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Transformation of differentiated thyroid cancer into poorly differentiated carcinoma is rare. This report describes a case in which preoperative fine needle aspiration suggested a squamous cell carcinoma whereas needle core biopsy favoured an undifferentiated carcinoma of probable thyroid origin. Histology of the subsequent total thyroidectomy specimen revealed a biphasic tumour comprising areas of tall cell papillary carcinoma merging with moderately to poorly differentiated squamous cell carcinoma. The immunohistochemical findings are discussed in detail.

International audienceAxillary nodal status is the most important prognostic indicator which in turn influences adjuvant therapy and long term outcomes. The aim of this study was to compare total nodal yields from primary axillary lymph node dissection (pALND) with completion ALND after a cancer positive SLNB: either concurrently (cALND) following intra-operative assessment (IOA) of the SLN's or as a delayed procedure (dALND) when the SLN was found to be cancer positive on post operative histological examination

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Introduction: Intra-operative assessment of sentinel nodes (SLNs) allows immediate completion axillary dissection (cALND) in breast cancer patients. Molecular assessment such as one-step nucleic acid amplication (OSNA) promises greater sensitivity and provides a more accurate quantitative assessment than traditional methods. Our unit policy is to proceed to cALND in patients with macrometastases but not for micrometastases. However, evidence of upstaging has led us to seek to raise the threshold for proceeding to cALND. The CK19 mRNA copy number is an expression of the metastatic burden in the SLN and may be related to the presence of additional disease in the cALND. Since the original copy number threshold between micro (250–5000 copies/microliter) and macrometastasis (>5000 copies/microliter) was based on few patients and serial pathological sections, we investigated the mRNA copy number in patients with and without additional disease in the cALND. Methods: All patients in our unit undergo pre-operative axillary ultrasound with fine needle aspiration cytology of any suspicious nodes. Those with malignant cytology proceed directly to ALND. Radiologically and cytologically node negative patients undergo sentinel lymph node biopsy (SLNB) and OSNA. Electronic records of consecutive patients with invasive breast cancer undergoing SLNB with OSNA from August 2011 to March 2012 were retrospectively reviewed. Two parameters of mRNA copy number were examined: Copy number of the highest copy number SLN and the summed copy numbers of all positive SLNs. Their relationship to the presence of further disease in the axilla was examined using Student's t test. Results: Of 201 SLNBs, 45 (22%) had macrometastasis-positive OSNA and therefore underwent cALND (1 patient declined). Twenty patients (45%) had no further positive nodes (a negative cALND) with a total axillary metastatic burden of 1–2 in 11–27 nodes. Twenty four (55%) showed further disease (a positive cALND) with a burden of 2–20 in 9–30 nodes, including the SLNs. There was no significant difference in tumour size or grade between patients with additional positive nodes in the cALND compared with those with no further disease. There was no significant difference in the copy number of the highest copy number positive SLN (p = 0.44) or in the summed copy number of all positive SLNs (p = 0.36) between the cALND positive and negative groups. Conclusion: OSNA CK19 mRNA copy number does not correlate with the cALND metastatic burden. Therefore, raising the copy number threshold may be too simplistic as a method to better select patients with high probability of a positive cALND. A predictive model will be derived based on multivariate analysis of the larger patient population (>400 patients) that will have undergone SLNB with OSNA by the time of SABCS. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-11.

Monteggia and Galeazzi fractures both result from falls onto the outstretched and pronated forearm 2. Bado 3 classi®ed Monteggia fractures into four types, of which type 1 (anterior dislocation of the radial head) is by far the commonest. This was the direction of dislocation in our case. In the single reported case of a combined fracture, in a child, treatment was by closed manipulation of the arm followed by plaster immobilization for 8 weeks; the outcome was good 1. For best functional results, however, Monteggia and Galeazzi fractures should usually be treated by anatomical reduction and internal ®xation 4. Close observation and elevation is essential, since neurovascular complications can develop at the time of the injury or later as a consequence of compartment syndrome. It should be remembered that a fracture involving both forearm bones will be associated with substantial soft-tissue injury. Wounds should be closed without tension to allow for postoperative tissue swelling; or, if this is not possible, they should be left open for subsequent delayed closure or skin grafting. On occasion, fasciotomy and carpal tunnel release will be indicated.

