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Oncotype DX™ (ODX) score estimates prognosis and predicts breast cancer recurrence. It also individualizes patient adjuvant chemotherapy prescription in breast cancer. This assay relies on genetic and molecular markers; the clinicopathological phenotype of which are tested routinely. The aim of this study was determine whether clinicopathological and immunohistochemical information predicts ODX recurrence score (RS). Secondly, to assess the impact on adjuvant chemotherapy (AC) and oncological outcome of ODX testing in patients in a European tertiary referral center. Estrogen receptor positive (ER+), human epidermal growth factor receptor-2 negative (HER2-), lymph node negative (LN-), and female breast cancer patients with ODX testing performed between 2007 and 2015 were categorized into low- (11), intermediate- (11-25), and high-risk (25) groups. Clinicopathological and immunohistochemical correlates of RS were determined. Predictors of RS were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan-Meier and Cox regression analyses. ODX was performed in 400 consecutive ER+LN- patients. Median follow-up was 74.1 months (3.0-144.4). Low grade (odds ratio [OR]:2.39; 95% confidence interval [CI]:1.04-5.51, p = 0.041) independently predicted low ODX, while high grade (OR:2.04; 95% CI: 1.19-3.49, p = 0.009) and reduced progesterone receptor (PgR) expression (OR: 2.57, 95% CI: 1.42-4.65, p = 0.002) independently predicted high ODX. Omission of AC in intermediate- (p = 0.159) and high-risk (p = 0.702) groups did not negatively impact survival. In conclusion, tumor grade independently predicts low and high RS, while PgR negativity predicts high RS. ODX reduced AC prescription without compromising oncological outcome.

BACKGROUND: Estrogen receptor (ER) status provides invaluable prognostic and therapeutic information in breast cancer (BC). When clinical decision making is driven by ER status, the value of assessing progesterone receptor (PgR) status is less certain. AIM: To describe the clinicopathologic features of ER positive (ER+) /PgR negative (PgR-) BC and to determine the effect of PgR negativity on oncologic outcomes in ER+ disease.METHODS: Consecutive female patients with ER+ BC managed in a single institution between 2005-2015 were included. Clinicopathological features of PgR- BC were determined. Factors associated with PgR- disease were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan-Meier curves and Cox regression analysis.RESULTS: 2660 patients were included with a median age of 59.6±13.3 years (21-99). Median follow-up was 97.2 months (3.0-181.2). 2208 cases were PgR+ (83.0%) and 452 were PgR- (17.0%). Being postmenopausal (OR:1.656, 95% Confidence interval (CI):1.249-2.195, P Citation Format: Matthew G Davey, Éanna J Ryan, Padraig J Folan, Niamh O'Halloran, Michael R Boland, Michael Kevin Barry, Karl J Sweeney, Carmel M Malone, Ray J McLaughlin, Michael J Kerin, Aoife J Lowery. The impact of progesterone receptor negativity on oncologic outcomes in estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS5-45.

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.

Tumour budding (TB) is an adverse histological feature in many epithelial cancers. It is thought to represent epithelial–mesenchymal transition, a key step in the metastatic process. The significance of TB in breast carcinoma (BC) remains unclear. The aim of this study is to investigate the relationship between TB and other histological and molecular features of BC. A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Der Simonian–Laird method. Quality assessment of the included studies was performed using the Newcastle–Ottawa scale (NOS). Seven studies with a total of 1040 patients (high-grade TB n = 519, 49.9%; low-grade/absent TB n = 521, 50.1%) were included. A moderate to high risk of bias was noted. The median NOS was 7 (range 6–8). High-grade TB was significantly associated with lymph node metastasis (OR 2.32, 95% c.i. 1.77 to 3.03, P

Breast cancer is the most commonly diagnosed female cancer. Diagnosis in younger women (under 35 years) is different to their older counterparts, and mammography is not considered as sensitive in this cohort. Consequentially, younger patients may present later with more advanced disease. This is a retrospective analysis of a prospectively updated database containing consecutive patients who presented to the symptomatic breast unit of Galway University Hospital between 2009 and 2015. Patient clinicopathologic factors, clinical examination features, diagnostic radiological modalities and Bi-RADS score were all assessed. Data was analysed using Statistical Package for the Social Sciences version 25. One thousand eight hundred thirty-six patients were diagnosed with breast cancer, and of these, 51 (2.8%) patients were

Introduction An arteriovenous malformation (AVM) is defined as an abnormal connection between arteries and veins, bypassing the capillary system. AVM of the breast is a rare clinical entity, with limited evidence to guide management. We present the case of a congenital AVM of the breast in an otherwise healthy woman, with an interesting presenting complaint. Case Description A 38-year-old female presented with a ‘buzzing’ sensation and mastalgia in her left breast. Examination revealed a visible pulsatile linear abnormality with a bruit on auscultation. Duplex ultrasonography demonstrated mixing of the arterial and venous flow, consistent with an AVM. Operative management entailed ultrasound guided identification, ligation and excision of all aneurysmal segments. Histopathologic evaluation demonstrated an AVM with no malignant features. At one year postoperatively, the patient reported complete symptom resolution. Literature review identified nine case reports, including two cases of congenital breast AVM, both treated surgically. Seven cases of iatrogenic AVM were identified, with diagnosis based on duplex ultrasonography and management by surgical ligation in all except one, which resolved spontaneously. Conclusions ongenital AVM of the breast is a rare clinical entity. Diagnosis can be established using duplex ultrasonography, while CT and MRI may be useful for preoperative planning. Endovascular management alone is associated with high recurrence rates and surgical excision is the favoured approach where technically feasible without major aesthetic or functional compromise.

