Quality assurance in a multidisciplinary symptomatic breast assessment clinic.

BACKGROUND: Although quality assurance guidelines for surgeons have been issued and adopted for use in population-based breast screening programs in Australia, similar guidelines are unavailable for women referred with symptomatic breast problems. METHODS: Six hundred and ninety-six women who attended the Royal Adelaide Hospital Women's Health Centre between February and November 1998 for investigation and management of a new breast-related complaint were prospectively evaluated. Investigation strategies and outcomes of the initial consultation were determined and the results compared with the performance quality standards for symptomatic breast disease according to the British Association of Surgical Oncology (BASO) Breast Surgeons' Group. RESULTS: A breast lump was the presenting symptom in 45%, while breast pain was present in 26%. Ninety per cent of women referred with breast symptoms were given a definitive benign or malignant diagnosis at the initial clinic visit. Although the median time delay between the date of general practitioner referral and breast clinic appointments for all patients was < or =7 days, the time delay for 'urgent' cases was not met according to BASO performance indicators. All other Royal Adelaide Hospital Breast Clinic audit data were within the range suggested by BASO performance indicators for new consultations in a symptomatic breast assessment clinic. CONCLUSIONS: A multidisciplinary breast clinic in a public hospital setting is able to provide clinical services to symptomatic women, with the majority of patients obtaining a confident diagnosis at the first presentation. Performance indicators for symptomatic breast disease are useful in identifying inadequacies at the clerical or clinical level which, following the implementation of subsequent changes, may lead to improvement in patient outcomes.

Reliability of sentinel node status in predicting axillary lymph node involvement in breast cancer.

OBJECTIVES: To assess the reliability of determining sentinel node status in staging regional lymph nodes in breast cancer. DESIGN AND SETTING: Prospective validation study in a major public teaching hospital, comparing histological sentinel node status with that of remaining axillary nodes. PATIENTS: 117 women who underwent sentinel node biopsy and axillary dissection for primary breast cancer between 1995 and 1998. MAIN OUTCOME MEASURES: Intraoperative success rate in sentinel node identification; false negative rate; predictive value of negative sentinel node status; overall accuracy of sentinel node status. RESULTS: The sentinel node was identified at operation in 95 patients (81.2%). Tumour involvement of the sentinel node was demonstrated in 29 of 31 women (93.5%; 95% CI, 79%-99%). Sixty-four of the 66 women in whom the sentinel node was negative for tumour showed no further involvement of remaining axillary nodes (standard haematoxylin-eosin histological assessment), giving a predictive value of negative sentinel node status of 97% (95% CI, 89%-100%). The overall accuracy in 95 women in whom sentinel node status was compared with axillary node status was 97.9%. CONCLUSIONS: Histopathological examination of the sentinel node is an accurate method of assessing axillary lymph node status in primary breast cancer and is likely to be incorporated into future surgical management of women with primary breast cancer.

Paradoxical embolus.

OBJECTIVE: To present two cases of paradoxical embolism. CLINICAL FEATURES: A 78-year-old woman presented to a hospital emergency department, seven weeks after a right total hip replacement, with chest tightness and sudden-onset left arm and leg pain and paraesthesia. Scanning showed multiple pulmonary emboli, right iliofemoral vein thrombosis, left popliteal and axillary artery embolism, a patent foramen ovale and a right to left shunt. A 41-year-old woman, with a 10-year history of Sjögren's syndrome, presented with sudden-onset left foot pain. Scanning showed emboli in the popliteal and profunda femoris arteries of the left leg, thrombosis involving the right deep calf veins, popliteal vein and superficial femoral vein, and a patent foramen ovale. Based on these critical findings, a diagnosis of paradoxical embolism was made in each case. INTERVENTION AND OUTCOME: Both patients required arterial embolectomy. After commencement of anticoagulant therapy there were no further episodes of embolism. CONCLUSIONS: Paradoxical embolism is an important syndrome which requires a high degree of clinical suspicion as well as several specific investigations for prompt diagnosis.