Cost-Effectiveness of Radar Localisation Versus Wire Localisation for Wide Local Excision of Non-palpable Breast Cancer.

BACKGROUND: Wire localisation (WL) is the "gold standard" localisation technique for wide local excision (WLE) of non-palpable breast lesions but has disadvantages that have led to the development of wireless techniques. This study compared the cost-effectiveness of radar localisation (RL) to WL. METHODS: This was a single-institution study of 110 prospective patients with early-stage breast cancer undergoing WLE using RL with the SCOUT® Surgical Guidance System (2021-2023) compared with a cohort of 110 patients using WL. Margin status, re-excision rates, and surgery delays associated with preoperative localisation were compared. Costs from a third-party payer perspective in Australian dollars (AUD$) calculated by using microcosting, break-even point, and cost-utility analyses. RESULTS: A total of 110 WLEs using RL cost a total of AUD$402,281, in addition to the device cost of AUD$77,150. The average additional cost of a surgery delay was AUD$2318. Use of RL reduced the surgery delay rate by 10% (p = 0.029), preventing 11 delays with cost savings of AUD$25,496. No differences were identified in positive margin rates (RL: 11.8% vs. WL: 17.3%, p = 0.25) or re-excision rates (RL: 14.5% vs. WL: 21.8%, p = 0.221). In total, 290 RL cases are needed to break even. The cost of WLE using RL was greater than WL by AUD$567. There was a greater clinical benefit of 1.15 quality-adjusted life-years (QALYs) and an incremental cost-utility ratio of AUD$493 per QALY favouring RL. CONCLUSIONS: Routine use of RL was a more cost-effective intervention than WL. Close to 300 RL cases are likely needed to be performed to recover costs of the medical device. CLINICAL TRIAL REGISTRATION: ACTRN12624000068561.

Avoiding unnecessary sentinel lymph node biopsy with the use of superparamagnetic iron oxide mapping agents (Magtrace®) in breast surgery.

BACKGROUND: Superparamagnetic iron oxide (SPIO) (Magtrace®) is a non-radioactive liquid tracer that can stay in the sentinel lymph nodes for 30 days. Injection of SPIO at time of primary breast surgery where upfront sentinel lymph node biopsy (SLNB) is not immediately indicated allows for a return to theatre if pathology then identifies invasive disease. SLNB is associated with paraesthesia, pain, seroma formation and lymphoedema risk. Hence, our study aims to assess the use of SPIO to avoid upfront SLNB in breast surgery for ductal carcinoma in situ (DCIS) and prophylaxis. METHODS: Retrospective single-centre study of consecutive patients who underwent injection of SPIO tracer at time of primary breast surgery to avoid upfront SLNB at Chris O'Brien Lifehouse, Sydney, NSW, Australia over a 10-month period. RESULTS: SPIO was injected 38 times, with 34 at time of mastectomy and four cases at time of wide local excision. The indication for surgery was DCIS in 18 cases, risk reduction in 17 cases and other indications in three patients. Six cases (15.8%) required delayed SLNB (D-SLNB) due to the finding of invasive disease on post-operative histopathology. All patients who underwent D-SLNB had nodes successfully localized with SPIO. CONCLUSION: In our cohort, 84.2% of cases were able to avoid upfront SLNB, and hence avoid the associated complications of SLNB. SPIO injection was successful in localizing the SLN in all cases at time of surgery for D-SLNB. This technique was safe with few associated complications.

Dermatofibrosarcoma protuberans of the breast in pregnancy.

Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive fibroblastic mesenchymal neoplasm, typically derived from the dermis, with the intramammary subtype being seen infrequently. We present a case of a 40-year-old woman whom was diagnosed with an intramammary DFSP during pregnancy, whom underwent successful surgical management during her second trimester. Our case demonstrates the importance of increased clinical awareness in the diagnosis and treatment of breast DFSP with careful multidisciplinary consideration.

Outcomes of adrenalectomy performed in regional New South Wales, Australia.