Background Human epidermal growth factor receptor-2 (HER2) is overexpressed in 20–25% of breast cancers. Complete eradication of disease following neoadjuvant therapies and chemotherapy has been referred to as pathological complete response (pCR). Aims To determine clinicopathological predictors of pCR to neoadjuvant therapies and to evaluate pCR as a surrogate to enhanced survival. Methods Consecutive female patients with HER2 positive (HER+) breast cancer managed surgically in a single institution between 2005 and 2015 were included. Descriptive statistics and binary logistic regression were used to determine predictors of pCR. Appraisal of pCR as a predictor of survival was performed using Kaplan-Meier curves and Cox regression analysis. Results 451 patients were included with a mean age of 56.6 ± 13.4 years (range 23–95). Disease-free (DFS) and overall survival (OS) was 82.3% (371/451) and 82.6% (376/451) respectively with a median follow-up of 108.0 months (range 3–184.0). 118 were treated in the neoadjuvant setting (26.2%): tumour size, Highlights • Clinicopathological data predict patients who achieve pCR in HER2+ breast cancer. • pCR is a sensitive biomarker of survival in HER2 positive breast cancer. • Patients achieving pCR have reduced risk of breast cancer recurrence and mortality. • pCR can aid patient prognostication in the era of personalised medicine.

Background Oestrogen receptor (ER) status provides invaluable prognostic and therapeutic information in breast cancer (BC). When clinical decision making is driven by ER status, the value of progesterone receptor (PgR) status is less certain. The aim of this study was to describe clinicopathological features of ER-positive (ER+)/PgR-negative (PgR-) BC and to determine the effect of PgR negativity in ER+ disease. Methods Consecutive female patients with ER+ BC from a single institution were included. Factors associated with PgR- disease were assessed using binary logistic regression. Oncological outcome was assessed using Kaplan–Meier and Cox regression analysis. Results In total, 2660 patients were included with a mean(s.d.) age of 59.6(13.3) years (range 21–99 years). Median follow-up was 97.2 months (range 3.0–181.2). Some 2208 cases were PgR+ (83.0 per cent) and 452 were PgR- (17.0 per cent). Being postmenopausal (odds ratio (OR) 1.66, 95 per cent c.i. 1.25 to 2.20, P Conclusions In ER+ disease, PgR- tumours have more aggressive clinicopathological features and worse oncological outcomes. Neoadjuvant and adjuvant therapeutic strategies should be tailored according to PgR status.

Background Tumour budding (TB) is an adverse histological feature in many cancers. It is thought to represent epithelial-to-mesenchymal transition, a key step in the metastatic process. The role of TB in breast carcinoma (BC) remains unclear. Aim To investigate the relationship between TB and other histological and molecular features of BC. Method A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Cochran–Mantel–Haenszel method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS). Result Seven studies with a total of 1040 patients (high grade TB n=519, 49.9%; low grade TB n=521, 50.1%) were included. A moderate- to high-risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node involvement (OR 2.28, 95% c.i. 1.74 to 2.98, P Conclusion High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC. Take-home message High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Introduction Sarcopenia in cancer may confer negative outcomes, but its prevalence and impact in the modern multimodal management of locally advanced breast cancer have not been systematically studied. Method Patients undergoing neoadjuvant therapy and surgery for locally advanced breast cancer between 2010 and 2015 were studied. Skeletal muscle index (SMI) and lean body mass (LBM) were determined. Sarcopenia was defined by computed tomography (CT) at L3 as SMI Result 258 patients were studied. Sarcopenia was present in 23.0%, 7.8% and 0.0% of patients with normal weight, overweight and obesity, respectively (P=0.001). Sarcopenia was not associated with baseline cT and cN stage, tumour grade, histologic type or receptor status. Patients with sarcopenia exhibited equivalent indices of neoadjuvant therapy response including ypT and ypN stage, pathologic complete response and Sataloff grade following surgical resection. Postoperatively, sarcopenia was not independently associated with comprehensive complications index (P=0.242), length of stay (P=0.716) or overall morbidity (P=0.365). However, on multivariable analysis, lower LBM independently predicted reduced invasive disease-free (P=0.049,HR0.93[95%CI0.87-1.00]) and overall (P=0.028,HR0.92[0.85-0.99]), but not disease-specific survival (P=0.070). Conclusion Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality. Take-home message Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality.

