The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer.

Contralateral risk-reducing mastectomy (CRRM) rates have tripled over the last 2 decades. Reasons for this are multi-factorial, with those harbouring a pathogenic variant in the BRCA1/2 gene having the greatest survival benefit. On May 14th, 2013, Angelina Jolie shared the news of her bilateral risk-reducing mastectomy (BRRM), on the basis of her BRCA1 pathogenic variant status. We evaluated the impact of this news on rates of CRRM in women with increased risk for developing breast cancer after being diagnosed with unilateral breast cancer. The prospective cohort study included all women with at least a moderate lifetime risk of developing breast cancer who attended our family history clinic (1987-2019) and were subsequently diagnosed with unilateral breast cancer. Rates of CRRM were then compared between patients diagnosed with breast cancer before and after Angelina Jolie's announcement (pre- vs. post-AJ). Of 386 breast cancer patients, with a mean age at diagnosis of 48 ± 8 years, 268 (69.4%) were diagnosed in the pre-AJ period, and 118 (30.6%) in the post-AJ period. Of these, 123 (31.9%) underwent CRRM, a median 42 (interquartile range: 11-54) days after the index cancer surgery. Rates of CRRM doubled following AJ's news, from 23.9% pre-AJ to 50.0% post AJ (p < 0.001). Rates of CRRM were found to decrease with increasing age at breast cancer (p < 0.001) and tumour TNM stage (p = 0.040), and to increase with the estimated lifetime risk of breast cancer (p < 0.001) and tumour grade (p = 0.015) on univariable analysis. After adjusting for these factors, the step-change increase in CRRM rates post-AJ remained significant (odds ratio: 9.61, p < 0.001). The AJ effect appears to have been associated with higher rates of CRRM amongst breast cancer patients with increased cancer risk. CRRM rates were highest amongst younger women and those with the highest lifetime risk profile. Clinicians need to be aware of how media news can impact on the delivery of cancer related services. Communicating objective assessment of risk is important when counselling women on the merits of risk-reducing surgery.

Galactorrhea/Galactocele After Breast Augmentation: A Systematic Review.

AIMS: To review cases of galactorrhea and galactocele postbreast augmentation, determine possible risk factors and consider management strategies of this rare complication. METHODS: A systematic literature review was conducted in July 2019 searching Pubmed, Embase, and Google Scholar. RESULTS: The searches revealed 19 articles (17 case reports/series and 2 retrospective chart reviews) collectively comprising 38 women. The average age was 28 years, 42% were on oral contraceptives, whereas a quarter were nulliparous. The most common incision was periareolar (48%) followed by transaxillary (24%). The most common implant location was subglandular (57%) followed by subpectoral (37%). The average time to symptom onset was 61 days (range, 3-912 days) but only 3 cases presented more than a month after implant insertion. Twenty-one patients had galactorrhea, 7 had galactocele, whereas 10 women had both. Bilateral symptoms were present in 72% of cases, whereas hyperprolactinemia was present in only 62%. Management strategies included simple surveillance, antibiotics, dopamine agonists, leukotriene receptor antagonists, estrogenic agents, surgical washout, and implant removal (8 patients). The mean time to symptom resolution was 22.6 days. CONCLUSIONS: The numbers are too small for definitive conclusions but there is a weak suggestion that periareolar incisions, subglandular implants, prior hormonal contraceptive use, gravidity, and recent history of breastfeeding (<1 year) may be risk factors for galactorrhea/galactocele. Symptom onset is usually within 3 months. Treatments providing the fastest response (2 days) comprised of a composite approach (antibiotics, dopamine agonist, surgical drainage, and implant removal), whereas the use of estrogenic medications appeared to confer little benefit.

Current Practice of Therapeutic Mammaplasty: A Survey of Oncoplastic Breast Surgeons in England.