BACKGROUND: Centralization of subspeciality procedures in Australia is difficult due to a vast geographical span and in the appropriate patient group, surgery in regional centres should be considered. Our study reviews the safety of adrenalectomy performed at a low-volume regional centre in regards to length of hospital admission, operative time, complication rate and conversion to open rate. METHOD: A retrospective cross-sectional study was performed of consecutive patients undergoing laparoscopic or open adrenalectomy over a nine-year period (2012-2021) at Dubbo Base Hospital, a regional hospital in Western New South Wales, Australia. These operations were all performed by a single Urologist. RESULTS: Thirteen patients underwent adrenalectomy at our institution over the nine-year period. The mean age was 51.7 years (SD10.1). There were seven women (53.8%) and six men (46.2%). Seven patients were considered low risk, four patients were medium risk and two patients were high risk as per the Charlson Comorbidity Index. All of our patients were overweight, with mean body mass index of 34.6 (SD 6.9). Mean operating time was 133.5 min (SD 36.3) and mean length of stay was 3.8 days (SD 2.2). There was one conversion to open (8.3%). Three patients (23.1%) had complications, of these complications, one was Clavien-Dindo grade II, and one was Clavien-Dindo grade IIIb. There were no mortalities. CONCLUSION: Our outcomes demonstrate that adrenalectomy in our low volume regional centre is safe with comparable outcomes of operative time, length of hospital stay and complication rate with other centres.

Cutaneous Mucormycosis in an Immunocompetent Child following a Minor Skin Trauma.

Cutaneous mucormycosis is a rare infection by the Zygomycetes class of fungi, which carries significant morbidity and mortality. While typically associated in patients with underlying immunocompromise (especially in the current era of COVID-19), it may also be seen in immunocompetent patients. We report a case of a healthy 4-year-old girl with acute right leg cellulitis and abscess formation, who required surgical debridement following poor response to antibiotic therapy and initial incision and drainage. Tissue histopathology returned cutaneous zygomycosis despite negative tissue cultures. At four-week follow-up, her wound was healed well. Clinicians should maintain a high degree of clinical suspicion for cutaneous mucormycosis given its potential for rapidly progressive and disseminated disease. Currently, the mainstay of diagnostic investigations is tissue histopathology, with a growing role for tissue fungal PCR. Treatment involves multidisciplinary management between surgeons and Infectious Diseases team to guide the role for surgical debridement and antifungal therapy.

Risk of bias judgements and strength of conclusions in meta-evidence from the Cochrane Colorectal Cancer Group.

BACKGROUND: The Cochrane Collaboration records risk of bias (ROB) judgements on the original studies it analyses. The aim of this review is to perform an audit of all literature produced by the Cochrane Colorectal Cancer Group (CCCG), focusing on whether intervention type has any relationship with ROB and the ability of a review to inform clinical practice. METHODS: The most recent version of every CCCG review from January 2000 to the end of July 2018 was included. Conclusions were categorized as informing clinical practice (I) or not (N). Both I and N categories were divided into firm (F) or tempered (T) based on the definitiveness of their language. ROB judgements were aggregated. Reviews were classed as Medical (M), Surgical (S), Medical & Surgical (MS) or Other (O) based on their intervention, with O reviews then excluded. Data were analyzed in SPSS. RESULTS: Ninety-five reviews were included, covering 1892 studies. Sixty-two percent (n = 59/95) informed clinical practice (I). Thirty-eight percent (n = 36/95) did not inform clinical practice (N). Of the N group, 53% (n = 19/36) were completely equivocal (firm) while 47% (n = 17/36) were moderately so (tempered). In the I group, 46% (n = 27/59) gave a conclusion that was firm and 54% (n = 32/59) were tempered. Seven thousand five hundred sixty-four cases of bias were assessed. Risk of bias was low in 43%, high in 20% and unclear in 37%. A review that regarded a medical intervention alone was significantly more likely to be comprised of studies with a low risk of bias than a review that included a surgical intervention (p < 0.001). CONCLUSION: The Cochrane Colorectal Cancer Group finds the risk of bias to be low in less than half of its judgements. A review that included a surgical intervention was less likely to display low risk of bias. Risk of bias was associated with whether a review informed clinical practice, but intervention type was not. Readers of colorectal literature should be cautious when considering original and meta-evidence in this field, particularly where a surgical intervention is assessed.

Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery.

BACKGROUND: Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy. OBJECTIVE: This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications. DESIGN AND SETTING: This is a retrospective cross-sectional study conducted at a single quaternary referral center. PATIENTS: Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included. MAIN OUTCOME MEASURES: The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism. RESULTS: One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38-3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67-5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37-6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47-4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04-4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11-49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications. LIMITATIONS: This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period. CONCLUSIONS: One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. "High-risk" patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these "high-risk" patients. See Video Abstract at http://links.lww.com/DCR/A747.