Background The benefit of chemotherapy (NAC) for patients with ER/PR positive, HER2 negative breast cancer is unclear. Our aim was to determine factors associated with histopathologic response and oncologic outcome following NAC in this group. Methods Consecutive female patients undergoing neoadjuvant therapy and surgery for locally advanced Luminal A breast cancer between 2010 and 2015 were studied. Multivariable linear, logistic, and Cox regression analysis was undertaken. Results 114 patients were studied. Pathological complete response (pCR) was achieved in 7.9% of patients, ypN0 in 25.5%, and downstaging in 33.6%. However, 43.9% exhibited a Sataloff C-D response. Tumor grade independently predicted pCR (P = 0.039), while PR score predicted ypN0 (P = 0.017) and downstaging (P=0.029). 5-year invasive disease-free (iDFS) and overall survival (OS) were 68.5 ± 4.7% and 77.7 ± 4.3%, respectively. Conclusion After NAC for Luminal A breast cancer, pCR rates are low. Patients with high grade tumors with weak PR expression exhibit the most promising response rates.

The cost of new cancer technologies has been the subject of intense debate in recent years. There have been significant advances in therapeutic techniques for breast cancer over the past 20 years. This has been accompanied by the concentration of services in designated cancer centres. The aim of this study was to examine the changing cost of breast cancer management over an 18-year period and identify factors underlying this. We use breast cancer services data from Galway University Hospital in 1995–1996, 2005–2006 and 2011–2012 to examine the changing pattern of care costs and survival. The number of patients treated for breast cancer rose from 200 in 1995–1996, to 411 in 2005–2006 and 563 in 2011–2012. Two-year survival rose in line with national figures from 84 to 89.78 and 92.07%, in the three-time periods respectively. Adjusting for inflation, the average cost per patient rose from €14,710 (95% C.I., €13,398 to €16,022) in 1995–1996 to €30,405 (95% C.I., €38,620 to €32,189) in 2005–2006, before falling to €14,458 (C.I., €13,343 to €15,572) in 2011–2012. We found significant changes in the pattern of costs, with some rising in relative and absolute terms while others fell as new therapies became available and/or moved off patent. Within an evolving context where services are centralised, new therapies emerge and subsequently come off patent, our understanding of the value of cancer therapies continues to evolve. This has important implications for the evaluation of new therapies and broader policy initiatives in this area.

Introduction Hormone receptor status has major implications for treatment and survival of breast cancer. Yet the impact of hormone receptor status on outcome after Trastuzumab has received little attention. The objective here was to explore any differential effects of Trastuzumab treatment (Trast +ve) on Luminal B HER2 or HER2+(ER−) breast cancer subtypes. Methods A cohort of 469 HER2 receptor-positive breast cancers was categorised by molecular subtype and Trastuzumab treatment. Effects of Trastuzumab treatment on survival, locoregional recurrence and distant metastasis were investigated by subtype, using univariate and multivariate analysis. Results Trast +ve Luminal B HER2 patients had significant improvements in 5-year DFS (p

Accelerated partial breast irradiation is a potential alternative to standard whole breast irradiation, following breast-conserving surgery, in the management of breast cancer. The MammoSite applicator–based technique allows for the delivery of a higher dose of radiation to the tumour bed and adjacent area, over a shorter treatment period. To investigate the long-term feasibility of the MammoSite technique in early stage breast cancer in an Irish cohort. Sixty-two patients with early stage breast cancer were enrolled in this prospective study between November 2005 and October 2012 at the University Hospital Galway. A single-entry MammoSite applicator was inserted post-operatively. A CT scan was performed to assess the balloon to skin distance, the conformance of target tissue to balloon surface and balloon symmetry. A total dose of 34 Gy was delivered over 10 fractions twice daily. Median follow-up was 10 years. 91.9% (57/62) completed the full course of MammoSite treatment. Technical issues with the MammoSite balloon precluded three patients from completing the full course of treatment. On last follow-up, 6.4% (4/62) of patients had developed an ipsilateral breast recurrence. Half of these recurrences occurred more than 10 years after the initial breast cancer treatment. The most common toxicities observed were fibrosis (67.7%), pain (61.3%) and skin erythema (35.5%). The use of the MammoSite technique, as an alternative to standard whole breast irradiation, is feasible in a typical Irish clinical setting with integrated multidisciplinary team input.

Neoadjuvant chemotherapy (NAC) is increasingly used in locally advanced breast cancer as it facilitates breast conserving surgery (BCS) and allows surgical treatment of patients considered inoperable at baseline. The aim of this study was to assess the trends in breast cancer management with regard to the administration of NAC and adjuvant chemotherapy and the effect this has on surgical practice, patient outcomes, and patterns of disease recurrence.Patients treated with chemotherapy from 2005 to 2014 were identified from a prospectively maintained database. Clinicopathologic details, timing of chemotherapy delivery, and surgical procedures carried out were analyzed.A total of 1619 patients were included in the study. The NAC group (n = 383) had a higher T stage (P .001) and higher grade disease than the adjuvant group (P = .017). Luminal A breast cancer was less likely to be treated by NAC. The proportion of patients treated with NAC has increased from 12.1% in 2005 to 48.3% in 2014 (P .001). There was an increase in the BCS rate over time (P = .002); however, a higher proportion of the neoadjuvant group (55.5%) underwent mastectomy. Timing of chemotherapy influenced the type of reconstructive procedure carried out (P = .003).The number of patients with breast cancer being treated with NAC is increasing, which is influencing the increasing rate of BCS, though mastectomy is still central to the surgical management of those in receipt of NAC.