Introduction Doctors who are diagnosed with breast cancer make up a small but unique subset of women owing to their medical knowledge. Anecdote suggests that doctors with breast cancer are more likely to opt for mastectomy than non-medically qualified patients. The primary aim of this study was to compare mastectomy rates in medically-qualified doctors with degree-educated controls with breast cancer. Methods Research ethics approval was obtained. Patients diagnosed with breast cancer between 1/1/2006 and 31/12/2011 and who had signed a generic research consent form were included in this observational study. Every patient was screened by occupation independently by 2 investigators to identify medically-qualified doctors and suitable (degree-educated) controls such as teachers, lawyers etc. Those with a medical background (e.g.nurse, physiotherapist etc) but not a medical doctor were excluded. Further exclusions were necessary if patients who were reviewed for a second opinion, reconstruction only or radiotherapy only or were male, surgery was not performed, BRCA positivity (might opt for bilateral mastectomy), unusual histology (e.g. lymphoma, sarcoma), recurrence or had a past history of contralateral breast cancer. Doctors and controls were compared by age, tumour characteristics and treatments using Student's t test for continuous variables and Fisher's exact test for categorical variables. Results: In total 8623 patients were reviewed and/or treated for breast cancer of whom 5215 had signed the generic research consent form. Overall 607 were either doctors or appropriate occupation controls. After exclusions 473 patients were eligible to be included in the analysis. Of these: 51 were medically-qualified doctors and 422 were degree-educated (controls). Comparison of tumour characteristics and treatment between doctors and controls DoctorsControlspNumber51422 Mean age (years)53.350.80.11Mean total tumour size (mm)32.231.60.89     Number (%)Number (%)pDCIS alone10(20)53 (13)0.18Node positive16 (31)157 (37)0.44ER positive45 (88)337 (80)0.18HER2 positive12 (24)113 (27)0.73    Neoadjuvant chemotherapy6 (12)58 (14)0.83Adjuvant chemotherapy14 (27)154 (36)0.21    mastectomy17 (33)145 (34)1.00Immediate reconstruction9 (53)65 (45)0.61Post mastectomy radiotherapy5 (29)68 (47)0.20Comparison of age, tumour characteristics, mastectomy, chemotherapy and post mastectomy radiotherapy rates between doctors and the control group There was no statistical difference in age and tumour characteristics between the doctors with breast cancer and the control group. There was no statistical difference in chemotherapy rate, mastectomy rate, or uptake of immediate breast reconstruction or post-mastectomy radiotherapy in mastectomy patients between the doctors with breast cancer and the control group. Conclusion Doctors in this study were not statistically more likely to undergo mastectomy than controls. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-18.

Introduction NAC has been used for downsizing of the tumour in breast and axilla to allow more conservative surgery. In the NAC setting, intraoperative assessment of sentinel lymph node(s) (SLN) is still considered necessary1. Current awareness of the prognostic value for axillary nodal down-staging has renewed interest in analysis of SLN post-NAC. In this study we want to examine the clinical utility of OSNA (based on CK19 mRNA detection) as a method of intra-operative analysis of SLN to assist real-time decision-making for axillary surgery post-NAC in early breast cancer (EBC). Methods Retrospective analysis of prospective data on 399 consecutive patients with EBC who received NAC followed by breast surgery with SLN biopsy (408 axillae) and assessment by OSNA, from September 2011 to January 2018 at the Royal Marsden Hospital (UK). OSNA readouts from the Sysmex RD-100i were collected separate to and blinded from clinico-pathological data. A negative or benign pre-treatment axillary ultrasound scan or indeterminate ultrasound with negative or benign axillary cytology/histology prior to NAC was considered cN0. Univariate analysis (significance at p<0.05) was used to identify risk of recurrence. Patients had a median (mean) follow up of 32.5 (36) months. Results The median age at diagnosis was 49 years, median BMI 26, 41 EBC (10%) were screen-detected, 292 (72%) were grade 3 and the most frequent phenotype was receptor triple negative (n=132, 32%). Of 408 axillae, 248 (60%) were initially cN0, of which 113 (46%) had a pathological complete response (pCR) in the breast. SLN in 54 (22%) cN0 patients were positive on OSNA, of which only 6 (9%) had further involved axillary nodes all 6 of which were ER+ Her2-. The remaining 160 (40%) axillae were cN1 of which 87 (54%) had conversion to ypN0 including 55 (34%) with both ypT0ypN0. Axillary lymphadenectomy (AL) was performed in 79 (19%) patients overall, of which n=22 (28%) were cN0 and 57 (72%) were cN1. Of these, 30 (53%) of the cN1 and 6 of 22 (45%) of cN0 had at least 1 additional positive AL node. Overall 59 (14.4%) patients relapsed. A significantly worse rate of relapse was observed in cN1 compared to cN0 patients (37/159 (23.3%) versus 22/244 (9%), p<0.001). Combined pCR of both breast and axilla (in cN1, n=54) was associated with a significantly reduced risk of relapse and death (p<0.001) compared to those without pCR of either breast or axilla (n=62). Of the latter 18 (29%) relapsed (including 10 deaths). The mean of both the single highest node tumour load (and total nodal tumour load), as measured by CK19mRNA copies/ul on OSNA, were significantly higher at 90,000 (98,300) for those who relapsed versus 23,100 (25,100) for those without relapse (p=0.027). Conclusions The OSNA assay is an accurate tool for axillary SLN analysis in patients after NAC and was helpful in intra-operative axillary management. OSNA reduces the need for a second surgery for AL in 20% of breast cancer patients with a positive-SLN after NAC and might offer additional prognostic value. Reference 1. NCCN. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology Breast Cancer.2016.Version 2.2016. Citation Format: Muscara F, Christaki G, Richardson C, O'Connell R, Padmanabhan P, Warwick J, Lee Y, Smith I, Nerurkar A, Osin P, Krupa K, Rusby J, Roche N, Gui G, MacNeil F, Barry P. Clinical utility of one-step nucleic acid amplification (OSNA) in axillary surgery after neoadjuvant chemotherapy (NAC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-14.