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Summary Multiple endocrine neoplasia type 1 (MEN1) is a rare inherited endocrine disorder with a high rate of penetrance. The incidence of MEN1 is 1/30,000 in the general population; however, it is quite rare for a patient to present for medical attention with MEN1 for the first time in pregnancy. Primary hyperparathyroidism (PHPT) is one of the most common features of MEN1. The incidence of PHPT occurring in pregnancy is 1%. Despite advances in the medical, surgical and obstetric care over the years, management of this condition during pregnancy may be challenging. It can be difficult to identify pregnant women with PHPT requiring intervention and to monitor safely. Hypercalcemia can result in significant maternal and fetal adverse outcomes including: miscarriage, intrauterine growth restriction, preterm delivery, neonatal hypocalcaemia, pre-eclampsia and maternal nephrolithiasis. Herein, we present a case study of a lady with a strong family history of MEN1, who was biochemically proven to have PHPT and evidence of Zollinger Ellison Syndrome (ZE) on endoscopy. This patient delayed her assisted pregnancy plans for in vitro fertilization (IVF) until completion of the MEN1 workup; nevertheless, she spontaneously achieved an unplanned pregnancy. As a result, she required intervention with parathyroidectomy in the second trimester of her pregnancy as her calcium level continued to rise. This case study highlights the workup, follow up and management of MEN1 presenting with PHPT and ZE in pregnancy. Learning points Women of childbearing age who are suspected to have a diagnosis of primary hyperparathyroidism ideally should have genetic testing and avoid pregnancy until definitive plans are in place. Zollinger Ellison syndrome in pregnancy means off-label use of high dose of proton pump inhibitors (PPI). Use of PPI in pregnancy is considered to be safe based on retrospective studies. Omeprazole, however, is FDA class C drug because of lack of large prospective studies or large case series during pregnancy. Calcium supplements in the form of calcium carbonate must be converted to calcium chloride by gastric acid in order to be absorbed, however, patients rendered achlorhydric as a result of PPI use will have impaired absorption of calcium. Therefore, use of calcium citrate might be considered a better option in this case.

Introduction Recent studies have suggested that sentinel lymph node biopsy (SLNB) can be omitted in newly diagnosed elderly breast cancer (BC) patients as it may not influence decisions regarding further therapeutic intervention. The aim of this study was to assess the impact of SLNB on further surgical intervention as well as adjuvant treatments in patients over the age of 80. Method A retrospective study was performed involving all BC patients over the age of 80 diagnosed between 2008 and 2017 who underwent SLNB as part of their initial surgery. Patient/tumour characteristics and adjuvant treatments were recorded. Result 127 patients underwent SLNB in the study period. The median age was 82 (Range: 80-95). 91/127 (71.6%) had ductal pathology, median tumour grade was 2, and oestrogen receptor positivity was seen in 89% of patients. The median number of sentinel nodes removed was 2 (Range: 1-6). 45 patients (35.4%) had a positive sentinel node (median positive nodes = 1). Of the 45 patients, 11 proceeded to axillary lymph node dissection (ALND) (11/127; 8.6%). The median number of nodes excised during ALND was 14 (Range:7-25) and 6 patients (6/11) had further positive nodes. 9% of patients with a positive node received adjuvant chemotherapy, 87% received adjuvant radiotherapy and 79% received hormonal therapy. Conclusion Although SLNB positivity is still used in the elderly patients, only a few patients ( Take-home message The use of SLNB in elderly patients needs to be considered in node negative patients

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.

Benign goiter remains a major public health issue around the globe. Bilateral subtotal thyroidectomy for management of goiter is associated with a high recurrence rate. Total thyroidectomy has now become the preferred surgical approach for treatment of symptomatic goiter. Reoperative thyroid surgery for recurrent symptomatic goiter requires careful preparation and should incorporate neuromonitoring to help preserve vocal cord function.

The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I2 = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.

Breast fibromatosis is a rare clinical entity, but poses significant diagnostic and therapeutic challenges. In light of recent changes in management practices, the aim was to review our institutional experience of breast fibromatosis and provide a review of current available literature on such management. A search of pathological databases within two tertiary institutions for all patients diagnosed with fibromatosis of the breast over a 10-year period (2007–2016) was performed. Clinicopathological characteristics and modes of treatment were recorded for each patient. Concurrently a comprehensive literature search was performed and studies relating to breast fibromatosis and its management were identified and reviewed. Sixteen patients were identified. Median age at diagnosis was 42 (range 21–70) and all patients were diagnosed with core biopsy. The most useful imaging modality in diagnosis was ultrasonography and magnetic resonance imaging. 13/16 were treated surgically whilst 3/16 were treated using a watch-and-wait approach. 6/13 (46%) required re-excision of margins and 2/13 (15%) had recurrence after surgery. On review of the literature, there is no dedicated guideline in place for the management of breast fibromatosis. Currently a ‘watch and wait’ approach is favoured over surgical intervention due to high levels of recurrence and associated surgical morbidity. All cases should be discussed at a sarcoma multidisciplinary team meeting and tyrosine kinase inhibitors should be considered in advanced cases. Breast fibromatosis is rare but affects young patients. Active surveillance is now favoured over surgical resection due to high recurrence rates and extensive morbidity. Dedicated guidelines are required to ensure best outcomes.

Neoadjuvant chemotherapy (NAC) can improve cosmesis by reducing resection volume. Breast-conserving surgery (BCS) aims to achieve clear excision margins while optimizing cosmesis. However, the influence of NAC on margin re-excision after BCS is unclear. This study examines the rate and determinants of margin re-excision in patients undergoing BCS following NAC in our institution. From 2011–2015, all patients treated with NAC prior to BCS were identified from a prospectively maintained database. Mann–Whitney and Fisher’s exact test tests were used to compare variables in patients who did and did not require re-excision. Patients undergoing primary surgical treatment in 2015 comprised an unmatched comparison group. Of 211 patients treated with NAC, 69 initially underwent BCS. The re-excision rate was 32% (n = 22) compared to 17% in the primary operable group (38 of 221, p = 0.02). Re-excision rates were lowest in triple-negative and HER2+ tumors (0% and 10%, respectively). Lobular carcinoma and ER+ tumors had a significantly higher rate of re-excision (100% and 42%, respectively). Of 22 patients undergoing re-excision, 9 had further BCS and 13 had a mastectomy. The re-excision rate following NAC is almost twice that of patients who underwent primary operative management. Her2+ and triple-negative tumors have lower re-excision rates and may represent a selected cohort most suitable for BCS. Patients with invasive lobular carcinoma or ER+ disease have significantly higher rates of margin positivity, and these patients should be considered for a cavity shave during primary surgery to reduce the rates of re-excision.