The molecular era has identified four breast cancer subtypes. Luminal A breast cancer (LABC) is defined by estrogen-receptor positive (ER+), progesterone-receptor positive (PgR+) and human epidermal growth factor receptor-2 negative (HER2-) tumours; these cancers are the most common and carry favourable prognoses.To describe clinicopathologic features, oncological outcome and relapse patterns in LABC.Consecutive female patients diagnosed with ER/PgR+/HER2-, lymph node negative (LN-) breast cancer between 2005 and 2015 were included. Clinicopathological and recurrence data was recorded using descriptive statistics. Oncological outcome was determined using Kaplan-Meier and Cox-regression analyses.Analysis was performed for 849 patients with median follow-up of 102.1 months. Mean disease-free (DFS) and overall survival (OS) were 85.8% and 91.8%. Seventy patients died during this study (8.2%), while 58 patients had recurrence; 7 had local recurrence (0.8%) and 51 had distant recurrence (DDR) (6.0%). Patients developing DDR were likely to be postmenopausal (P = 0.028), present symptomatically (P 0.001) and have larger tumours (P 0.001). The mean time to DDR was 65.7 months, with fatal recurrence occurring in 66.6% of patients with DDR (34/51). Systemic chemotherapy prescription did not influence DDR (P = 0.053). Age65 (hazards ratio (HR):1.66, 95% Confidence Interval (CI):1.07-2.55, P = 0.022), presenting symptomatically (HR:2.28, 95%CI:1.21-4.29, P = 0.011) and tumour size20 mm (HR:1.81, 95%CI:1.25-2.62, P = 0.002) predicted DFS, while age65 (HR:2.60, 95%CI:1.49-4.53, P = 0.001) and being postmenopausal at diagnosis (HR:3.13, 95%CI:1.19-8.22, P = 0.020) predicted OS.Our series demonstrated excellent survival outcomes for patients diagnosed with LN- LABC after almost a decade of follow-up. However, following DDR, fatal progression is often imminent.

Background The rate of immediate breast reconstruction is rising. Postoperative infections are more frequent in patients who undergo reconstruction. The inflammatory response to a postoperative infection can increase the risk of tumour recurrence in other forms of cancer through the release of proinflammatory mediators. The aim of this study was to assess the relationship between complications and breast cancer recurrence in patients undergoing immediate reconstruction. Methods This was a review of a prospectively maintained database of all patients who had immediate breast reconstruction between 2004 and 2009 at Galway University Hospital, a tertiary breast cancer referral centre serving the west of Ireland. All patients had a minimum follow-up of 5 years. Outcomes assessed included the development of wound complications and breast cancer recurrence. The data were evaluated by univariable and multivariable Cox regression analysis. Results A total of 229 patients who underwent immediate reconstruction were identified. The overall 5-year recurrence-free survival rate was 85·6 per cent. Fifty-three patients (23·1 per cent) had wound complications, of whom 44 (19·2 per cent) developed a wound infection. There was a significantly greater risk of developing systemic recurrence among patients who experienced a postoperative wound complication compared with those without a complication (hazard ratio 4·94, 95 per cent c.i. 2·72 to 8·95; P < 0·001). This remained significant after adjusting for Nottingham Prognostic Index group in the multivariable analysis. The 5-year recurrence-free survival rate for patients who had a wound complication was 64 per cent, compared with 89·2 per cent in patients without a complication (P < 0·001). Conclusion This study has demonstrated that wound complications after immediate breast reconstructive surgery have significant implications for patients with breast cancer. Strategies are required to minimize the risk of postoperative wound complications in patients with breast cancer undergoing immediate reconstruction.

Angiosarcomas account for less than 1% of primary breast cancers. Typically, they occur in young women with a low-risk personal or family history. Diagnosis, resection and reconstruction require a multidisciplinary team of breast surgeons, oncologists and plastic reconstructive surgeons. Cross-disciplinary awareness among these specialities enables dimensional patient treatment. We report a case of primary angiosarcoma of the breast in a 33-year-old woman, with no previous radiotherapy exposure, treated with a radical mastectomy and chest wall reconstruction with a deep inferior epigastric perforator (DIEP) Flap. There is a general consensus in current literature regarding the difficulty for curative treatment in angiosarcomas. There is a requirement for surgical intervention to be aggressive to ensure oncological clearance. Subsequently, the extensive reconstructive task proves a major procedure for any plastic surgeon. DIEP autologous flap chest wall reconstruction accompanying radical mastectomy can be used in efforts to eradicate risks of deep margin incomplete excision in breast angiosarcomas. This case report and review of the current literature aim to provide guidance for colleagues managing angiosarcomas and also highlight the versatility of the DIEP flap.

