Patient-reported outcomes post prophylactic risk-reducing mastectomy: improved breast and psychosocial satisfaction yet poorer physical well-being.

BACKGROUND: Few studies have investigated patient-reported outcomes (PROs) for patients with high breast cancer risk undergoing elective risk reduction mastectomy and reconstruction. These patients incur operative risk in the absence of active cancer, which renders their treatment experience unique. This study aimed to identify longer-term quality of life (QoL) issues that persist in this patient cohort. METHODS: A cross-sectional cohort study assessed PROs in 48 women with high breast cancer risk who attended the Royal Melbourne Hospital Risk Management Clinic, at least 12 months post-mastectomy and reconstruction, with surgery between 2011 and 2020, using the BREAST-Q© Likert surveys. The BREAST-Q© internationally validated QoL instrument scales survey data from 0 (worst) to 100 (best) in 14 domains addressing satisfaction and psychosocial issues. RESULTS: There was higher overall breast and psychosocial satisfaction, with scores of 11 and four, respectively, yet lower chest, abdomen and sexual well-being scores with 14, three and four, respectively, in contrast to normative BREAST-Q© data from >1000 women without prior breast cancer or breast operations. High average scores >90 were found for patient satisfaction with surgical, medical and office staff. Twenty-one patients had an average score of 63 for satisfaction with breast implants, while 27 patients post-DIEP had average scores >72 for abdominal well-being, appearance and overall outcomes. Higher mean QoL outcomes were found with DIEP flap in all domains, compared with breast implant reconstruction. CONCLUSION: QoL assessment with PROs 12 months post-risk reduction mastectomy and reconstruction demonstrated higher psychosocial well-being, yet highlights physical implications, with patients experiencing reduced chest, abdomen and sexual well-being, compared with normative BREAST-Q© control data. Higher mean QoL outcomes were found with DIEP flap compared with breast implant reconstruction. PROs studies can identify unmet needs and facilitate change in service provision.

How does thyroidectomy for benign thyroid disease impact upon quality of life? A prospective study.

BACKGROUND: Choosing which patients to recommend surgery for benign thyroid conditions can be difficult due to the subjective nature of compressive thyroid and hormonal symptoms. The aim of this prospective study was to analyse changes in quality of life (QOL) following thyroid surgery using a validated disease-specific assessment tool, the thyroid-related patient-reported outcome (ThyPRO) questionnaire. METHODS: Participants undergoing elective thyroid surgery for benign conditions were recruited. Patient demographics and clinical data were collected. ThyPRO consists of 85 questions grouped into 13 physical, mental and social symptom domains. Patients completed a ThyPRO questionnaire pre-operatively and at 6 weeks and 6 months post-operatively. ThyPRO items were scored according to protocol to produce 13 subscales. Repeated measures linear models with no random effects were performed using data for each outcome. RESULTS: Results were available for a total of 72 patients. The sample was predominately female (n = 63, 88%) with average age 49.8 years. The majority of patients underwent surgery for multi-nodular goitre. At 6 weeks post-operatively, significant improvement was demonstrated in the goitre, hypothyroid, hyperthyroid and anxiety symptom domains. At 6 months post-operatively, significant improvement was demonstrated in all but four domains. No domains demonstrated significant increase in impairment post-operatively. CONCLUSION: Patients had significant improvement in nine of 13 symptom domains following surgery. Patients did not experience a negative impact on QOL following surgery. Further studies with larger patient cohorts may be able to identify potential pre-operative predictive factors for a post-operative improvement in QOL for benign thyroid disease.

Exploring the facilitators and barriers to using an online infertility risk prediction tool (FoRECAsT) for young women with breast cancer: a qualitative study protocol.