Background Neoadjuvant chemotherapy for breast cancer has the potential to achieve a pathological complete response in up to 40 per cent of patients, converting disease that was initially node-positive to node-negative. This has raised the question of whether sentinel lymph node biopsy could be an alternative to axillary lymph node dissection in these patients. The aim was to undertake a systematic review and meta-analysis of the accuracy and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer. Methods A literature search was conducted using PubMed, Ovid MEDLINE, Embase and Web of Science databases up to 30 April 2017. Inclusion criteria for studies were pathological confirmation of initial node-positive disease, and sentinel lymph node biopsy performed after neoadjuvant chemotherapy followed by axillary lymph node dissection. Results A total of 13 studies met the inclusion criteria and were included in the analysis (1921 patients in total). The pooled estimate of identification rate was 90 (95 per cent c.i. 87 to 93) per cent and the false-negative rate was 14 (11 to 17) per cent. In subgroup analysis, the false-negative rate with use of dual mapping was 11 (6 to 15) per cent, compared with 19 (11 to 27) per cent with single mapping. The false-negative rate was 20 (13 to 27) per cent when one node was removed, 12 (5 to 19) per cent with two nodes removed and 4 (0 to 9) per cent with removal of three or more nodes. Conclusion Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with biopsy-proven node-positive breast cancer is accurate and reliable, but requires careful patient selection and optimal surgical techniques.

Background The optimal timing of (neo)adjuvant trastuzumab initiation with respect to chemotherapy and surgery remains undefined. Methods Retrospective analysis of a large institutional database of HER2-positive patients who received anti-HER2 therapy. We included all Stage I to III patients treated with trastuzumab with a minimum follow up of 3 years. The date of first breast biopsy was recorded as initial diagnosis. Results A total of 506 patients [adjuvant: 386 (76%)-neo-adjuvant: 120 (24%)] were included. The median time-to-first-trastuzumab (TFT) from diagnosis was 12 weeks (range 1.9–122.3). Median follow-up is 73.3 months (range 1.4–176.3). TFT was significantly shorter in the neo-adjuvant than in the adjuvant cohort (median: 4.4 vs. 14 weeks, p 12 weeks. Early concomitant regimens were associated with superior DFS over delayed-concomitant and sequential regimens. Conclusions Initiating trastuzumab more than 12 weeks from diagnosis has a negative impact on clinical outcome. Neo-adjuvant anti-HER2 therapy could be the optimal strategy to treat early stage HER2-positive breast cancer.

Background Optimal evaluation and management of the axilla following neoadjuvant chemotherapy (NAC) in patients with node-positive breast cancer remains controversial. The aim of this study was to examine the impact of receptor phenotype in patients with nodal metastases who undergo NAC to see whether this approach can identify those who may be suitable for conservative axillary management. Methods Between 2009 and 2014, all patients with breast cancer and biopsy-proven nodal disease who received NAC were identified from prospectively developed databases. Details of patients who had axillary lymph node dissection (ALND) following NAC were recorded and rates of pathological complete response (pCR) were evaluated for receptor phenotype. Results Some 284 patients with primary breast cancer and nodal metastases underwent NAC and subsequent ALND, including two with bilateral disease. The most common receptor phenotype was luminal A (154 of 286 tumours, 53·8 per cent), with lesser proportions accounted for by the luminal B–Her2 type (64, 22·4 per cent), Her2-overexpressing (38, 13·3 per cent) and basal-like, triple-negative (30, 10·5 per cent) subtypes. Overall pCR rates in the breast and axilla were 19·9 per cent (54 of 271 tumours) and 37·4 per cent (105 of 281) respectively. Axillary pCR rates were highest in the Her2-overexpressing group (27 of 35, 77 per cent) and lowest in the luminal A group (35 of 153, 22·9 per cent) (P

Background Young women ( Methods YWBC were identified from pathology databases at 2 tertiary centers. Pts were divided into 2 cohorts: BC diagnoses from 2000-2007 (G1) and 2008-2015 (G2). ClinPath and Rx data were retrieved from clinical, radiology and histology databases. Statistical analysis was performed using SPSS. Results We identified 347 pts. Tumor features are shown in Table I. Median age is 36 (23-39). By histology, 90.8% (n=315) had invasive ductal carcinoma, 53.1% (n=181) had Grade III BC and 56.3% (n=171) had lymphovascular invasion. Pregnancy-associated BC occurred in 10.7% (n=34). Mastectomy (MX) was performed in 53% (n=176) and axillary lymph node clearance (ALNC) in 63.8% (n=192 [G1: 84.3% vs. G2: 48.6%, p Table 1Tumor features Group 1 (n=149)Group 2 (n=198)Total (n=347)p-valueMedian tumor size (mm) 252222.5p=0.115Node positivity 88 (60.3%)100(51.5%)188 (55.3%)p=0.109Median node count 4 (1-44)1 (1-30)2 (1-44)p Rx characteristics are shown in Table 2. 85 pts received neo-adjuvant therapy (NAT); 48.3% (n=41) ER+/HER2-, 27% (n=23) HER2+ and 24.7% (n=21) TNBC. Pts receiving NAT in G2 trended towards improved pCR rate (G2: 24.6% vs G1: 8.3%, p=0.057). Endocrine Rx alone was received by 9.8% (n=22); 13.6% (n=18) in G2 vs 4.3% (n=4) in G1. OncotypeDx(ODx) was used in 23 pts (14.9%) (median score 17), 1 had a DR (ODx Score = 18). Table 2Tx characteristics n=347 Chemotherapy Total300(86.4%) NAT85 (28.3%)Pathological Complete Response (pCR)* pCR (n=16, 19.8%)No pCR (n=65, 80.2%) ER+/HER2-18.8%(n=3)53.9% (n=35) HER2+/ER+18.8%(n=3)13.8% (n=9) HER2+/ER-31.2% (n=5)9.2% (n=6) TNBC31.2%(n=5)23.1%(n=15)Local relapse 1 (6.2%)1(1.5%)Distant relapse (DR) 022(33.8%)*Data incomplete n=4 DR occurred in 50 pts (16%), including 13 (20.3%) HER2+ pts. Of note, 92.3% (n=12) of these were in G1. Relapse rates (RR) in TN and ER+/HER- pts were 19.6% (n=11) and 13.7% (n=26) respectively. There was a higher RR in G1 (34.8% vs 11.4%, p Conclusion In line with existing data, locally advanced dx is more prevalent in YWBC. MX and ALNC rates were high and most received multimodal Rx. The extent of axillary surgery declined. Pts in G2 had lower volume BC at diagnosis suggesting increasing awareness. TN and HER2+ subtypes accounted for a slightly higher proportion of BC cases. Pts with PCR had better outcomes. Only 16% relapsed with metastatic dx. The impact of HER2 Rx is highlighted by reduced RR in HER2+ G2 pts. Outcomes were unchanged in pts with ER+/HER2- and TNBC. These remain a priority for future research. Citation Format: Greally M, Kielty J, Das G, Malouf C, O'Riordan L, Coleman N, Quinn C, McDermott E, Gullo G, Kelly C, Crown J, Prichard R, Walshe J. Retrospective cohort study of patients (pts) diagnosed with breast cancer (BC)