Recent studies have shown that breast cancer subtype can change from the primary tumour to the recurrence. Discordance between primary and recurrent breast cancer has implications for further treatment and ultimately prognosis. The aim of the study was to determine the rate of change between primary and recurrence of breast cancer and to assess the impact of these changes on survival and potential treatment options.Patient demographics were collected on those who underwent surgery for breast cancer between 2001 and 2014 and had a recurrence with biopsy results and pathology scoring of both the primary and recurrence.One hundred thirty two consecutive patients were included. There were 31 (23.5%) changes in subtype. Discordance occurred most frequently in luminal A breast cancer (n = 20), followed by triple negative (n = 4), luminal B (n = 3) and HER2 (n = 3). Patients who changed from luminal A to triple negative (n = 18) had a significantly worse post-recurrence survival (p 0.05) with overall survival approaching significance (p = 0.064) compared to concordant luminal A cases (n = 46). Overall receptor discordance rates were: estrogen receptor 20.4% (n = 27), progesterone receptor 37.7% (n = 50) and HER2 3% (n = 4). Loss of estrogen receptor and progesterone receptor was more common than gain (21 vs. 6 (p = 0.04) and 44 vs. 6 (p = 0.01) respectively). Nine patients (6.8%) gained receptor status potentially impacting treatment options.Discordance in subtype and receptor status occurs between primary and recurrent breast cancer, ultimately affecting survival and potentially impacting treatment options.

Background Recent studies have shown that breast cancer subtype can change from the primary tumour to the recurrence. Discordance between primary and recurrent breast cancer has implications for further treatment and ultimately prognosis. The aim of the study was to determine the rate of change between primary and recurrence of breast cancer and to assess the impact of these changes on survival and potential treatment options. Methods Patient demographics were collected on those who underwent surgery for breast cancer between 2001 and 2014 and had a recurrence with biopsy results and pathology scoring of both the primary and recurrence. Results One hundred thirty two consecutive patients were included. There were 31 (23.5%) changes in subtype. Discordance occurred most frequently in luminal A breast cancer (n = 20), followed by triple negative (n = 4), luminal B (n = 3) and HER2 (n = 3). Patients who changed from luminal A to triple negative (n = 18) had a significantly worse post-recurrence survival (p

Background: It remains difficult to distinguish between complicated appendicitis (CAP) and uncomplicated appendicitis (UAP). There is a paucity of studies utilizing inflammatory markers to stratify the severity of acute appendicitis. This study aimed to evaluate and demonstrate the potential clinical utility of inflammatory markers as adjuncts in distinguishing CAP and UAP. Methods: A comparative observational study was performed. Patients diagnosed with acute appendicitis were categorized as (a) complicated (necrosis, perforation, abscess) and (b) uncomplicated (inflamed, edematous). Hematological indices were combined to generate the following ratios: white cell lymphocyte ratio (WLR), white cell neutrophil ratio (WNR) and neutrophil lymphocyte ratio (NLR). Parameter accuracy was assessed using summary receiver operating characteristic (sROC) curves, classification and regression tree analysis and confusion matrix generation. Results: On sROC analysis, neutrophils (area under the curve (AUC) 0.79, p < 0.001), WLR (AUC 0.79, p < 0.001) and NLR (AUC 0.79, p < 0.001) were the most accurate parameters in distinguishing CAP and UAP. White cell count (WCC; AUC 0.76, p < 0.001) and C-reactive protein (AUC 0.75, p < 0.001) were less accurate. WCC >12.25 (sensitivity 70%, specificity 68%) and NLR >5.47 (sensitivity 78%, specificity 70%) were the most accurate in identifying CAP. Conclusion: Inflammatory marker cutoff points can be generated and utilized to differentiate between UAP and CAP. This may be useful when deciding between conservative and operative management.

Integration of general practitioners (GPs) into a tertiary care team is a model used internationally to assist with provision of patient care. Symptomatic breast clinics have seen significant increases in attendances and consequential staffing issues. We wished to analyze the integration of GPs into a tertiary breast care team and establish whether their inclusion is a cost-effective approach. A prospectively maintained database was used to identify 1614 new and 1453 review patients seen in the clinic between September and December 2013. The triple assessment clinical, radiological, and biopsy scores of patients assessed by GPs were compared to those assessed by registrars and to the overall number of patients seen. A cost analysis was performed based on the hourly rates of GPs and registrars. 1614 new patients seen over the 4-month period. GPs reviewed a mean of 153.6 new patients and registrars reviewed a mean of 97.8. Registrars reviewed patients who were allocated higher ‘S’ scores, with 46 % of patients allocated an S4 and 21 % of patients allocated an S5 score. GPs reviewed a mean of 115.6 return patients and registrars reviewed a mean of 110.1 return patients. The weekly cost of employing 3 GPs for 15 h was €835. This compares favorably to the cost of employing a full-time registrar. This study demonstrates that GPs can play a substantial role in the provision of a symptomatic breast service. In addition, the incorporation of GPs in this setting can prove cost-effective.