INTRODUCTION: As cancer treatments may impact on fertility, a high priority for young patients with breast cancer is access to evidence-based, personalised information for them and their healthcare providers to guide treatment and fertility-related decisions prior to cancer treatment. Current tools to predict fertility outcomes after breast cancer treatments are imprecise and do not offer individualised prediction. To address the gap, we are developing a novel personalised infertility risk prediction tool (FoRECAsT) for premenopausal patients with breast cancer that considers current reproductive status, planned chemotherapy and adjuvant endocrine therapy to determine likely post-treatment infertility. The aim of this study is to explore the feasibility of implementing this FoRECAsT tool into clinical practice by exploring the barriers and facilitators of its use among patients and healthcare providers. METHODS AND ANALYSIS: A cross-sectional exploratory study is being conducted using semistructured in-depth telephone interviews with 15-20 participants each from the following groups: (1) premenopausal patients with breast cancer younger than 40, diagnosed within last 5 years, (2) breast surgeons, (3) breast medical oncologists, (4) breast care nurses (5) fertility specialists and (6) fertility preservation nurses. Patients with breast cancer are being recruited from the joint Breast Service of three affiliated institutions of Victorian Comprehensive Cancer Centre in Melbourne, Australia-Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Royal Women's Hospital, and clinicians are being recruited from across Australia. Interviews are being audio recorded, transcribed verbatim and imported into qualitative data analysis software to facilitate data management and analyses. ETHICS AND DISSEMINATION: The study protocol has been approved by Melbourne Health Human Research Ethics Committee, Australia (HREC number: 2017.163). Confidentiality and privacy are maintained at every stage of the study. Findings will be disseminated through peer-reviewed scholarly and scientific journals, national and international conference presentations, social media, broadcast media, print media, internet and various community/stakeholder engagement activities.

Systematic differences between ultrasound and pathological evaluation of thyroid nodules: a method comparison study.

BACKGROUND: The size of thyroid nodules as measured by ultrasound (ultrasound size, USS) is routinely used in clinical decision-making. Reports of discrepancy between USS and pathological size (PS) evaluation have not analysed their systematic differences. The objective of this study was to uncover the lack of agreement (bias) between USS and PS measurements. METHODS: A retrospective study was performed on 121 patients who had a total or hemi-thyroidectomy for a solitary nodule. Ordinary least product regression was used to detect and distinguish constant and proportional bias in unidimensional size measurements between USS and PS evaluation. Three-dimensional volume measurements were compared in a subgroup of 31 patients. Pre-specified acceptable limits of interchange were defined as 20% difference. RESULTS: Ordinary least product regression demonstrated no constant or proportional bias between the two methods; regression equation: USS = (0.863) + (1.040) × PS. When nodules were grouped by size, discrepancies between the two methods were observed in nodules <10 mm (P = 0.004). However, potential overtreatment of patients with USS >10 mm but PS <10 mm only accounted for 4.1% of total patients. Subgroup analysis of volume measurements showed no bias between USS and PS evaluation. CONCLUSIONS: USS and PS measurements were interchangeable, as there was no evidence of constant or proportional bias between the two measurements. However, USS may misclassify the size for smaller nodules and potentially lead to unnecessary workup and treatment. Discrepancy in size measurements between USS and PS should be taken into account in clinical practice, particularly in smaller nodules.

Assessing the usefulness and acceptability of a low health literacy online decision aid about reproductive choices for younger women with breast cancer: the aLLIAnCE pilot study protocol.

