Evaluating the Necessity for Routine Sentinel Lymph Node Biopsy in Postmenopausal Patients Being Treated for Clinically Node Negative Breast Cancer the Era of RxPONDER.

INTRODUCTION: Traditionally, sentinel lymph node biopsy (SLNB) was performed to inform adjuvant chemotherapy prescription and prognosis in breast cancer. Following RxPONDER, the OncotypeDX Recurrence Score (RS) guides adjuvant chemotherapy prescription for all postmenopausal patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative (ER+/HER2-) breast cancer with 0 to 3 positive lymph nodes (0-3 + LN). AIMS: To establish the oncological safety of omitting SLNB in postmenopausal patients with ER+/HER2- breast cancer indicated to undergo SLNB and to evaluate the primary determinants of chemotherapy prescription for these patients. PATIENTS AND METHODS: A retrospective cohort study was undertaken. Cox regression and Kaplan-Meier analyses were performed. Data analytics was performed using SPSS v26.0. RESULTS: Five hundred and seventy five consecutive patients were included (mean age: 66.5 years, range: 45-96). The median follow-up was 97.2 months (range: 3.0-181.6). Of the 575 patients, just 12 patients had positive SLNB (SLNB+) (2.1%). Using Kaplan-Meier analyses, SLNB+ failed to impact recurrence (P = .766) or mortality (P = .310). However, using Cox regression analyses, SLNB+ independently predicted poorer disease-free survival (hazard ratio: 1.001, 95% confidence interval (95% CI): 1.000-1.001, P = .029). Logistic regression analysis identified RS as the sole predictor of chemotherapy prescription (odds ratio: 1.171, 95% CI: 1.097-1.250, P < .001). CONCLUSION: Omitting SLNB may be safe and justifiable in postmenopausal patients with ER+/HER2- breast cancer with clinically negative axillae. Following RxPONDER, RS is the most important guide of chemotherapy use in these patients and SLNB may be less important than previously perceived. Prospective, randomized clinical trials are required to fully establish the oncological safety of omitting SLNB in this setting.

Appendicitis-related acute referrals to Children's Health Ireland from Non-Specialist Paediatric Surgical Centres.

BACKGROUND: Acute appendicitis is the most common surgical emergency in children. Eighty percent of paediatric appendicectomies are performed by adult general surgeons on an annual basis. The remaining 20% are performed at Children's Health Ireland (CHI) centres. Occasionally patients are transferred from Non-Specialist Paediatric Surgical Centres (NSPSC) for specialised pre-operative or post-operative care. AIM: To assess the rates of and characterise appendicitis-related referrals to CHI at Crumlin from NSPSC. METHODS: A retrospective review of all appendicitis-related transfers to CHI at Crumlin between January 2020 and December 2021 was performed. Data relating to indications for transfer, referring hospital level, patient demographics, management, type of surgery, length of stay (LOS), and radiological studies were collected and analysed. RESULTS: Seventy-two patients were transferred to CHI at Crumlin over the 2-year period. A total of 60.9% were male, mean age 9 ± 4.3 years, mean LOS 6.0 ± 2.2 days (range 1-30 days). Nineteen percent were under 5 years of age. Seventy-three percent were transferred from level 4 centres. Ninety-seven percent were transferred pre-operatively, 25% of those transferred pre-operatively had imaging in CHI confirming appendicitis. Fifty-five percent (40/72) of patients had pre-operative imaging performed. A total of 37.5% (15/40) confirmed complicated appendicitis. Twenty percent (8/40) underwent both ultrasound and computerised tomography (CT) at the referring centre. A total of 2.7% (2/72) were transferred with known co-morbidities. Ninety-two percent (66/72) underwent appendicectomy. Eight percent (6/72) were managed non-operatively (NOM) - 2 failed NOM, 2 underwent interval appendicectomy. Of those managed operatively, 76% (50/66) underwent laparoscopic appendicectomy, and 24% (16/66) were performed open. CONCLUSION: The majority of paediatric appendicectomies are performed at Non-Specialist Paediatric Surgical Centres. It is vital to maintain this working relationship so that specialist paediatric centres are available to provide care to complex paediatric patients.

Clinically guided core biopsy and cutaneous punch biopsy in the evaluation of breast lesions: a necessary test or an obsolete skill?