Currently, breast cancer affects approximately 12% of women worldwide. While the incidence of breast cancer rises with age, a younger age at diagnosis is linked to increased mortality. We discuss age related factors affecting breast cancer diagnosis, management and treatment, exploring key concepts and identifying critical areas requiring further research. We examine age as a factor in breast cancer diagnosis and treatment relating it to factors such as genetic status, breast cancer subtype, hormone factors and nodal status. We examine the effects of age as seen through the adoption of population wide breast cancer screening programs. Assessing the incidence rates of each breast cancer subtype, in the context of age, we examine the observed correlations. We explore how age affects patient's prognosis, exploring the effects of age on stage and subtype incidence. Finally we discuss the future of breast cancer diagnosis and treatment, examining the potential of emerging tests and technologies (such as microRNA) and how novel research findings are being translated into clinically relevant practices.

Background Z0011 study suggests patients with minimal disease do not require axillary clearance. Exclusions include T3 tumours, mastectomy or neoadjuvant treatment. This study assessed the utility of pre-operative US-guided core biopsy of axillary nodes and its correlation with nodal macrometastases. Methods 247 women with breast cancer outside Z0011 criteria were reviewed retrospectively. Sensitivity and specificity of pre-operative axillary ultrasound and core biopsy compared to final histology was assessed by contingency tables. Results 75/247 patients had macrometastases. Ultrasound-axilla was 72% sensitive and 77% specific in predicting macrometastasis. The positive (PPV) and negative predictive value (NPV) was 58% and 86.4% respectively. Core-biopsy of axilla node, was 92.6% sensitive and 66.7% specific in detecting macrometastasis. PPV and NPV 79.4% and 86.7% respectively. Conclusion Positive pre-operative ultrasound-guided core biopsy accurately predicts macroscopic involvement of axillary nodes. Selected patients outside Z0011 parameters can proceed to axillary clearance without sentinel node biopsy or risking overtreatment.

Highlights • Pre-operative diagnosis of fish bone perforation of the bowel is difficult. • It usually mimics common abdominal pathology. • A low threshold must be maintained to perform a diagnostic laparoscopy., Introduction The diagnosis of abdominal complications due to fish bone ingestion is particularly difficult as the presentation may mimic common abdominal pathologies. Presentation of case 65 year-old male presented with a two day history of right iliac fossa pain. He denied any nausea and vomiting. He had no systemic systems including fever, change in bowel habit. He had tenderness and guarding localized to the right iliac fossa. He had raised inflammatory markers. A CT scan of the abdomen was performed which showed fat standing in proximity to the terminal ileum, with the appearance of Crohn’s disease. The clinical picture did not match the imaging and so the patient underwent a diagnostic laparoscopy. Findings included an acutely inflamed terminal ileum. A foreign body was identified piercing through at the small bowel wall at the terminal ileum. The foreign body was removed and revealed a fish bone. Intracorporeal sutures were inserted at the site of the microperforation. The patient was discharged well two days post operatively. Discussion Fish bone perforation is not a common cause of gastrointestinal perforation. Unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. CT scans can be useful to aid diagnostics. It is not however fully sensitive in detecting complications arising from fishbone ingestion. Conclusion Management therefore, should be based taking into account primarily the clinical picture & may necessitate diagnostic laparoscopy.

Introduction: The inflammatory response to a post-operative infection can increase the risk of tumour recurrence in cancer through the release of pro-inflammatory mediators. The aim of this study was review the literature to assess the relationship between post-operative complications and cancer recurrence. Methods: We performed a literature review of the mechanism of such an association and looked at evidence in different cancer subtypes. Results: A relationship has been identified for many cancer subtypes, and multiple theories have been proposed for the mechanism of this association. Methods to reduce post-operative complications may impact positively on cancer recurrence rates. Conclusion: This review demonstrates that wound complications after surgery can have significant implications for cancer patients. Strategies are required to minimize the risk of post-operative wound complications in patients undergoing cancer resection.

Background The pressures on tertiary hospitals with increased volume and complexity related to regionalization and specialization has impacted upon availability of operating theatres with consequent displacement of emergencies to high risk out of hours settings. Methods A retrospective review of an electronic emergency theatre list prospectively maintained database was performed over a two year period. Data gathered included type of operation performed, Time to Theatre (TTT), operation start time and length of stay (LOS). Results Of 7041 emergency operations 25% were performed out of hours. 2949 patient had general surgical emergency procedures with 910 (30%) performed out of hours. 53% of all emergency laparotomies and 54% of appendicectomies were out of hours. 57% of cases operated on out of hours had been awaiting surgery during the day. Mean TTT was shorter for those admitted at the weekend compared to those admitted during the week (15.6 vs 24.9 h) (p Conclusion The majority of major emergency surgery is performed out of hours in a way unfavorable to good clinical outcomes. It is of concern that more than half of the most life threating procedures involving laparotomy, take place out of hours. Regionalization needs to be accompanied by infrastructure planning to accommodate emergency surgery.