BACKGROUND: Young women diagnosed with breast cancer may be confronted by many difficult decisions, especially around fertility preservation prior to commencing cancer treatment. The information to be conveyed is complex, and it may be difficult to weigh up the risks and benefits of the different fertility preservation options available. This complexity is compounded by the widespread low levels of literacy and health literacy in Australia, which may result in greater difficulties in understanding available health information and in decision-making. METHODS/DESIGN: A working group of experts have developed a fertility-related online decision aid for a low health literacy population, guided by health literacy principles. The decision aid will be pilot tested with 30 women diagnosed with early breast cancer between 5 years and 6 months previously. To be eligible, at the time of diagnosis, women must be between 18 and 40 years (inclusive), pre-menopausal, have no history of metastatic disease, have not completed their families, be able to give informed consent and have low health literacy. Participants will be asked to reflect back to the time in which they were diagnosed. Participants will complete a questionnaire before and after reviewing the decision aid to determine the feasibility, use and acceptability of the decision aid. The decision aid will be modified accordingly. Participants may also choose to review a previously developed (high literacy) decision aid and provide feedback in comparison to the low health literacy decision aid. DISCUSSION: This project represents the first study to develop an online fertility decision aid developed from low health literacy models in the context of breast cancer. It is anticipated that the low health literacy decision aid will be useful and acceptable to young women with low health literacy who have been diagnosed with breast cancer and that it will be preferred over the high literacy decision aid. TRIAL REGISTRATION: ACTRN12615001364561p.

Patient and medical barriers preclude uptake of tamoxifen preventative therapy in women with a strong family history.

AIMS: To assess the eligibility, uptake and impediments to tamoxifen use in high-risk women attending a risk management clinic due to family history. PATIENTS AND METHODS: All patients with a germline mutation in a cancer predisposing gene or at high genetic risk (based on family history) attending a Breast and Ovarian cancer risk management clinic from February 2014 to May 2015 received both verbal and written evidence-based information on preventive therapy and were recommended to consider endocrine prevention if not contraindicated. Endocrine therapy initiation, use and cessation were captured. Patient eligibility was analysed and reasons for declining, ceasing or contraindications for medication use were recorded. RESULTS: During the study period, 237 women were seen over 305 consultations for breast surveillance and preventative therapy discussion. They comprised 38 BRCA1 and 42 BRCA2 mutation carriers, 4 with Peutz-Jegher syndrome, 153 with a strong family history. Their median age was 39.4 years. Endocrine preventative was considered and discussed with all but 19 women. Of the remaining 218, 34 chose bilateral prophylactic mastectomy, while endocrine preventative was not recommended in 50 women due to contraindications and 25 women declined treatment due to their intention to fall pregnant. In 118 patients who remained eligible, 18.6% (22) tried prevention and 9.4% (14) remained on therapy. CONCLUSIONS: Physician-reluctance is not a dominant reason for poor uptake of endocrine prevention even by high-risk premenopausal women in a specialised risk management clinic. Many women are not eligible, and most elect for alternative options.

Practice patterns among thyroid cancer surgeons: implications of performing a prophylactic central neck dissection.

BACKGROUND: Indications for performing a prophylactic central neck dissection (pCND) in papillary thyroid cancer (PTC) remain controversial. It is unclear how identification of lymph node (LN) metastases should impact the decision to treat with radioactive iodine (RAI). The goals of this study were to identify indications for performing pCND and identify factors that predict the use of adjuvant RAI. METHODS: This was a population based cross-sectional analysis. A prospectively collected database identified 594 patients who underwent total thyroidectomy +/- CND. A multivariate model was constructed to identify indications for pCND and predictors of the use of RAI. RESULTS: 425 CNDs were performed of which 224 were prophylactic. Conventional risk factors (age, tumor size, extra-thyroidal extension) were not associated with performing a pCND. The presence of clinically suspicious lymphadenopathy was the only factor associated with performing CND, thus rendering the CND therapeutic. Positive LNs were retrieved in 39 % of pCND's, upstaging 87 patients. Among all peri-operative predictors of receiving RAI, presence of LN metastases was the strongest predictor [OR = 5.9 (3.7-9.5)], while tumor size was a modest predictor [OR = 1.8 (1.5-2.1)]. Other conventional risk factors did not predict use of adjuvant RAI. CONCLUSIONS: Conventional risk factors were not indications for performing a pCND, implying that the decision was based on individual surgeon preference. Performing pCND upstaged 39 % of patients from cN0 to pN1a, increasing the likelihood of receiving RAI 6-fold. Conventional risk factors were not predictors of receiving adjuvant RAI. This highlights the need for a unified approach to performing a pCND and administering RAI.