The rationalization of cancer services in Ireland saw all women with symptomatic breast problems referred to one of the eight regional cancer centers. A pilot triaging system was introduced in St Vincent’s University Hospital to streamline these services. Women over 35 years who do not meet urgent referral criteria are referred for a mammogram prior to a clinic appointment (“image first”). The aim of this study was to retrospectively determine the recall rates, biopsy rates, and rate of breast cancer identification within this cohort of patients. This was compared to a screening population of patients. Patients triaged into the “image first” group within a one-year period were identified. Results of the initial mammogram, further imaging and subsequent biopsies were recorded. Data relating to number of recalls, number of patients biopsied and number of cancers identified within the Merrion Unit of the National Breastcheck Screening Program was obtained for comparison. One thousand six hundred eighty-eight referrals were triaged as “image first” over this period. 185 (11%) of patients required a biopsy of an identified lesion. Breast cancer was diagnosed in 65 patients (3.9%). During the same study period, of the 42,099 women who were screened for breast cancer, 496 (1.8%) underwent biopsy and 267 (0.63%) were diagnosed with breast cancer. Image first patients, who represent a cohort of “symptomatic” non-urgent women, have a greater rate of breast cancer detection than an asymptomatic screening population. This may have an impact on the appropriate triaging of symptomatic women in a national cancer center.

An association between interval breast cancers (cancer detected after a normal mammogram and before the next scheduled mammogram) and tumour aggressiveness has been postulated which may reflect their relatively poor overall prognosis. The aim of this study was to evaluate known prognostic features of screen detected breast cancers compared to interval breast cancers.Patients diagnosed with breast cancer between January 2010 and 2013 at a single unit of the National Breast Screening Program (NBSP) in Ireland and those between the ages of 50 and 65 diagnosed at a symptomatic breast clinic were included in the study. Patients who had not had a screening mammogram within the proceeding two years or had a previous history of breast cancer were excluded. Data were retrospectively collected on patient demographics, tumour type, grade, hormone receptor status and stage of disease at presentation.There were 915 patients included in the study, with 92% (n = 844) diagnosed through the NBSP. Ductal carcinoma in-situ accounted for 19% (n = 160) of screen-detected breast cancers but only 2.8% of interval cancers (p 0.05). The most common type of invasive cancer was invasive ductal carcinoma. Tumour grade was significantly higher in interval breast cancers (p 0.05). Interval cancers were identified at a significantly higher stage (Stage 1 versus 2; p 0.001) than screen-detected cancers. Interval breast cancers were less likely to be ER positive (76% versus 81%; p 0.05) and significantly more likely to over-express HER2 (20% vs 10%, p 0.05) than screen-detected cancers.This study highlights the fact that interval cancers appear to have a number of adverse prognostic markers for overall breast cancer survival when compared to women with screen-detected breast cancers. Interval cancers were more likely to be invasive, of a higher grade and stage and with a greater predominance of HER2 and triple negative molecular subtypes. Therefore this heterogeneous group of tumours may be biologically more aggressive and account disproportionately to overall breast cancer mortality.

Introduction Recent years have seen a dramatic shift to more conservative management of the axilla in patients with a positive sentinel lymph node biopsy (SLNB). Identification of nodal disease with positive pre-operative ultrasound guided axillary fine needle aspiration cytology (AUS/FNAC) may represent a higher axillary disease burden mandating an axillary clearance and thus an upfront SLNB may be avoided. The aims of this study were to quantify nodal burden in patients with positive pre-operative AUS/FNAC and identify patients who may have been able to avoid an axillary clearance (ALND) based on ACOSOG Z011 criteria. Methods A retrospective review of a prospectively maintained database identified patients with positive pre-operative AUS/FNAC between 2007 and 2012. Core biopsies were excluded. Demographic and tumour characteristics were analysed. Eligibility for ACOSOG Z011 criteria was assessed and patients who may have avoided ALND were identified. Results 432 patients were identified with positive AUS/FNAC. 85 patients were excluded leaving 347 for analysis. Median age was 56 years (22–87), median tumour size was 25 mm (1.5 mm–150 mm) and median tumour pathology was grade 3 (50%) and invasive ductal carcinoma (82%). Median number of nodes removed at ALND was 23 (1–55) with a median number of positive nodes being 4 (1–47). 134 (39%) patients had ≤2 positive nodes identified on ALND making them eligible for the ACOSOG Z011 study. When other ACOSOG Z011 exclusion factors were applied only 27 (7.8%) patients may have avoided ALND. Conclusions Nodal positivity on AUS/FNAC is associated with higher axillary disease burden. Few patients would satisfy ACOSOG/Z011 criteria and avoid ALND making an upfront SLNB unnecessary.

