Should cavity shave margins be performed as a routine in breast conserving surgery? A review of randomised controlled trials

Breast conserving surgery (BCS) is the standard of care for women with early breast cancer. The margin status is crucial in breast conserving surgery and is an important determinant for local recurrence. Local recurrence is associated with decreased overall and disease-free survival. Several studies have shown that cavity shave margin reduces the rate of positive margins and local recurrence. This review analyses the randomised controlled trials to compare the role of cavity shave margin in breast conserving surgery and its effect on positive margins and re-excision rates. Methods A systematic search of literature published before December 2016 for randomised controlled trials in MEDLINE, Pubmed, EMBASE, Proquest, Cochrane central register of controlled trials and Google scholar was peformed. Out of 12 articles 2 randomised controlled trials were eligible. Positive margins and re-excision rates were analysed using odds ratio and risk difference. Results Out of 12 studies, 2 were suitable for review. Overall positive margins were 18.3% and 36% in the CSM and No-CSM groups respectively, with an odds ratio of 0.373 (95% CI, 0.189 to 0.739, P = 0.232) and risk difference of -0.194 (95% CI, -0.336 to -0.053, P= 0.198). The re-excision rates were lower in the CSM group when compared to the No-CSM group (12.2% vs 31.3%) with an odds ratio of 0.28 (95% CI, 0.160 to 0.520, P=0.578) and risk difference was -0.199 (95% CI, -0.309 to -0.089, P=0.264). Conclusion Analysis of the randomised controlled trials showed that cavity shave margins significantly reduced the risk of positive margins and the need for re-excision. It is a beneficial technique in women undergoing lumpectomy and breast conserving surgery. Keywords: Early breast cancer, breast conserving surgery, cavity shave margins

Vitamin D deficiency in a man with multiple myeloma

CONTEXT Vitamin D deficiency is extremely common in multiple myeloma, and it represents a surrogate for clinical multiple myeloma disease status. Patients may complain of dull, persistent, generalized musculoskeletal aches and pains with fatigue or decrease in muscle strength. CASE REPORT A 63 year old male with multiple myeloma on Bortezomib presented with worsening generalized musculoskeletal pain, weakness, and multiple falls. On initial examination he was pale with a depressed affect. He had resting tremor, generalized bony tenderness, worse on movement and weight bearing, muscle weakness, and a waddling gait. His bone studies showed features of osteomalacia with a very low Vitamin D level of less than 20 nmol/L. He was treated with 3000 units of Vitamin D daily and physiotherapy. After 4 months, although his multiple myeloma deteriorated, there was a significant decrease in his generalized musculoskeletal pain. CONCLUSIONS This case highlights that vitamin D deficiency is common in patients with multiple myeloma, and can cause generalized musculoskeletal pain and increase the risk of falls, yet it often goes unrecognized. In patients with non-specific musculoskeletal pain, and inadequate sun-exposure medical practitioners must have a high index of suspicion for vitamin D deficiency

Solid papillary carcinoma of the breast: A review

Solid papillary carcinoma of breast is a low-grade tumour originating in the ductal epithelium. It is commonly seen in post-menopausal women and account for <1% of all breast cancers. Patients can be asymptomatic, have nipple discharge or present with abnormal mammographic findings. Despite of some radiological features solid papillary carcinoma cannot be accurately diagnosed on imaging alone. The most important characteristic of this tumour is its behaviour and interesting pathological feature of lack of myoepithelial cells at the periphery. Its diagnosis can be challenging and its management is still debated. Management varies from breast conserving surgery to mastectomy. Currently there is no evidence to support the role of sentinel lymph node biopsy, radiotherapy and hormonal therapy. Therefore, accurate diagnosis with adequate local excision with breast conserving surgery is the optimal treatment

Percutaneous Emergency Needle Caecostomy for Prevention of Caecal Perforation

Caecal perforation is a life-threatening complication of large bowel obstruction with a reported mortality of 34% to 72%. This case describes the novel use of percutaneous needle caecostomy as a life-saving measure to prevent imminent caecal perforation in a 68-year-old lady with large bowel obstruction secondary to an incarcerated incisional hernia. After careful review of computed tomography images and measurement of distances from the abdominal wall to the caecum, the patient’s caecum was decompressed in the emergency department using a needle under local anaesthetic. The patient subsequently underwent laparoscopic hernia repair and had an uncomplicated recovery. When conducted safely and with precision in an appropriate patient, percutaneous needle caecostomy can provide immediate symptom relief, reduce risk of caecal perforation, and allow a laparoscopic surgical approach