A multidisciplinary team approach minimises prophylactic mastectomy rates.

BACKGROUND: Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making. METHODS: We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded. RESULTS: Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%). DISCUSSION: MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Transplantation of a latissimus dorsi flap between identical twins.

We present a case of composite tissue transplantation of a latissimus dorsi flap between monozygotic twins. The recipient twin, a 19 year old male, suffered from a complex spinal kyphoscoliosis for which he had undergone multiple previous operations over many years. Soft tissue breakdown on his back causing metalwork exposure had necessitated the removal of his most recent spinal rod. This in turn led to rapid severe deterioration of his spinal deformity and consequent critical impairment of lung function. Robust soft tissue cover was required urgently in order to allow the insertion of a new spinal rod. His previous surgeries and body habitus precluded an adequate autologous reconstruction. Instead, reconstruction using composite tissue transplantation from his identical twin brother was successfully undertaken. We discuss the ethical, psychological and surgical issues involved in this case.

The role of sentinel node biopsy in the management of melanocytic lesions of uncertain malignant potential (MUMP).

Melanocytic lesions of uncertain malignant potential (MUMP) is a term which is useful in identifying melanocytic tumours where the distinction between benign and malignant is a histological problem. Sentinel node biopsy is recognised to provide unmatched prognostic information in melanoma patients, but has recently been advocated for diagnostic purposes in MUMP. We present the case of a seven-year-old girl who presented with a six-month history of a changing pigmented lesion on her left upper arm. Excision biopsy not only showed a melanocytic lesion with some spitzoid features but also marked atypia making it appropriate to use the term MUMP. Sentinel node biopsy was undertaken. This case demonstrates that sentinel node biopsy can be performed safely in children. Given the low morbidity of the procedure we advocate that this technique should be considered in this difficult diagnostic situation to further the management of these patients.

A chemoenzymatic total synthesis of ent-bengamide E.

The cis-1,2-dihydrocatechol 3, which can be obtained in enantiomerically pure form by microbial dihydroxylation of bromobenzene, has been converted into the enantiomer, ent-1, of the cyclolysine-based marine natural product bengamide E (1).

Multi-component assembly of the bicyclic core associated with the tRNA synthetase inhibitors SB-203207 and SB-203208. Application to the synthesis of biologically active analogues.

The ketone (+/-)-5, which embodies the bicyclic core associated with the title tRNA synthetase inhibitors 1 and 2, has been prepared via a three-component coupling reaction involving 2-(hydroxymethyl)cyclopent-2-enone (15), methylamine (6) and propiolamide (10); straightforward elaboration of the readily derived acetates (-)-21 and (+)-21 has provided the biologically active analogues 23 and 24, respectively, of the title compounds.

Chemoenzymatic synthesis of (+)-aspicilin from chlorobenzene.

The enantiomerically pure cis-1,2-dihydrocatechol 2, which is obtained by microbial oxidation of chlorobenzene, has been converted, via intermediate 3, into the natural product (+)-aspicilin (1).

Analogues of SB-203207 as inhibitors of tRNA synthetases.

SB-203207 and 10 analogues have been prepared, by elaboration of altemicidin, and evaluated as inhibitors of isoleucyl, leucyl and valyl tRNA synthetases (IRS, LRS, and VRS, respectively). Substituting the isoleucine residue of SB-203207 with leucine and valine increased the potency of inhibition of LRS and VRS, respectively. The leucine derivative showed low level antibacterial activity, while several of the compounds inhibited IRS from Staphylococcus aureus WCUH29 more strongly than rat liver IRS.

Electrocyclic ring-opening/pi-allyl cation cyclization reaction sequences involving gem-dihalocyclopropanes as substrates: application to syntheses of (+/-)-, (+)-, and (-)-gamma-lycorane.

The readily prepared gem-dibromocyclopropanes (+/-)-13 and (+/-)-19 each engage in a silver(I)-promoted electrocyclic ring-opening/pi-allyl cation cyclization sequence to deliver the hexahydroindole (+/-)-20, which participates in a Suzuki cross-coupling reaction with arylboronic acid 3 to give the tetracyclic compound (+/-)-21. Catalytic hydrogenation of this last compound proceeds in a completely stereoselective manner to give the saturated analogue (+/-)-24, which undergoes Bischler-Napieralski cyclization on reaction with phosphorus oxychloride. The resulting lactam (+/-)-25 is then reduced with lithium aluminum hydride to give (+/-)-gamma-lycorane [(+/-)-1]. By using (-)-menthyl-derived carbamates 27 and 28, this chemistry has been extended to the synthesis of the (+)- and (-)-modifications of the title compound.

Sequential retroperitoneal venous hemorrhage and embolism of an angio-seal puncture closure device complicating iliac artery angioplasty.

PURPOSE: To present a case of iatrogenic puncture closure device embolization complicating surgery for retroperitoneal hemorrhage (RPH) secondary to angioplasty-induced common iliac vein trauma. METHODS AND RESULTS: A 78-year-old woman with rest pain underwent successful kissing balloon dilation of her aortoiliac bifurcation for a calcified ostial stenosis of the left common iliac artery. Hemostatic puncture closure devices (Angio-Seal) were used to secure both femoral punctures. A right-sided retroperitoneal hematoma developed, and during surgical exploration of the right groin, the Angio-Seal device was removed. The only bleeding site found was the external iliac artery puncture and it was repaired. She again became hypovolemic 18 hours later and was returned to surgery, where bilateral groin explorations and laparotomy by the vascular surgical team found a tear in the left common iliac vein. After repair, the patient was stable for 48 hours when the left leg became critically ischemic. Angiography detected a new high-grade stenosis in the left profunda femoris artery; embolectomy retrieved a footplate from the left puncture closure device. The patient died 11 days later from multiorgan failure. CONCLUSIONS: RPH should be considered early as an occult cause of hypovolemic shock developing soon after even technically straightforward iliac angioplasty. Interventionists should be aware that using the Angio-Seal device risks acute limb ischemia if footplate embolization occurs.