Objective: Thyroid nodules are common within the general population. Cytological analysis of fine needle aspirates (FNAs) of these lesions allows for identification of those that require further surgery. A numerical classification system is in place to streamline reporting. The 3a category is used for lesions that are neither benign nor malignant but show atypia of undetermined significance. We reviewed our use and clinical outcomes of Thy3a over a 4-year period. Methods: All thyroid FNAs performed at this institute from January 2012 to December 2015 were identified from our laboratory information system using SNOMED codes. Cytology was correlated with histology. Results: Of the 1,259 FNAs reported at this institute, Thy3a constituted only 1.2% ( n = 16) of all cases, with a malignancy rate of 7%. Five Thy3a cases had a repeat FNA that was reported as Thy2 (benign), 1 as Thy1c (cyst), 1 as Thy3f (follicular lesion), and 1 as Thy5 (malignant). Six cases without repeat FNA were follicular adenomas at resection. Two cases were lost to follow-up. Within all thyroid cytology categories in this 4-year period, we had a false-positive rate of 1.9% and a false-negative rate of 0.3%. Conclusions: The Thy3a subclassification has varied diagnostic criteria and lacks reproducibility. Despite the rare use of the Thy3a category at our centre, our diagnostic accuracy remained high. At this time, further Thy3a cohort studies are required to assess the real benefits of this category.

INTRODUCTION The recently published AJCC Cancer Staging Manual 8th edition, scheduled to be adopted into clinical practice in January 2018, proposes a new breast cancer (BC) Prognostic stage that includes histological grade, estrogen receptor (ER), progesterone receptor (PR), and HER2 status in addition to the traditional Anatomic TNM stage. In a further modification, patients with ER positive, HER2 negative, lymph node negative BC and an Oncotype DX® recurrence score (RS) of less than 11 will be assigned to Prognostic stage 1A irrespective of histological grade and size (up to 5cm). The changes have been proposed in recognition of the prognostic influence of these parameters and in attempt to improve personalised patient care. The aim of this study is to profile the impact on staging by comparing Prognostic stage, with and without RS, to traditional Anatomic stage, in a series of patients with early BC and an RS of less than 11. METHODS The study population comprised 127 patients with primary BC and an RS of less than 11, derived from a consecutive series of 729 patients with ER positive, Her2 negative, lymph node negative, primary BC whose tumors were tested using the Oncotype DX® multigene assay between November 2011 and December 2016. The median patient age was 57 years (35-78). Pathological tumour size was T1a (n=2), T1b (n=19), T1c (n=79) and T2 (n= 27). Median tumor size was 15mm. Histological tumour grade was grade 1 (n=14), 2 (n=98) and 3 (n=15). Each patient was assigned an Anatomic and Prognostic stage, with and without RS modification, according to the AJCC Classification of Cancer Staging, 8th edition. The three staging categories were compared and the impact on stage profiled. RESULTS Applying the traditional Anatomic Stage (TNM), 100 patients were assigned to stage IA (T1N0) and 27 patients to stage IIA (T2N0). Applying the Prognostic stage (without RS) 89 patients were assigned to stage IA, 33 to stage IB, four to stage IIA, and one to stage IIB. All patients were assigned to stage IA according to the Prognostic stage that includes a RS of < 11. Comparing Prognostic stage without RS to traditional Anatomic stage, 26.7% of patients (n=34) underwent a change in stage, 9.4% (n=12) to a higher stage and 17.3% (n=22) to a lower stage. 21.3% (n=27) of patients were down staged when comparing Prognostic stage including RS to traditional Anatomic stage. Comparing Prognostic stage including RS to Prognostic stage without RS, 29.9% (n=38) of patients were down staged. CONCLUSION Breast cancer staging is an important tool in guiding patient management. This study demonstrates that the introduction of the Prognostic stage and the modified Prognostic stage to include RS will alter the assigned stage in approximately 25% of patients with early BC. REFERENCE Edge SB, Greene FL, Byrd DR, Brookland RK, Washington MK, Gershenwald JE et al (2016). AJCC Cancer Staging Manual, 8th edn. Springer, Chicago. Citation Format: O'Cearbhaill RM, Gannon JM, Devane LA, Prichard RS, Walshe J, McDermott EW, Quinn CM. AJCC prognostic stage including oncotype DX®RS: Impact on breast cancer staging compared with traditional anatomic TNM stage [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-05.

Introduction Recent years have seen a dramatic shift to more conservative management of the axilla and the presence of a positive sentinel lymph node biopsy does not now automatically mandate an axillary clearance. This is based largely on data from the American College of Surgeons Oncology Group (ACOSOG) Z11 study, which failed to demonstrate a difference in local recurrence or overall survival when an axillary clearance was omitted in a highly selective group of patients with a positive sentinel lymph node. However, the presence of a positive pre-operative ultrasound guided axillary FNAC(Fine Needle Aspiration Cytology) may be representative of a higher burden of axillary disease. Aim Therefore, the aims of this study were firstly to quantify the actual nodal burden in breast cancer patients with a positive pre-operative ultrasound guided axillary FNAC and secondly to identify the number of patients who may have been spared an axillary clearance based on Z11 eligibility criteria. Methods A retrospective review of a prospectively maintained database within a tertiary breast cancer referral centre was performed. All patients with a positive pre-operative axillary FNAC were identified within a five year period (2007 – 2011). Demographic, tumour and biological characteristics and final nodal status were analysed. Eligibility for randomisation according to the Z11 criteria was assessed based on the final pathology and the number of patients who could have been spared an axillary clearance was identified. Results A total of 360 patients were identified with a positive axillary ultrasound guided FNAC. Sixty-three patients had no axillary surgery and three patients had recurrent disease, leaving a total of 294 for analysis. The mean age was 56 years (range 22 – 87). The mean size of the tumour was 31.3mm (range 4mm – 132mm) and the majority were an invasive grade 3 (57%) ductal carcinoma (84%). Luminal A (63%) was the commonest sub-type. The mean number of nodes removed at axillary clearance was 24 (range 7 – 58) while the mean number of positive nodes excised was 6 (range 0 – 47). Of these, the mean number of level I positive nodes was 4, level II was 1 and level III nodes was Overall a total of 78 patients had less than three positive nodes identified in the axilla and potentially may have been eligible for the Z11 study. However, when patients who had a mastectomy, neo-adjuvant chemotherapy were excluded and the presence of extra-capsular nodal involvement was accounted for only 19 (6.4%) patients may have been spared an axillary clearance. Conclusions The presence of nodal positivity on a pre-operative FNAC is associated with a higher burden of axillary disease. Only a minority of these patients would be able to avoid an axillary clearance in the setting of the recent Z11 study. Performing an axillary ultrasound and FNAC of suspicious nodes allows patients to avoid an unnecessary sentinel lymph node biopsy and proceed directly to an axillary clearance. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-05.

