Background Ductal carcinoma in situ (DCIS) is associated with risk of positive resection margins following breast-conserving surgery (BCS) and subsequent reoperation. Prior reports grossly underestimate the risk of margin positivity with IBC containing a DCIS component (IBC + DCIS) due to patient-level rather than margin-level analysis. Objective The aim of this study was to delineate the relative risk of IBC + DCIS compared with pure IBC (without a DCIS component) on margin positivity through detailed margin-level interrogation. Methods A single institution, retrospective, observational cohort study was conducted in which pathology databases were evaluated to identify patients who underwent BCS over 5 years (2014–2019). Margin-level interrogation included granular detail into the extent, pathological subtype and grade of disease at each resection margin. Predictors of a positive margin were computed using multivariate regression analysis. Results Clinicopathological details were examined from 5454 margins from 909 women. The relative risk of a positive margin with IBC + DCIS versus pure IBC was 8.76 (95% confidence interval [CI] 6.64–11.56) applying UK Association of Breast Surgery guidelines, and 8.44 (95% CI 6.57–10.84) applying the Society of Surgical Oncology/American Society for Radiation Oncology guidelines. Independent predictors of margin positivity included younger patient age (0.033, 95% CI 0.006–0.060), lower specimen weight (0.045, 95% CI 0.020–0.069), multifocality (0.256, 95% CI 0.137–0.376), lymphovascular invasion (0.138, 95% CI 0.068–0.208) and comedonecrosis (0.113, 95% CI 0.040–0.185). Conclusions Compared with pure IBC, the relative risk of a positive margin with IBC + DCIS is approximately ninefold, significantly higher than prior estimates. This margin-level methodology is believed to represent the impact of DCIS more accurately on margin positivity in IBC.

Background Following therapeutic mammoplasty (TM), the contralateral breast may require a later balancing procedure to optimize shape and symmetry. The alternative is to offer patients simultaneous TM with immediate contralateral symmetrization via a dual-surgeon approach, with the goal of reducing costs and minimizing the number of subsequent hospital appointments in an era of COVID-19 surges. The aim of this cost-consequence analysis is to characterize the cost-benefit of immediate bilateral symmetrization dual-operator mammoplasty versus staged unilateral single operator for breast cancer surgery. Method A prospective single-centre observational study was conducted at an academic teaching centre for breast cancer surgery in the UK. Pseudonymized data for clinicopathological variables and procedural care information, including the type of initial breast-conserving surgery and subsequent reoperation(s), were extracted from the electronic patient record. Financial data were retrieved using the Patient-Level Information and Costing Systems. Results Between April 2014 and March 2020, 232 women received either immediate bilateral (n = 44), staged unilateral (n = 57) for breast cancer, or unilateral mammoplasty alone (n = 131). The median (interquartile range (i.q.r.)) additional cost of unilateral mammoplasty with staged versus immediate bilateral mammoplasty was euro5500 (euro4330 to euro6570) per patient (P < 0.001), which represents a total supplementary financial burden of euro313 462 to the study institution. There was no significant difference between groups in age, Charlson comorbidity index, operating minutes, time to adjuvant radiotherapy in months, or duration of hospital stay. Conclusion Synchronous dual-surgeon immediate bilateral TM can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity. Synchronous dual-surgeon immediate bilateral therapeutic mammoplasty can deliver safe immediate symmetrization and is financially beneficial, without delay to receipt of adjuvant therapy, or additional postoperative morbidity in breast conservation.

This is a cohort study including 283 patients who underwent breast and urological procedures in three UK centres during the peak of COVID-19. COVID-related 30-day mortality was zero, as well as COVID-related admissions. Only 12 patients developed COVID-19 symptoms, although none had a positive COVID swab. Non-emergency surgery for breast and urological conditions was safe during the peak of the COVID-19 pandemic, provided contemporaneous safety measures were followed.

Introduction: For patients requiring level II breast conserving surgery, immediate contralateral symmetrisation seeks to reduce the psychological impact of asymmetry and improve quality of life. In a SARS-CoV-2 era of value-based care, the aim of this study was to investigate the patient level cost impact of unilateral (+/- staged) single operator versus bilateral immediate symmetrisation dual operator mammoplasty.

The coronavirus disease-2019 pandemic has had a significant impact on the delivery of surgical services, particularly reconstructive surgery. This article examines the current evidence to assess the feasibility of recommencing immediate breast reconstruction services during the pandemic and highlights considerations required to ensure patient safety.