INTRODUCTION: Therapeutic mammaplasty (TM) is a useful technique in the armamentarium of the oncoplastic breast surgeon (OBS). There is limited guidance on patient selection, technique, coding, and management of involved margins. The practices of OBS in England remain unknown. METHODS: Questionnaires were sent to all OBS involved with the Training Interface Group. We assessed the number of TM cases performed per surgeon, criteria for patient selection, pedicle preference, contralateral symmetrisation, use of routine preoperative MRI, management of involved margins, and clinical coding. RESULTS: We had an overall response rate of 43%. The most common skin resection technique utilised was wise pattern followed by vertical scar. Superior-medial pedicle was preferred by the majority of surgeons (62%) followed by inferior pedicle (34%). Twenty percent of surgeons would always proceed to a mastectomy following an involved margin, whereas the majority would offer reexcision based on several parameters. The main absolute contraindication to TM was tumour to breast ratio >50%. One in five surgeons would not perform TM in smokers and patients with multifocal disease. DISCUSSION: There is a wide variation in the practice of TM amongst OBS. Further research and guidance would be useful to standardise practice, particularly management of involved margins and coding for optimal reimbursement.

The Manchester guidelines for contralateral risk-reducing mastectomy.

BACKGROUND: Rates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM. METHODS: We reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines. RESULTS: A simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups. CONCLUSION: These guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.

Morphine delays discharge following ambulatory surgery: a prospective institutional study.

INTRODUCTION: Morphine is used regularly in day surgery despite its known side-effects. We assessed whether this delayed discharge. PATIENTS AND METHODS: 100 patients were divided into 2 groups: 50 patients received morphine and 50 patients received non-morphine analgesia. Demographic data and reasons for delayed discharge were recorded. RESULTS: 73% of all major cases received morphine compared to only 19% of minor cases. Operative and recovery times were significantly greater in the morphine group. 58% of patients given morphine had a delayed discharge compared to 14% of patients not given morphine. CONCLUSIONS: Morphine use in day surgery is associated with increased operating and recovery times and higher rates of delayed discharge.

Isolated duodenal rupture due to go-karting accidents--braking news.

INTRODUCTION: Isolated duodenal injury due to blunt abdominal trauma is extremely rare. We present a series of three such injuries due to go-karting accidents, which presented to our hospital over 5 months. CASE REPORTS: Between October 2007 and February 2008, three cases of D3/D4 duodenal rupture presented to our hospital after go-karting accidents. Trauma occurred as a result of the steering wheel impacting on the abdomen. All patients presented similarly with symptoms of epigastric and right upper quadrant pain. In all cases, computed tomography scanning was highly suggestive of duodenal injury and, in particular, demonstrated presence of retroperitoneal air centred around the duodenum. Treatment required laparotomy and operative repair in all cases. CONCLUSIONS: Duodenal injury presents insidiously due to its retroperitoneal position. A low threshold for investigating patients presenting with epigastric and right upper quadrant pain should be adopted along with active clinical vigilance to exclude serious and life-threatening trauma after go-karting accidents.

Mobility one year after unilateral lower limb amputation: a modern, UK institutional report.

The aim of this current retrospective study was to assess postoperative mobility one year after above knee (AKA) or below knee amputation (BKA) in a district general hospital. Data on patient demographics, diabetic status, risks for peripheral vascular disease, mortality and mobility at one year were recorded from the vascular database. Seventy-five patients underwent lower limb amputation over a 70-month period (AKA n=31, BKA n=44). Operative mortality was 10% and mortality at one year 13.7%. Fourteen out of the 31 patients (45.1%) who underwent AKA were mobile independently or with a walking stick compared to 54.5% (24/44) in the BKA group (P=0.44). Fifteen patients (48.3%) were diabetic in the AKA group compared to 26 patients (59.1%) in the BKA group (P=0.49). In the under 60 years group and over 60 years group there was no significant difference in type of amputation (P=0.64) or mobility (P=0.69). In this current series, there was no significant rehabilitation benefits in patients undergoing BKA compared to AKA. With an ageing population who inherently have increasing significant medical problems, the perceived benefit in preserving the knee joint may not be as significant as previously reported.