Primary thyroid lymphoma is rare, composing approximately 5% of all thyroid malignancies and less than 3% of all extranodal lymphomas. It typically presents as a rapidly enlarging goiter with associated compressive symptoms. Thyroid ultrasound and fine needle aspiration cytology, using flow cytometry and immunohistochemistry, remain the main modalities used to confirm the presence of lymphoma. The increasing use of an ultrasound-guided core biopsy to achieve an accurate diagnosis has further limited the role of surgery. An open surgical biopsy may still be required not only for definitive diagnosis but also to confirm the subtype of lymphoma. There are limited numbers of randomized or prospective trials to guide management, and controversy remains over optimal treatment. Treatment and prognosis of this disease can be dichotomized into two separate groups: pure mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL) or mixed subtypes. Early stage (stage IE) intrathyroidal MALT lymphomas typically have an indolent course and may be treated with single-modality surgery, radiotherapy, or a combination of both. DLBCLs are more aggressive, and survival outcomes are highest with multimodal therapy incorporating monoclonal antibodies, chemotherapy, and radiotherapy. The prognosis is generally excellent but can be varied because of the heterogeneous nature of thyroid lymphomas. The aim of this paper is to discuss the changes in diagnostic modalities and to focus on the recent alterations in the management of this rare disease, including targeted therapies as well as the more limited role of the endocrine surgeon.

Learning Objectives Discuss the advances in molecular genetics which have uncovered new hereditary and germline mutations contributing to the development of pheochromocytoma and paraganglioma and identify the genotype/phenotype patterns which facilitate more accurate determination of malignant potential. Describe the current imaging modalities used in the diagnosis of pheochromocytoma and paraganglioma and evaluate the efficacy of functional imaging modalities according to tumor genotype. Evaluate the current preclinical molecular research contributing to the selection of targeted therapies for malignant pheochromocytoma and paraganglioma. Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.

Axillary status remains an important prognostic indicator in breast cancer. Certain patients with a positive sentinel node (SLNB) may not benefit from axillary clearance (AC). Uncertainty remains if this approach could be applied to patients diagnosed with axillary metastases on ultrasound-guided fine needle aspiration cytology (USFNAC). The aim of this study was to compare nodal burden in patients with positive USFNAC and a positive SLNB. A retrospective study was performed involving all BC patients between 2007 and 2014 who had either pre-operative USFNAC or a SLNB. Patient/tumour characteristics and nodal burden were examined in all patients proceeding to AC. 974 patients were eligible for analysis. 439 patients (45 %) had positive USFNAC and 535 (55 %) had a positive SLNB. USFNAC-positive patients were more likely to undergo mastectomy (Chi-square test; p

The aim of this study was to determine whether a focused minimally invasive parathyroidectomy (MIP) for patients with primary hyperparathyroidism and concordant pre-operative localization studies is appropriate for patients with a family history of the disease. Familial hyperparathyroidism may be seen as a chronic disease in which recurrence is inevitable. Patients frequently undergo subtotal or total parathyroidectomy for perceived 4-gland parathyroid hyperplasia in an attempt to reduce this risk. Controversy remains regarding whether a MIP is appropriate in this setting. Patients undergoing an MIP were identified from prospectively maintained databases. Chart review confirmed the presence of a family history of hyperparathyroidism in a direct relative. Patients with and without a family history were compared regarding overall complications, recurrence, and cure rates. A total of 1,652 patients underwent a MIP. Of these, 34 patients had a positive family history. There was no statistically significant difference in age, gender, preoperative biochemistry, gland weight, or complication rates between the groups. The cure rate at 6 months from a single operation was equivalent between the 2 groups (97 vs. 98%). With a median of 39 months follow-up, the recurrence rate was higher in those with a family history compared with those without (8.8 vs 1.1%; P = 0.002). Reoperation was successful in the small population of familial patients who did present with recurrent hyperparathyroidism. The vast majority of patients who underwent a MIP were surgically cured. Although recurrence rates remain higher in the familial hyperparathyroidism group, these data suggest that this alone should not be a contraindication to MIP.

Background: Permanent hypoparathyroidism is a well-recognized complication of total thyroidectomy, and a commonly reported clinical indicator of that procedure. However, a small number of patients still require ongoing calcium supplementation post-operatively in order to avoid the symptoms of hypocalcaemia, despite a normal serum parathyroid hormone level. The aim of this study was to characterize this disorder of post-operative partial hypoparathyroidism and to identify any risk factors. Methods: A retrospective study of patients undergoing a total thyroidectomy was performed. Patients with permanent hypoparathyroidism were excluded. Patients completed a telephone interview and had serum calcium and parathyroid hormone (PTH) measured. Patient demographics, operative indications and intervention, the number of parathyroid glands autotransplanted, the presence of ongoing symptoms and calcium requirements were documented. Results: One hundred ninety-six patients participated. The overall rate of permanent hypoparathyroidism over the duration of the study was 0.77%. An additional 10 (5%) patients were identified with a normal PTH level but who were still requiring calcium supplementation to prevent the symptoms associated with hypocalcaemia and to maintain a normal serum calcium level. Nine patients were female with a mean age of 48.5 years. A mean of 1.4 parathyroid glands were autotransplanted and the mean PTH level was 3.95 pmol/L. Conclusion: This study demonstrates that in a small group of patients following total thyroidectomy, re-vascularization of parathyroid cells may be partial, with inadequate parathyroid reserve to avoid symptoms despite measurable PTH levels. This disorder of partial hypoparathyroidism has not been previously described and represents a small but important complication of total thyroidectomy.

