given the diagnosis (median 5.5 days). Age range of these patients was 24e83 (median 56.5) years. 19 out of 72 patients in ILC group (26.4%) had change in their planned operation from wide local excision (WLE) to a different operation based on the MRI. This included 7 patients with multifocal cancers, 10 patients with significantly larger size of the cancer shown on the MRI than mammogram/ ultrasound and 2 patients with contralateral malignancy. Instead of simple WLE, different operations in these 19 patients included 15 mastectomies, 1 double wire guided WLE, 1 therapeutic mammoplasty and 2 bilateral operations. With regards to the size of cancers, MRI (median 25mm) correlated significantly better with histopathology (median 23mm) than mammogram (median 17mm) and ultrasound scans (median 14.5mm). Over a median 37 months follow up (range 20e78), 2.7% mortality rate (2/72) was observed with no loco-regional recurrence or distant metastases. Conclusions: One out of every four patients (26.4%) with ILC had a change in planned operation, including 20.8% needing mastectomies instead of planned WLE due to MRI findings, hence proving its usefulness in ILC.

Although unilateral male breast swelling is relatively common, a histological diagnosis is infrequently obtained. From 1998 to 2003 we routinely performed needle core biopsy on all men presenting with unilateral breast swelling in whom there was diagnostic uncertainty. Of 113 patients, 93% had gynaecomastia, two patients had primary breast cancer and one had metastatic lymphoma. One patient had chronic mastitis. Gamolenic acid treatment produced a 73% response rate amongst patients presenting with pain. Core biopsy is a safe and effective method of diagnosing unilateral male breast swelling, which allows either confident reassurance or definitive treatment of those with cancer or pain.

Phalangeal bone metastasis is rare. Breast cancer is known to metastasise to bone but rarely to fingers. This case presents the first site of breast cancer metastasis found on a single proximal phalanx causing pain and affecting hand function. For surgical symptomatic treatment the patient had a ray resection. Post-operatively the patient was pain free with excellent hand function.

The key to diagnosis for deformed or scaling nipple is cytology or histology. While scrape cytology and punch biopsy do not provide underlying breast tissue for histology wedge excision requires more time and resource. We present the technique of nipple core biopsy (NCB) in 40 patients with deformed or scaling nipple done as a part of triple assessment yielding both skin and breast tissue for histological examination. Histological diagnosis confirmed eczema in 24, Paget's disease of nipple in 9 and chronic inflammation in 2. Among 5 remaining patients with normal skin histology, underlying breast invasive ductal carcinoma was seen in 3, ductal carcinoma in situ (DCIS) in 1 and adenoma in 1. NCB identified 5(55%) significant breast pathologies in Paget's disease and detected a further 2 invasive cancers in the absence of a palpable mass. The technique also provides additional information in the form of oestrogen receptor, which can have direct impact on patient management.

When mammogramography detects a non-palpable lesion the surgeons may be called upon to establish a diagnosis. Various techniques are currently employed. We describe a technique, which can be used both for diagnostic and for therapeutic procedures. The technique essentially involves localising the tip of a guide-wire, placed under mammographic guidance, with ultrasound scanning. This minimises many of the problems encountered with wire guided excision. We conducted a prospective non-randomised study using our combined image guidance technique (CIG) for patients undergoing diagnostic ( n =24) and therapeutic biopsy ( n =13). We found that significantly smaller diagnostic biopsy weights were achievable using CIG, compared to non-CIG techniques. Reduced biopsy weights are recommended by current guidelines.

Introduction: Mucinous carcinoma of the breast is an uncommon disease, characterized by a large amount of mucin production. Histologically, it is classified into two subgroups— pure type and mixed type. It usually affects postmenopausal women and is commonly associated with good prognosis. case report: We present a case of a 53-year-old female with a palpable breast lump which was clinically as well as radiologically suspicious of breast cancer. A free hand needle core biopsy was carried out. the biopsy material retrieved had a distinctive gross appearance, with soft, gelatinous consistency and a glistening clear surface. On this typical macroscopic appearance, a diagnosis of ‘mucinous breast carcinoma’ was made, which was subsequently confirmed on histological examination. the typical gross appearance of specimen on needle core biopsy is similar to the appearance of wallpaper paste; hence we describe it as ‘wallpaper paste sign’. conclusion: the hallmark of mucinous carcinoma is extracellular mucin production that gives it a typical glistening macroscopic appearance. Keeping in mind the ‘wallpaper paste sign’ we describe, mucinous breast carcinoma can be

Introduction Elderly and medically unfit patients make up a small but significant proportion of breast cancer patients. Methods A prospective study of breast cancer wide local excisions (WLE) performed under local anaesthesia (LA) from Mar 2008 to Apr 2011. Results 17 patients were included, with average age of 81 years (range 59 – 94 years). 10 patients had American Society of Anaesthesia (ASA) grade 3 and 7 patients had ASA grade 2. Mini mental state examination (MMSE) range was 8-10 (average 8.75). Preoperative Portsmouth Physiologic and Operative Severity Score for enumeration of Mortality and Morbidity (PPOSSUM), score predicted morbidity at 28.5 % (range 15 – 60%) and mortality at 1.8 % (range 0.1 – 6.1%). The observed morbidity was 5.8 % and mortality was 0%. Tumor size was 13-47mm (median 26mm). 10 patients were oestrogen receptor (ER) negative and 7 were positive. 100% disease free survival has been observed. The follow-up range was 8-54 months (median 39 months). Conclusions WLE of breast cancer under LA is a useful option. All patients in this selected ‘unfit’ group were treated as day cases. All patients currently remain disease free. Disclosure All authors have declared no conflicts of interest.

Background Reducing cost whilst providing high quality care is a challenge to surgeons. Care is taken in planning list order to maximise day case rates whilst minimising starvation and preoperative hospital stay. We aimed to assess how well the planned list order is followed. Methods All main theatre lists in 2010 under one consultant were obtained from medical records. The planned list order was compared to the actual operating sequence. Results Fifty operating lists were included with 353 operations. Conclusions Planned list order was frequently changed making it difficult to accurately predict the time the operation would be performed. This resulted in longer preoperative starvation, patient anxiety/discontent and longer hospital stay. It also placed additional pressure on theatre staff when planning their working day. *(Matthew 20:16). Disclosure All authors have declared no conflicts of interest.

Introduction There has been an increasing trend towards image guided core biopsy than free hand biopsy for symptomatic breast lesions. We aimed to study our own practice. Methods All patients presenting to one stop breast clinic needing core biopsies over an 18 month period under a single consultant were prospectively included in this study. Information was collected regarding method & number of biopsies, time delay between patient initial assessment, core biopsy and results given. Results 400 consecutive breast core biopsies were performed over this 18 month period. Table 1 . Free hand biopsy Image guided biopsy p value Total number (%) 304 (76%) 96 (24%) Median number of cores taken per biopsy (range) 2 (1-8) 4 (1-7) Median number of days lapsed between patient assessment and core biopsy (range) 0 (0-50) 8 (0-34) Median number of days lapsed between patient assessment and result given (range) 7 (2-52) 16 (2-44) Sensitivity 294/304 (96.7%) 95/96 (98.9%) 0.19 Cancer Ratio 1:1.1 1:2.5 0.04 Conclusions 76 % of biopsies have been performed free hand with no significant difference in diagnostic sensitivity compared with image guided biopsies. In a selected group, free hand biopsies provide the added advantage of early diagnosis and subsequent treatment. Disclosure All authors have declared no conflicts of interest.