Extent of central neck dissection among thyroid cancer surgeons: Cross-sectional analysis.

BACKGROUND: It is unclear if surgeons are performing comprehensive central neck dissections for well-differentiated thyroid cancer. The purpose of this study was to determine mean lymph node retrieval in central neck dissection as well as variability across surgeons and institutions. METHODS: A prospectively collected database identified 18 surgeons performing 425 central neck dissections, 313 unilateral and 112 bilateral. Demographics, perioperative, and pathologic factors were analyzed. RESULTS: Mean lymph node yield was 7.4 and 11.9 for unilateral and bilateral central neck dissection, respectively. Although 224 central neck dissections were prophylactic, both total and pathologic lymph node yields were significantly higher in therapeutic central neck dissection. There was a significant variation in lymph node yield across individual surgeons, institutions, and regions. High-volume central neck dissection surgeons have significantly lower lymph node yield compared to low-volume surgeons. CONCLUSION: Central neck dissection seems to be performed adequately; however, there is a significant variation in lymph node yield. Future initiatives should try to standardize the central neck dissections performed, with emphasis on obtaining a sufficient yield. © 2015 Wiley Periodicals, Inc. Head Neck 38: E328-E332, 2016.

A population-based assessment of melanoma: Does treatment in a regional cancer center make a difference?

BACKGROUND: Regionalization of care to specialized centers has improved outcomes for several cancer types. We sought to determine if treatment in a regional cancer center (RCC) impacts guideline adherence and outcomes for patients with melanoma. METHODS: In Alberta, Canada, 561 patients with stage I-IIIC primary melanoma were diagnosed between January 2009 and December 2010. The electronic health record was used to capture demographic and pathologic data. Provincial guidelines for sentinel lymph node biopsy (SLNB) and wide local excision (WLE) are based on recommendations of several pre-existing guidelines including the National Comprehensive Cancer Network. RESULTS: 148 of 561 patients were identified as having been treated at a RCC. Median follow-up was 45 months. Patients treated at the RCC presented with higher stage melanomas. The RCC was more likely to follow guideline recommendations for performing SLNB (81.3% vs. 55.4%, P < 0.0001) but not for the extent of WLE (76.6% vs. 84.1%, P = 0.054). Overall survival was impacted by tumor thickness (HR 1.14, P < 0.0001), ulceration (HR 5.58, P < 0.0001), and mitoses (HR 0.59, P = 0.05). CONCLUSIONS: The RCC more closely followed guidelines for SLNB but not for WLE. Despite patients treated at the RCC presenting with a more advanced stage, overall survival and disease-free survival appear to not be affected by treatment center.

Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome) Following Total Laparoscopic Hysterectomy.

Rapid identification of acute colonic pseudo-obstruction (ACPO), or Ogilvie's syndrome, is paramount in the management of this condition, which, if unresolved, can progress to bowel ischemia and perforation with significant morbidity and mortality. We present the first case report, to our knowledge, of ACPO following total laparoscopic hysterectomy. We describe the presentation and management of ACPO in a patient who underwent uncomplicated total laparoscopic hysterectomy to treat menorrhagia and dysmenorrhea after declining conservative treatment. Following initial conservative management, the patient rapidly deteriorated and required laparotomy for clinically suspected cecal ischemia. Cecal resection, colonic decompression, and end ileostomy formation were performed. A brief review of the current literature is presented with respect to the case report.

Kikuchi-Fujimoto lymphadenitis imitating metastatic melanoma on positron emission tomography: a case report.