OBJECTIVE: The vast majority of breast cancers are diagnosed via image-guided procedures yet despite significant advances, imaging does not identify all breast malignancies. Clinically suspicious breast lesions with normal breast imaging remain a cause for concern. The aim of this study is to determine the diagnostic value of clinical core and cutaneous punch biopsies in the diagnosis of breast malignancy in clinically suspicious lesions with normal breast imaging. METHODS: All patients with suspicious clinical breast findings and normal imaging who underwent a clinical core and/or cutaneous punch biopsy from 2012 to 2019 were reviewed retrospectively. Patients with subsequent breast malignant diagnosis were analysed. RESULTS: A total of 283 biopsies (166 clinical core, 117 cutaneous punch) performed over the 7-year period were included in the analysis. A total of 263/283 (93%) yielded a benign outcome. A total of 2/283 (0.7%) yielded B3 lesions (probably benign). These lesions were benign on final surgical excision. A total of 18/283 (6.3%) yielded a malignant histopathology. Sixteen out of 18 were cutaneous punch biopsies, and 2/18 were clinical core biopsies. A total of 14/18 patients presented with nipple changes, while 4/18 had a palpable area of concern. Histopathological analysis demonstrated Paget's disease of the nipple in 8/18, invasive carcinoma in 9/18 out of which two represented a recurrence of breast malignancy. Cutaneous squamous cell carcinoma was diagnosed in 1/18. CONCLUSION: Clinical core and cutaneous punch biopsies remain a valuable tool in the diagnosis of breast cancer particularly in the management of clinically suspicious radiographically occult malignancies.

Comparison of the Nottingham Prognostic Index and OncotypeDX© recurrence score in predicting outcome in estrogen receptor positive breast cancer.

INTRODUCTION: Traditionally, Nottingham prognostic index (NPI) informed prognosis in patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative, node negative (ER+/HER2-/LN-) breast cancer. At present, OncotypeDX© Recurrence Score (RS) predicts prognosis and response to adjuvant chemotherapy (AC). AIMS: To compare NPI and RS for estimating prognosis in ER + breast cancer. METHODS: Consecutive patients with ER+/HER2-/LN- disease were included. Disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier and Cox regression analyses. RESULTS: 1471 patients met inclusion criteria. The mean follow-up was 110.7months. NPI was calculable for 1382 patients: 19.8% had NPI≤2.4 (291/1471), 33.0% had NPI 2.41-3.4 (486/1471), 30.0% had NPI 3.41-4.4 (441/1471), 10.9% had NPI 4.41-5.4 (160/1471), and 0.3% had NPI>5.4 (4/1471). In total, 329 patients underwent RS (mean RS: 18.7) and 82.1% had RS < 25 (270/329) and 17.9% had RS ≥ 25 (59/329). Using multivariable Cox regression analyses (n = 1382), NPI independently predicted DFS (Hazard ratio (HR): 1.357, 95% confidence interval (CI): 1.140-1.616, P < 0.001) and OS (HR: 1.003, 95% CI: 1.001-1.006, P = 0.024). When performing a focused analysis of those who underwent both NPI and RS (n = 329), neither biomarker predicted DFS or OS. Using Kaplan Meier analyses, NPI category predicted DFS (P = 0.008) and (P = 0.026) OS. Conversely, 21-gene RS group failed to predict DFS (P = 0.187) and OS (P = 0.296). CONCLUSION: In our focused analysis, neither NPI nor RS predicted survival outcomes. However, in the entire series, NPI independently predicted both DFS and OS. On the 40th anniversary since its derivation, NPI continues to provide accurate prognostication in breast cancer, outperforming RS in the current study.

Documentation of chaperone presence in breast clinic, a complete audit cycle.