Learning Objectives After completing this course, the reader will be able to: Review the role and describe the limitations of conventional therapies for adrenocortical carcinoma.Evaluate the current preclinical molecular research contributing to the rational selection of targeted therapies for adrenocortical carcinoma. CME This article is available for continuing medical education credit at CME.TheOncologist.com Adrenocortical carcinoma (ACC) is a rare but aggressive malignancy with a poor prognosis. Complete surgical resection offers the only potential for cure; however, even after apparently successful excision, local or metastatic recurrence is frequent. Treatment options for advanced ACC are severely limited. Mitotane is the only recognized adrenolytic therapy available; however, response rates are modest and unpredictable whereas systemic toxicities are significant. Reported responses to conventional cytotoxic chemotherapy have also been disappointing, and the rarity of ACC had hampered the ability to undertake randomized clinical studies until the establishment of the First International Randomized Trial in Locally Advanced and Metastatic Adrenocortical Carcinoma. This yet-to-be reported study seeks to identify the most effective first- and second-line cytotoxic regimens. The past decade has also seen increasing research into the molecular pathogenesis of ACCs, with particular interest in the insulin-like growth factor signaling pathway. The widespread development of small molecule tyrosine kinase inhibitors in broader oncological practice is now allowing for the rational selection of targeted therapies to study in ACC. In this review, we discuss the currently available therapeutic options for patients with advanced ACC and detail the molecular rationale behind, and clinical evidence for, novel and emerging therapies.

Appendicectomy for acute appendicitis is the commonest emergency surgical operation. With widespread acceptance of minimal access surgery most appendicectomies are now performed laparoscopically. The aim of this study was to assess whether the rate of normal appendicectomy has changed following the introduction of laparoscopic techniques in our institution. A retrospective study of patients having emergency appendicectomies over a 1-year period (2005) in a large teaching hospital was undertaken. A comparison of data was made from a prior study performed at the same hospital in 1988. 196 adult patients underwent appendectomies during this period. The normal appendectomy rate was 10.2% compared to 22.8% in the previous study. This rate was twice as high in women of reproductive age as compared to men. There has been widespread uptake of laparoscopic appendectomy in our hospital. This technique has reduced the rate of histologically normal appendicectomies due to intra-operative visualization of the appendix.

Background The majority of women with breast cancer present with localized disease. The optimal strategy for identifying patients with metastatic disease at diagnosis remains unclear. The aim of this study was to evaluate the additional diagnostic yield from isotope bone scanning when added to CT staging of the thorax, abdomen and pelvis (CT-TAP) in patients with newly diagnosed breast cancer. Methods All patients diagnosed with breast cancer who underwent staging CT-TAP and bone scan between 2011 and 2013 were identified from a prospective database of a tertiary referral breast cancer centre that provides a symptomatic and population-based screening breast service. Criteria for staging included: biopsy-proven axillary nodal metastases; planned neoadjuvant chemotherapy or mastectomy; locally advanced or inflammatory breast cancer and symptoms suggestive of metastases. Results A total of 631 patients underwent staging by CT-TAP and bone scan. Of these, 69 patients (10·9 per cent) had distant metastasis at presentation, with disease confined to a single organ in 49 patients (71 per cent) and 20 (29 per cent) having metastatic deposits in multiple organs. Bone metastasis was the most common site; 39 of 49 patients had bone metastasis alone and 12 had a single isolated metastatic deposit. All but two of these were to the axial skeleton. No preoperative histological factors identified a cohort of patients at risk of metastatic disease. Omission of the bone scan in systemic staging would have resulted in a false-negative rate of 0·8 per cent. Conclusion For patients diagnosed with breast cancer, CT-TAP is a satisfactory stand-alone investigation for systemic staging.

Sentinel lymph node biopsy (SLNB) has become the gold standard for axillary staging. Debate remains as to the optimal method of SLN detection.Determine whether patients undergoing an SLNB required the addition of isosulfan blue dye to radioisotope when an SLN was identified on a preoperative lymphoscintigram.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.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).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.

Spontaneous oesophageal rupture (Boerhaave's syndrome) is rare, and carries a high attendant risk of mortality.A retrospective eight-year review from a tertiary unit.Eighteen patients were managed, with a mean age of 57 (39 - 88 years). Eight patients presented early and underwent surgery, seven with primary closure and one with exclusion and diversion. There was one death in this group. Ten patients were managed conservatively. In this group, two underwent an oesophagectomy because of failed conservative measures, and four had an endoprosthesis inserted. One patient died in this group on the first admission, but two patients with stents in situ died from massive bleeding relating to an aorto-oesophageal fistula at 39 days and 189 days respectively following presentation.Surgical intervention remains the gold standard when the diagnosis is made early. For late diagnoses, this series suggests caution in the use of endoprostheses.

An adrenal “incidentaloma” is defined as an unexpected finding on radiological imaging performed for unrelated indications. Improvements in radiological technology have seen a dramatic increase in this phenomenon. We report the unique case of a 60-year-old female presenting with a 6-month history of abdominal pain, altered bowel habit, and rectal bleeding. Her past medical history included situs inversus totalis and a patent ductus arteriosus. Colonoscopy revealed an ulcerated tumour in her sigmoid colon. Staging PET-CT confirmed a sigmoid tumour and also identified a large heterogenous enhancing FDG-avid right adrenal mass. Biochemical testing/MIBG imaging confirmed a right adrenal phaeochromocytoma. Hypertension was controlled and excision was performed via a transperitoneal laparoscopic adrenalectomy, in the left lateral decubitus position. Uniquely, liver retraction was not required due to its position in the left hypochondrium. Histology confirmed a benign 46 mm phaeochromocytoma. Subsequent uncomplicated sigmoid colectomy/right salpingo-oophorectomy for a locally advanced colonic tumour was performed with adjuvant chemotherapy. This case highlights the importance of accurately identifying functioning adrenal tumours before elective surgery as undiagnosed phaeochromocytomas carry significant intraoperative morbidity/mortality. Right adrenalectomy was made easier in this patient by the liver’s unique position. Uncomplicated colorectal resection was made possible by combined preoperative functional/anatomical imaging.

Background Although breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast. Objective To review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions. Methods A literature review was performed using the Medline database. Conclusions PMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.