BACKGROUND: Accurate staging is critical for decision-making for the treatment of malignant conditions. Fluoro-deoxy-glucose positron emission tomography-computed tomography (FDG PET-CT) is a highly sensitive imaging modality for the assessment of distant metastases; however false positive results are possible due to its lower specificity with detection of other hypermetabolic pathologies. CASE PRESENTATION: A patient with high-risk thigh melanoma was staged with FDG PET-CT. Four ipsilateral inguinal nodes (three superficial, one deep) demonstrated intense hypermetabolic activity. Metastatic melanoma was confirmed in the largest superficial inguinal node with ultrasound-guided fine needle aspiration. Histopathology demonstrated metastatic melanoma in one superficial node and histiocytic necrotizing lymphadenitis, also known as Kikuchi-Fujimoto disease in five deep inguinal nodes. CONCLUSION: This case illustrates a false positive FDG PET-CT due to coincidental, synchronous melanoma and Kikuchi-Fujimoto disease in the same draining lymph node basin.

Isolated limb infusion: Efficacy, toxicity and an evolution in the management of in-transit melanoma.

BACKGROUND: Isolated limb infusion (ILI) delivers low-flow chemotherapy via percutaneous catheters to treat melanoma in-transit metastases. OBJECTIVE: To describe the experience of two regional referral centres with ILI. METHODS: A retrospective review of patients who underwent ILI between 2002 and 2012 was performed. Outcomes were measured using the WHO criteria for response, the Wieberdink toxicity score and long-term limb function using the Toronto Extremity Salvage Score (TESS). RESULTS: Fifty-two patients (mean age 66 years [range 27 to 90 years], female sex 65%, and lower [treated] limb in 86%) with 54 ILIs were reviewed. Wieberdink toxicity score was ≥3 in 21 (39%) procedures. Median follow-up was 18 months (range one to 117 months). Initial complete response (CR) was 29%, partial response 27%, stable disease 18% and progressive disease 27%. Predictors of better initial response were low disease burden and previous treatment. One or more treatments after ILI were common (65%). At 12 months, 19% of ILI patients had died from melanoma but 44% of surviving patients experienced limb CR. At 24 months, 57% of surviving patients experienced limb CR. The quality of life in the surviving, contactable patients according to the Toronto Extremity Salvage Score was 89%. CONCLUSION: Even if ILI does not result in CR for melanoma intransit metastases. it may slow disease progression as a single therapy, but more frequently in combination with other modalities.

HISTORIQUE: La perfusion d'un membre isolé (PMI) libère une chimiothérapie à faible dose par des sondes percutanées afin de traiter les métastases en transit des mélanomes. OBJECTIF: Décrire l'expérience de deux centres régionaux spécialisés à l'égard de la PMI. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective des patients qui ont subi une PMI entre 2002 et 2012. Ils ont mesuré les résultats à l'aide des critères de réponse de l'OMS, du score de toxicité de Wieberdink et de la fonction des membres à long terme selon le score de sauvetage des membres de Toronto (TESS). RÉSULTATS: Les chercheurs ont analysé le cas de 52 patients (âge moyen de 66 ans [plage de 27 à 90 ans], 65 % de femmes et jambe [traitée] dans 86 % des cas) ayant eu 54 PMI. Dans 21 (39 %) des interventions, le score de toxicité de Wieberdink s'élevait à 3 ou plus. Le suivi médian était de 18 mois (plage de un à 117 mois). La réponse complète (RC) initiale était de 29 %, la réponse partielle de 27 %, la stabilisation de 18 % et l'évolution de 27 %. Un faible fardeau de la maladie et un traitement antérieur étaient les prédicteurs d'une meilleure réponse initiale. Il était courant d'administrer au moins un traitement après la PMI (65 %). Au bout de 12 mois, 19 % des patients étaient décédés à cause du mélanome, mais 44 % des survivants présentaient une RC du membre. Au bout de 24 mois, 57 % des survivants présentaient une RC du membre. La qualité de vie des survivants non perdus au suivi s'établissait à 89 % d'après le TESS. CONCLUSION: Même si la PMI ne suscite pas une RC des métastases en transit des mélanomes, elle peut ralentir l'évolution de la maladie seule, mais surtout en association avec d'autres modalités.

Evaluating population-based breast cancer surgical practice in real time with a web-based synoptic operative reporting system.