Introduction: Re-operative intervention due to close positive margins (PM) following Breast Conserving Surgery (BCS) carries human and economic burden. The mean rate of re-operation in England is 20%, impalpable tumours, such as ductal carcinoma in situ (DCIS) pose a greater threat (29.5%). We aimed to examine the predictors of PM at our institution to determine clinicopathological factors that influence re-operation.

The coronavirus disease-2019 pandemic has had a significant impact on the delivery of surgical services, particularly reconstructive surgery. This article examines the current evidence to assess the feasibility of recommencing immediate breast reconstruction services during the pandemic and highlights considerations required to ensure patient safety. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Introduction: Margin involvement increases local recurrence rates therefore re-excision is recommended, however in 50% no residual tumour is found. We suspect, despite suture orientation of breast specimens, subsequent margin disorientation may occur. The aim was to determine if intra-operative marking sutures correlate with correct margin identification in the pathology laboratory.

IntroductionThe aim of this study was to determine the ability of MRI to identify and assess the extent of disease in patients with pathological nipple discharge (PND) with an occult malignancy not evident on standard pre-operative evaluation with mammography and ultrasound.MethodsPatients presenting to the breast unit of Imperial College Healthcare NHS Trust between December 2009 and December 2018 with PND and normal imaging were enrolled in the study. Pre-operative bilateral breast MRI was performed in all patients as part of our protocol and all patients were offered diagnostic microdochectomy.ResultsA total of 82 patients fulfilled our selection criteria and were enrolled in our study. The presence of an intraductal papilloma (IDP) was identified as the cause of PND in 38 patients (46.3%), 14 patients had duct ectasia (DE-17%) and 5 patients had both an IDP and DE. Other benign causes were identified in 11 patients (13.4%). Despite normal mammography and ultrasound a malignancy was identified in 14 patients (17%). Eleven patients had DCIS (13.4%), two had invasive lobular carcinoma and one patient had an invasive ductal carcinoma. The sensitivity of MRI in detecting an occult malignancy was 85.71% and the specificity was 98.53%. The positive predictive value was 92.31% and the negative predictive value was 97.1%.ConclusionsAlthough a negative MRI does not exclude the presence of an occult malignancy the high sensitivity and specificity of this diagnostic modality can guide the surgeon and alter the management of patients with PND.

Introduction: CPM has no proven survival advantage in sporadic BC, and when coupled with autologous reconstruction has major resource implications and morbidity. Arguably, CPM should be reserved for patients with high contralateral breast cancer risk (CBRC) [NICE threshold:>30% lifetime risk]. We aimed to evaluate the impact of BODICEA CBCR calculations versus survival predictions (PREDICT) on retrospective decision-making for CPM, within confines of service evaluation.

Patients with sporadic breast cancer (BC) have low contralateral breast cancer risk (CLBCR; approximately 0.7% per annum) and contralateral prophylactic mastectomy (CPM) offers no survival advantage. CPM with autologous reconstruction (AR) has major morbidity and resource implications.

Introduction: Acute mastitis and/or breast abscess are frequently managed by non-specialist Accident and Emergency staff and General Surgeons on-call. Sub-optimal practice includes variable antibiotic prescribing, unnecessary/prolonged hospitalisation, lack of ultrasound assessment/aspiration, frequent surgical drainage, inconsistent follow-up and significant diagnoses being missed. The objective was to evaluate management across a multi-site NHS Trust and address deficiencies with a ‘best-practice’ algorithm, encompassing National Institute for Health and Care Excellence (NICE) and Guidelines and Audit Implementation Network (GAIN) recommendations.

BACKGROUND:High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS.METHODS:The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.RESULTS:The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).CONCLUSION:The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

Introduction: Bilateral mastectomy (BM) and addition of reconstruction is thought to increase the risk of complications when compared to unilateral mastectomy and reconstruction (UM) alone.

Introduction: For patients with sporadic breast cancer, rates of contralateral cancer are low (0.7%/annum) and there is no evidence to suggest contralateral prophylactic mastectomy (CPM) offers survival advantage. However, CPM with autologous reconstruction has major resource implications. The aim was to review the implications of bilateral reconstructive surgery in patients with unilateral breast cancer.

Introduction: Free hand clinical biopsy (FHCB) and FNA aims to avoid missing radiologically occult breast cancers but is associated with laboratory processing. The aim was to assess the diagnostic performance of clinical FHCB/FNA for patients presenting with a palpable abnormality and normal imaging.