Asymptomatic thyroid nodules are an increasingly common clinical problem. Lesions greater than a centimetre require cytological assessment. Indeterminate lesions often need surgical excision to establish a definitive diagnosis and plan further management. If a definitive diagnosis could be accurately predicted pre-operatively, the most appropriate surgical procedure could be performed at the initial operation.The aim of this study was to identify whether specific thyroid ultrasound features could predict malignancy in indeterminate thyroid nodules.A retrospective review of all patients undergoing surgery for an indeterminate thyroid lesion between 2006 and 2012 was performed. Demographic features, surgical intervention and final histological findings were determined. Pre-operative ultrasound findings and final histology were correlated and the ultrasonic markers predictive of malignancy were determined.A total of 40 patients were identified as having undergone surgical intervention for indeterminate thyroid nodules. The majority of patients were diagnosed with a follicular adenoma (n = 22; 55 %). Papillary thyroid carcinoma was identified in three patients (7.5 %) and follicular carcinoma in a further 3 (7.5 %). Ultrasound features associated with malignancy included poorly defined nodule borders and increased vascularity. The presence of malignancy was not related to nodule size, echogenicity or the presence of calcifications.The majority of indeterminate thyroid lesions are benign on final histological assessment. High nodule vascularity associated with ill-defined borders is associated with malignancy. Further research is warranted to identify predictors of malignancy in indeterminate nodules in order to avoid unnecessary or repeated procedures.

Primary mucoepidermoid carcinoma (MEC) of the thyroid is a rare clinical and pathological entity that accounts for0.5% of all thyroid malignancies. Although the histogenesis has been controversial, most investigators now favor it as arising from either metaplasia of thyroid follicular epithelium or heterologous de-differentiation from papillary thyroid carcinoma (PTC). We report three cases of thyroid MEC found in continuity with, and clearly arising from de-differentiation of, well-differentiated thyroid carcinomas (WDTCs).The cases presented here included two women (aged 22 and 52) and one man (aged 58). One of these cases arose in conjunction with PTC, one with follicular thyroid carcinoma (FTC), and one with Hurthle cell carcinoma (HCC). In all three cases, there was a gradual transition in morphology between the areas of typical WDTC and the areas showing MEC differentiation. In addition, immunohistochemistry demonstrated a gradual loss of thyroid specific markers (thyroid transcription factor-1, thyroglobulin) mirroring the change in morphology.We conclude that thyroid MEC can arise from metaplastic de-differentiation of WDTC, including FTC or HCC in addition to PTC. Currently, we recommend that after excision, each of the WDTC and MEC components of these tumors be treated with targeted adjuvant therapies, which may involve radioactive-iodine ablation, thyrotropin suppression, and external beam radiotherapy.

The management of older women with breast cancer is often suboptimal based on perceived patient comorbidities. The aim of this study was to evaluate the choice of treatment modality based on clinicians 'gut-feeling' compared to comorbidity scoring indices. A retrospective review of women over 70 presenting with breast cancer was performed. Presenting comorbidities (Charlson Comorbidity Index and Cumulative Illness Rating Scale) and the treatment received was documented. Sixty-six patients were identified. Forty-six had surgery while twenty patients had primary endocrine manipulation. The mean age of patients having surgery was 76.4 in comparison to 84.4 for the endocrine group (p = 0.001). The CCI scores for the surgical group and endocrine group were 6.62 and 9.26 respectively (p = 0.001). The scores for the CIRS were 8.93 and 22.68 (p = 0.001). This study has demonstrated that physician's "gut feelings' are often correct in identifying patients who may benefit from primary hormone therapy.

Thyroid carcinoma is the commonest endocrine malignancy. The majority of these are differentiated thyroid carcinomas, which have a good overall prognosis. Treatment includes surgical excision, radio-iodine ablation and long-term thyrotropin suppression. The degree and length of suppression required, as well as the potential side-effect remain controversial. Therefore, the aim of this study was to establish the degree of thyrotropin suppression achieved in a cohort of patients with differentiated thyroid carcinoma. A retrospective review was performed of a prospectively maintained database. All patients with a diagnosis of differentiated thyroid carcinoma between January 1998 and January 2008 were identified. Demographic data, pathological stage and the treatment that the patient received was documented. TSH and free T4 levels were identified at specific time points post-operatively. Eighty-eight patients with differentiated thyroid carcinoma were identified. Seventy patients (79.5%) were female. The mean age was 55, with a range of 18 to 79 years. The majority of patients underwent a total thyroidectomy (n=79; 89.7%) and of those 29 (32.9%) had an associated modified neck dissection. Accurate follow-up was available on forty-nine patients. TSH and free T4 were measured at 3 and 6 months, as well as at 1 and 2 years post-operatively. Adequate TSH suppression was taken at a level0.1 mU/L. The majority of patients (69.5%) had achieved adequate TSH suppression at 2 years. However, 65% of these same patients had a high free T4 at 2 years indicating a degree of hyperthyroidism. This study has demonstrated that TSH suppression is being adequately achieved in the majority of patients with differentiated thyroid carcinoma. However, this must be carefully weighed against the potential detrimental side-effects of long-term sub-clinical hyperthyroidism.

The use of surgical drains in patients undergoing thyroid surgery is standard surgical teaching. Life-threatening complications, arising from post-operative haematomas, mandates their utilization. There is increasing evidence to suggest that this is an outdated practice. This paper determines whether thyroid surgery can be safely performed without the routine use of drains. A retrospective review of patients undergoing thyroid surgery, over a three year period was performed and post-operative complications documented. One hundred and four thyroidectomies were performed. 63 (60.6%) patients had a partial thyroidectomy, 27 (25.9%) had a total thyroidectomy and 14 (13.5%) had a sub-total thyroidectomy. Suction drains were not inserted in any patient. A cervical haematoma did not develop in any patient in this series and no patient required re-operation. There is no evidence to suggest the routine use of surgical drains following uncomplicated thyroid surgery reduces the rate of haematoma formation or re-operation rates and indeed is now unwarranted.