OBJECTIVE: The General Medical Council (GMC) and Irish Medical Council (IMC) recommend the presence of a chaperone for all intimate examinations and that it should be clearly documented. The aim of this report is to assess doctors' compliance with obtaining a chaperone and documenting their presence, determining possible causes of non-compliance and implement interventions to increase compliance. METHODS: Prospective audit of patients seen in the breast clinic in Beaumont hospital over the week starting 8th February 2021. The medical charts were reviewed for documentation of chaperone presence. Doctors were surveyed using (SurveyMonkey) for causes of non-compliance. Interventions included a stamp in the medical notes for chaperone presence and details, an educational email with GMC and IMC guidelines, and posters put up in clinic rooms. The intervention was reassessed at 1-week and 6-week intervals. RESULTS: In the assessment phase, 126 patients were recruited. A chaperone was present 100% of the time where a male doctor examined a female patient; however, chaperone presence was not documented in any of the medical charts (0/126). A survey was sent to 22 breast surgery doctors to explore causes of non-compliance. Response rate was 95%, 50% did not know documentation was necessary, and 25% forgot to document. One week after intervention, 64 patients were recruited. Chaperone documentation increased to 80% (51/64). Reassessment at six weeks included 120 patients, and chaperone documentation rate was 74% (89/120).

The histopathological and molecular features of breast carcinoma with tumour budding-a systematic review and meta-analysis.

PURPOSE: Tumour budding (TB) is an adverse histological feature in many epithelial cancers. It is thought to represent epithelial-mesenchymal transition, a key step in the metastatic process. The significance of TB in breast carcinoma (BC) remains unclear. The aim of this study is to investigate the relationship between TB and other histological and molecular features of BC. METHODS: A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Der Simonian-Laird method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS). RESULTS: Seven studies with a total of 1040 patients (high-grade TB n = 519, 49.9%; low-grade/absent TB n = 521, 50.1%) were included. A moderate to high risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node metastasis (OR 2.32, 95% c.i. 1.77 to 3.03, P < 0.001) and lymphovascular invasion (OR 3.08, 95% c.i. 2.13 to 4.47, P < 0.001). With regard to molecular subtypes, there was an increased likelihood of high-grade TB in oestrogen (OR 1.66, 95% c.i. 1.21 to 2.29, P = 0.002) and progesterone receptor-positive (OR 1.48, 95% c.i. 1.09 to 2.02, P = 0.01) tumours. In contrast, triple-negative breast cancer had a reduced incidence of high-grade TB (OR 0.46, 95% c.i. 0.30 to 0.72, P = 0.0006). CONCLUSION: High-grade TB is enriched in hormone receptor-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic process of BC.

Should all paediatric appendicectomies be performed in a specialist or high-volume setting?

INTRODUCTION: Acute appendicitis is a common surgical emergency in children. The majority of appendicectomies in children are performed by general surgeons, rather than specialist paediatric surgeons. AIM: To assess the impact of hospital specialization, hospital volume, and surgeon volume on outcomes for children undergoing appendicectomy in Ireland. METHODS: NQAIS (National Quality Assurance and Improvement System) data for all appendicectomies performed on children in Ireland between January 2014 and November 2017 was examined. Hospitals were categorized as specialist paediatric centres (SPCs), high-volume general (HVGHs), moderate-volume general (MVGHs), or low-volume general (LVGHs) by annual case volume. Similarly, surgeons were categorized as high-volume (HVSs), moderate-volume (MVSs), or low-volume (LVSs) by annual volume. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care, and readmission rates were collected and analysed. RESULTS: About 9593 appendicectomies were performed in 21 hospitals by 134 surgeons. Patients in SPCs had lowest overall rates of laparoscopic surgery (48% v 66% (HVGHs) v 70% (MVGHs) v 57%(LVGHs), p < 0.001). In SPCs 30-day readmission rates were lower for younger children (5.3% for 5-8-year olds v 6.7% (HVGHs) v 7.3%(MVGHs) v 10.5% (LVGHs), p = 0.023). HVSs performed more laparoscopic appendicectomies on younger patients (0-4 years: 40% v 6% (MVSs) v 17%(LVSs), p < 0.001) but performed the least on older children (13-16 years: 76% v 82%(MVSs) v 82%(LVSs), p < 0.001). CONCLUSION: Children younger than 8 years undergoing appendicectomy in HVGHs or SPCs, or by HVSs, have marginally better outcomes. In older children, marginally shorter in-hospital stays and higher laparoscopic rates are seen in those looked after outside of high-volume or specialist units. Our results show that nonspecialist centres provide an essential, and safe, service to paediatric patients with acute appendicitis.

Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines.

BACKGROUND/AIMS: Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy. METHODS: A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)). RESULTS: Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy. CONCLUSIONS: There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.