BACKGROUND: A Web-based synoptic operative reporting system (WebSMR) incorporates implicit guidelines and real-time feedback of a surgeon's practice compared with provincial data. This study compares rates of total mastectomy (TM) between the overall provincial and WebSMR patients and examines decision-making factors in WebSMR patients. METHODS: Patients treated for invasive breast cancer (2007 to 2011) were identified from WebSMR and the Alberta Cancer Registry. Reports include surgery type and reasons for TM. RESULTS: Among 5,787 patients in WebSMR (2007 to 2011), TM rate decreased from 48% to 42% (P < .001). In 2011, the provincial cancer registry recorded a 56% TM rate compared to 42% in WebSMR patients. Patient preference accounted for 36% in the latter group. CONCLUSIONS: In WebSMR patients, TM rates were lower than the overall provincial rate and decreased significantly during the study period. Reasons are unclear, but guidelines and real-time feedback likely plays a role.

Predictors of treatment with mastectomy, use of sentinel lymph node biopsy and upstaging to invasive cancer in patients diagnosed with breast ductal carcinoma in situ (DCIS) on core biopsy.

BACKGROUND: There are few established indications for sentinel lymph node biopsy (SLNB) in breast ductal carcinoma in situ (DCIS). This study examines factors contributing to the high rate of SLNB in DCIS in Alberta, Canada. METHODS: Patients who underwent definitive surgery from January 2009 to July 2011 for DCIS diagnosed on preoperative core-needle biopsy were identified using a provincial synoptic operative report database (WebSMR). The relationship between baseline patient and tumor characteristics and treatment with total mastectomy (TM), use of SLNB, and upstaging were examined. RESULTS: There were 394 patients identified in the study cohort. Mean age was 57 years, and average preoperative tumor size was 3 cm. Overall, 148 patients (37.6 %) underwent TM; predictors were preoperative tumor size [odds ratio (OR), 1.92 per 1-cm increase in size; 95 % CI 1.65-2.24] and surgeon. Upstaging to invasive cancer at surgery occurred in 23 %, predicted only by preoperative tumor size (OR 1.14 per 1 cm; 95 % CI 1.03-1.27). SLNB was performed in 306 patients overall (77 %) and 140 of those treated with BCS (61 %). Predictors of SLNB were larger preoperative tumor size (OR 1.55 per 1 cm; 95 % CI 1.18-2.04) and the surgeon. In patients treated with BCS, 3 patients who were upstaged had positive SLNs (>0.2 mm), and no patients with DCIS had a positive SLN. CONCLUSIONS: SLNB use is high in patients undergoing BCS for DCIS. Tumor size and the operating surgeon predicted SLNB use. Despite a 23 % upstaging rate, the rate of clinically significant positive SLNs in patients treated with BCS is low, supporting omission of upfront SLNB.

Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision.

BACKGROUND: Mohs micrographic surgery (MMS) is an accepted treatment for nonmelanoma skin cancer and has an evolving role in melanoma. OBJECTIVE: To review oncologic outcomes of MMS and wide local excision (WLE) treatments for facial melanoma. METHODS AND MATERIALS: A retrospective review of patients with invasive melanoma of the face between 1997 and 2007 identified from the Alberta Cancer Registry (Canada) was performed. Outcome measures were local recurrence (recurrence <2 cm from excision scar), distant recurrence (regional or systemic), and disease-specific survival. RESULTS: One hundred fifty-one patients were available for analysis (60 MMS, 91 WLE). Median follow-up time was 48 months. The groups differed in tumor location and mitotic rate. Overall, there was no significant difference in 5-year local recurrence (7.9% WLE vs 6.2% MMS, p = .58), regional or systemic recurrence (18.8% vs 8.8%, p = 0.37) or disease-specific survival (82.8% vs 92.4%, p = .59). Breslow thickness was the only consistent predictor of local recurrence or other recurrence and disease-specific survival on multivariate analysis. Subset analysis of tumors with Breslow thickness less than 2 mm did not reveal any difference in outcomes. CONCLUSION: Mohs micrographic surgery has oncologic outcomes of local recurrence, distant recurrence and overall survival similar to those of WLE for invasive facial melanoma.