Treatment of pregnancy associated breast cancer (PABC) is usually compromised as both foetal and maternal health has to be taken into consideration. We have identified on our database twelve patients with PABC and twenty-four age-matched controls diagnosed in the same time-frame. The mean age was 36 and 38 years respectively. There was no difference in time to presentation between the two groups. The mean tumour size was 48.72 mm and 26.30 mm respectively (p = 0.001). Lymphovascular invasion and lymph node involvement were more common in the PABC group. In the PABC group, 5 patients (42%) were treated with neo-adjuvant chemotherapy including one patient in first trimester. All patients underwent surgery. Adjuvant chemotherapy was given to seven (58.3%) of the PABC patients. At median follow up of 36 months, there was a single mortality and two patients (17%) had developed recurrent disease. All children are healthy with no deformity or learning disability.

Rectal cancer remains a major source of morbidity and mortality with its prognosis relating directly to the initial stage of the disease at presentation. This report highlights the potentially serious morbidity and mortality, which may be associated with neo-adjuvant chemoradiotherapy in advanced rectal cancer, emphasising the need for thorough discussion with patients on the risks and benefits of such treatment.

To assess changing trends in histological types of thyroid cancer in an Irish hospital over the past 30 years. Biographical data, tumour characteristics, treatment and outcome from 190 patients with thyroid carcinoma from 1970 to 2000 were reviewed retrospectively. Detailed records of 190 patients with thyroid cancer were identified with a mean age at presentation of 50 years. From 1970 to 1979 the distribution of histological types was: papillary carcinoma; 9 patients (4.7%), follicular; 17 patients (8.9%), anaplastic; 9 patients (4.7%), medullary; 1 patient (0.5%) and lymphoma; 1 patient (0.5%). From 1980 to 1989 papillary carcinoma accounted for 32 patients (16.8%), follicular; 14 patients (7.3%), anaplastic; 13 patients (6.8%), medullary; 7 patients (3.7%) and lymphoma; 5 patients (2.6%). From 1990 to 1999 papillary cancer accounted for 48 patients (25.2%), follicular; 14 patients (7.3%), anaplastic; 8 patients (4.2%), medullary; 7 patients (3.7%) and lymphoma; 5 patients (2.6%). Survival rates were significantly better for those aged less than 45 years (P

Background Despite advances in the early detection and treatment of breast carcinoma, the mortality and morbidity rates associated with this disease remain high. Primary prevention, therefore, offers the best chance of making a major impact on outcome. Methods The aim was to review the rationale, current stage of development and adverse effects of the strategies involved in the primary prevention of breast carcinoma. A review of the literature was undertaken by searching the MEDLINE database for the period 1966–2002 without language restrictions. Results and conclusion Currently, the only agent to have general approval for chemoprevention of breast carcinoma is tamoxifen. Women who derive the greatest benefit in terms of risk reduction from tamoxifen are premenopausal with a 5-year Gail risk factor of more than 1·66 per cent, postmenopausal with a 5-year Gail risk factor of more than 3 per cent, and postmenopausal without a uterus. In these specific subgroups, tamoxifen should be considered for the chemoprevention of breast carcinoma. Raloxifene, retinoids, aromatase inhibitors and cyclo-oxygenase 2 inhibitors require further clinical investigation before adoption in this context. Surgical intervention should largely be limited to those women who have a BRCA1 or BRCA2 mutation.

BackgroundThe incidence of malignant melanoma is rising; it now has an incidence of ten per 100 000 per annum in the UK. The development of metastases is unpredictable, but prognosis is linked directly to the initial stage at diagnosis. Positron emission tomography (PET) can allow the detection of malignant cells at a relatively early stage.MethodsA review of the literature was undertaken by searching the Medline database for the period 1980–2000 without any language restrictions.ResultsThe overall sensitivity and specificity of PET are 74–100 and 67–100 per cent respectively. PET has a reduced sensitivity and specificity for thinner lesions (less than 1·5 mm). Comparison with computed tomography and magnetic resonance imaging has shown a higher sensitivity and specificity for PET in all regions of the body except the thorax.ConclusionCurrently the accepted indication for PET is recurrent melanoma when surgical intervention is being considered. However, other potential indications include the detection of occult or distant metastasis at initial presentation and the clarification of abnormal radiological findings at follow-up. The routine use of PET for American Joint Commission on Cancer stage I or II disease is of uncertain benefit and is not indicated at present.

Introduction The advent of multimodal and targeted breast cancer treatment has seen a radical shift from aggressive surgical intervention to a more minimalist approach, both within the breast and axilla. Primary among these changes is the utilisation of the sentinel lymph node biopsy (SLNB) to detect disease within the axilla and a move away from an obligatory axillary clearance when the sentinel node is positive. This depends on the accurate identification of the SLN and initial studies describe a higher identification rate and a lower false negative rate with a dual tracer identification technique. This encompasses a combination of a blue / green dye and radio-labelled isotope. The use of blue dye has been, of itself, associated with significant morbidity and therefore many clinicians may opt for single tracer identification. Aims The aim of the current study was to determine whether the addition of blue dye to radio-isotope increased the positive SLN detection rate, where the SLN was identified pre-operatively on a lymphoscintigram. Methods A prospective randomised controlled trial comparing the combined techniques of isosulphan blue dye and isotope scanning versus isotope scanning alone was performed at a single tertiary referral centre. Ethical approval was obtained prior to commencing the study from the hospital ethics committee. Enrolment commenced in March 2010 and ceased in September 2012. The study design was a randomised open label controlled parallel group trial. The primary outcome measure was the effect of the omission of the blue dye on the identification of SLN if the lymphoscintigram was positive (1 -3 nodes identified). Results A total of 673 patients were included in the final analysis with 344 patients receiving the combination (blue dye and radio-isotope) and 329 patients who received radio-isotope scanning alone. The groups were evenly matched both demographically and pathologically. The mean age was 48 years (48.3 versus 47.7 years; P = 0.47), the mean tumour size was 23.1mm (23.2mm versus 23.0mm; p = 0.89) and there was no statistically significant difference in the grade of the tumours between the two groups (p = 0.58). Overall, there was no difference in the number of nodes retrieved between the two groups (563 versus 523; p = 0.30). Similarly, there was no difference in the number of positive lymph nodes that were identified between the two groups (107 versus 98; 23.8% versus 22%; p = 0.65). Conclusions The addition of isosulphan blue dye does not aid in the identification of the SLN in patients who have a positive lymphoscintigram when radioisotope colloid is used. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-01.