Centralisation of breast cancer services in Ireland has resulted in a significant increase in the number of patients attending symptomatic breast units (SBU). A considerable proportion of patients referred to SBU present with non-suspicious symptoms and fall into a “low-risk” category for breast cancer. It has been proposed that consideration be given to a primary care-delivered service for these patients. To evaluate SBU attendances and correlate with diagnosis to identify a cohort of patients who may be suitable for management in the primary care setting. Data were collected from a prospectively maintained database on patients attending SBU at two tertiary referral centres (Beaumont Hospital and University College Hospital Galway) from January 2011 to 2012. Reasons for attendance, outcome of triple-assessment and incidence of malignancy were analysed. 14,325 patients underwent triple assessment at the SBU in this time period. 5,841 patients were referred with mastalgia, of whom 3,331 (57 %) reported mastalgia as the only symptom. The incidence of breast cancer in patients presenting with mastalgia alone was 1.2 %. All patients diagnosed with breast cancer in this cohort were over 35 years of age. The incidence of breast cancer in patients referred to SBU with mastalgia as an isolated symptom is extremely low. Patients under 35 years of age, with mastalgia as an isolated symptom do not require breast imaging and have a sufficiently low risk of breast cancer that they may be suitable for management in the primary care setting.

Introduction Triple-negative breast cancers (TNBC) are associated with a poor prognosis owing to an aggressive phenotype. We aimed to carry out a prospective study comparing management strategies and response to therapy in TNBC and non-TNBC patients. Methods Data were obtained from a prospectively maintained database of patients treated for breast cancer. Results A total of 142 TNBC and 142 age-, stage- and NPI-matched non-TNBC patients were treated. The difference in overall survival between the 2 groups was statistically significant (77% of TNBC patients alive at a mean follow-up of 32 months, versus 92% of non-TNBC patients at a mean follow-up of 38 months, P = 0.0 Log rank test). This survival difference was found to be independent of NPI (P = 0.0 Log rank test). Locoregional recurrence rates were similar between TNBC patients who were treated with wide local excision versus mastectomy (P = 0.449 Log rank test). A significant difference in survival was noted between TNBC patients who responded differentially to neoadjuvant chemotherapy (P = 0.035 Log rank test). Conclusion Patients with TNBC have adverse outcomes despite aggressive treatment. The development of effective targeted therapies is essential for this breast cancer subtype.

Macromastia and in particular unilateral macromastia is a rare clinical entity. It relates to massive enlargement of the breast in non-obese women. This case report describes an initially mild unilateral asymmetry occurring nine months postpartum in a 33-year-old female. However, following her second pregnancy within 12 months, her left breast became severely enlarged. This did not improve on delivery. No discrete lesion was seen on imaging and no significant abnormalities were seen in her blood chemistry. Surgical treatment was a mammoplasty and 580 g of mammary tissue was removed. Grossly, there was spongiform subcutaneous tissue with diffuse extension. On histology, this consisted of a highly complex and diffuse pattern of infiltration and of cavernous empty channels lined by a delicate attenuated endothelium which was CD34 and D2-40 positive. The appearances were consistent with lymphangiomatosis, more commonly encountered in the limbs, heretofore. Lymphangiomatosis has not been previously described in breast tissue and only a single case report exists for such a lesion in axillary tissue. Treatment of such lesions in the periphery by surgical excision is very difficult and excision without being radical can be impossible. Follow up of our patient, shows no evidence of recurrence in this patient. Our case report describes the clinicopathological features, differential diagnosis to be considered and treatment, in addition to reviewing the relevant literature.

Background: Perou and Serlie's molecular portraits of breast tumors explain the phenotypic heterogeneity of breast cancers by demonstrating diversity in gene expression, and classify tumors into 5 unique subgroups. The commonest breast cancer intrinsic subtype, Luminal A (ER/PR+, HER2-), generally carries a good prognosis with lower incidence of metastatic spread and longer disease free and overall survival compared to non-luminal tumors. Yet within the Luminal A subgroup there appears to be heterogeneous outcome; and debate continues as to the need for adjuvant chemotherapy within this cohort. In the absence of validated molecular predictors of response to chemotherapy, we aimed to assess the outcomes of a large cohort of Luminal A breast cancer patients in order to determine prognostic factors which may guide future treatment strategies for this subgroup. Methods: 1355 breast cancer patients treated in a tertiary referral symptomatic breast cancer unit, with known molecular subtype, were identified. 965 had Luminal A primary breast tumors, of whom 57% had received adjuvant chemotherapy. Clinicopathological details of all patients were reviewed, including particular details of the chemotherapeutic regimens administered. Current outcome in terms of disease-free (DFS) and overall survival (OS) was determined. Kaplan-Meir & multivariate analyses were performed to identify tumor/patient characteristics indicative of poor response to adjuvant chemotherapy. Results: Mean follow-up was 61.3 months. Overall & disease free survival were significantly better for those who received adjuvant chemotherapy (Mean OS: 60 vs. 54 months, p=0.051. DFS: 54 vs. 44 months, P Conclusion: Adjuvant chemotherapy is beneficial in the cohort of Luminal A's with advanced disease at diagnosis. However it is critically importance to identify this particular subgroup & spare those with early disease the toxicity of treatment from which they are unlikely to derive further benefit. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-10.