Quality indicators for ductal carcinoma in situ (DCIS) of the breast: development using a multidisciplinary delphi process and its use in monitoring population-based treatment.

BACKGROUND AND OBJECTIVES: Evaluation of the management of DCIS poses challenges, as standard breast cancer outcome measures such as mortality do not apply. We have developed quality indicators (QIs) to measure the quality of DCIS treatment in Alberta, Canada. METHODS: A modified Delphi process was used to determine QIs in the treatment of DCIS after review of evidence-based clinical practice guidelines. Patients diagnosed with DCIS from 2000 to 2001 (cohort 1) and 2009-2010 (cohort 2) were identified from the Alberta Cancer Registry and QIs were retrospectively abstracted. RESULTS: The expert panel developed eight QIs to assess the overall quality of care for DCIS patients. Five hundred eighty eligible patients were identified in the two cohorts. There was significant improvement in radiation oncology referral, radiation post lumpectomy and complete pathology reporting. Axillary staging significantly increased from 20% (axillary dissection in cohort 1) to 60% (sentinel node biopsy in cohort 2). Other QIs did not differ significantly. CONCLUSIONS: By developing QIs, performance measures for DCIS may assessed and compared over time. Although there have been significant improvements with pathology reporting and radiation oncology assessment and treatment, axillary staging rates are unexpectedly high, necessitating further investigation.

Primary small cell carcinoma of the breast with TTF-1 and neuroendocrine marker expressing carcinoma in situ.

Primary small cell carcinoma (SmCC) of the breast is very rare and may be difficult to distinguish from metastatic small cell carcinoma. Confident histopathological diagnosis of a primary breast SmCC requires the demonstration of an in situ component. We report a case of primary small cell carcinoma of the breast with coexisting carcinoma in situ in which the invasive carcinoma and in situ component both expressed neuroendocrine markers and Thyroid transcription factor-1 (TTF-1) by immunohistochemistry. Expression of neuroendocrine markers and TTF-1 in the in situ component allowed a highly confident diagnosis of primary small cell carcinoma of the breast. To our knowledge there is only one previous report of TTF-1 expressing in situ carcinoma associated with a primary SmCC of the breast.

Proximal esophageal amyloidoma presenting with life-threatening dysphagia.

Amyloidoses are abnormal deposits of insoluble proteins in tissues that can lead to tissue dysfunction. Although elderly patients often have amyloid deposition in the gastrointestinal tract, they are usually asymptomatic. When symptoms are present, they are most often functional in nature; rarely are they caused by a localized amyloid deposition (amyloidoma). We report the case of an elderly man who presented with severe dysphagia secondary to an upper esophageal amyloidoma. Unfortunately, the patient died of his disease before management could be instituted.

Outcomes of ERCP: prospective series from a rural centre.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the investigation and management of pancreaticobiliary disease. There is a recognized potential for significant morbidity, and a number of studies have identified patient and operator risk factors for the development of complications, including small case volume. We look at the outcomes of ERCP from a single operator at a rural centre and compare these with published figures. METHOD: Findings from 700 consecutive ERCP were collected prospectively between August 1997 and May 2006. Patients were included on an intention to treat basis, and all predetermined morbidity criteria were recorded. RESULTS: Five hundred and forty-four therapeutic and 156 diagnostic ERCP were included in the study. There were a total of 40 complications (5.71%), with three cases of ERCP-specific mortality (0.4%). The success of therapeutic intervention was 94.3%. CONCLUSIONS: The importance of comparing personal audit to published prospective studies has been emphasized. This has provided quality assurance finding, confirming that comparable success rates, morbidity and mortality are possible in a low-volume rural centre with an operator who has been properly trained and has ongoing ties with a tertiary hepatobiliary unit, a dedicated and skilled local team and suitable patient selection.