There has been conflicting evidence on the impact of bilateral breast cancer (BBC) on the survival and management of patients. The objectives of this study were to address the incidence of BBC and to investigate its characteristics and outcome compared to unilateral cancer. Data were acquired from the prospectively maintained NUIG breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous (after 12 months of first tumour). SPSS was used for data analysis. The incidence of BBC in our population was 4.4% (112 of 2,524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (P = 0.021) and had smaller size (P = 0.001) and earlier stage (P < 0.001) tumours at diagnosis. We identified the HER2/neu positivity as a risk factor for developing contralateral breast tumour and ER negativity as a risk factor for developing metachronous tumours. While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (P > 0.05), the synchronous tumour was associated with poorer survival (P = 0.010) in comparison to metachronous tumour. This large single-institutional experience does not support the increasing practice of prophylactic mastectomy but does justify regular follow-up with mammography for early detection of contralateral tumour.

Background: In response to the requirements of the European Working Time Directive (EWTD), a national implementation group was formed to liaise with local implementation groups at nine different pilot sites. As part of this process, a pilot EWTD compliant rota was run for six weeks amongst general surgical SHOs in University Hospital Galway. Methods: A rota was devised for nine general surgical SHOs, the aim being to achieve EWTD compliance. SHOs were asked to complete questionnaires to assess the effectiveness of the pilot. Result: During the pilot SHOs were rostered for an average of 53.6 hours. Actual hours worked were 58.1 hours. Fifty-two point five per cent of working weeks were non-compliant with the provisions of the EWTD. Seventy per cent of the time SHOs felt that continuity of care was not achieved. Eighty-one per cent felt that patient care deteriorated during the pilot. SHOs spent an average of 2.5 days per week engaged in sessional commitments with their consultant. Fifty percent of SHOs missed elective operating sessions or outpatient clinics. SHOs attended an average of 1.3 emergency operations per week (range 0-8) and 5.5 elective procedures per week (range 0–12). All SHOs reported a deterioration in quantity or quality of training. However, 69% reported an improvement in their quality of life during the pilot. Conclusions: With this tightly defined shift system, hours worked were in breach of the provisions of the EWTD. Sixty-nine per cent of SHOs reported an improvement in quality of life, but all reported a deterioration in training and 81% felt that patient care suffered.

Background: Acute appendicitis is increasingly being managed in the setting of a dedicated emergency theatre. However understanding of hospital factors that influence time-to-theatre (TTT) is poor. Thus, the aim of this study is to identify factors that influence TTT and to observe the effect of prolonged TTT on patient outcome. Methods: A retrospective review of an electronic prospectively maintained database was performed over a 2 year period. Factors thought to influence TTT were highlighted. A delay was defined as TTT > 8 hours. Data analysis was performed using SPSS 20. Results: 1,000 cases of suspected acute appendicitis were identified. Median age was 19 years. Appendicectomy was performed in 90.7%. 68.1% underwent laparoscopic appendicectomy. Overall mean TTT was 12 hours, 27 minutes. There was a significant association between delayed TTT and female gender (p = 0.017), older age (p = 0.001), pre-operative radiology (< 0.001), normal WCC (p < 0.001), normal neutrophils (p < 0.001) and histological non-perforated appendix (p < 0.001). However, on multivariate analysis, younger age, a neutrophilia and presence of a perforation had a shorter TTT. Delayed TTT did not affect outcome variables including post-operative collection (3.59% v 4.38%, p = 0.528), readmission rate (6.54% v 5.72%, p = 0.403) and length of stay (3.1 days v 3.34 days, p = 0.823). Conclusions: This study highlights key hospital factors that influence TTT in patients with suspected appendicitis. Identification of these influential factors adds greatly to our understanding of patient prioritisation. Finally, TTT delays greater than 8 hour do not appear to affect short-term patient outcomes.

Adhesion formation is one of the foremost obstacles to a reliably good outcome in tendon and joint surgery. Thermal preconditioning has been found to reduce the inflammatory response through the induction of molecular chaperone expression, a recently described family of cytoprotective intracellular proteins. The authors analyzed the effect of thermal preconditioning on the inflammatory response to surgery, on tendon healing, and on the formation of peritendinous adhesions in 16 New Zealand White rabbits. Very significant decreases in adhesion formation and in the gliding and dimensions of tendons in animals that had thermal preconditioning were found. Tendons from these animals also showed a decreased level of adhesion formation and a significantly diminished inflammatory response on histologic examination with no biomechanically significant deleterious effect on the strength of tendon healing on testing load to failure. These findings are consistent with induction of heat shock proteins by hyperthermic pretreatment. Such prevention of peritendinous adhesions and the inflammatory response to injury and surgery without compromising healing are findings that have significant implications for tendon surgery and all surgery involving joints and soft tissues.