Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Magnetic resonance imaging (MRI) is highly sensitive in detecting invasive lobular carcinoma (ILC) of the breast. In our institution, patients who are deemed to be suitable for breast conserving surgery (BCS) with unifocal small ILC on standard imaging are offered breast MRI to exclude multifocal and larger ILC. Our study investigates the usefulness of breast MRI in ILC. A prospective cohort study over a 58-month period, including all consecutive patients with ILC having breast MRI. Primary objective was to find out the proportion of ILC patients where preoperative MRI caused a change in the surgical treatment. Secondary objectives included finding mastectomy rate (initial & final), re-operation rate, cancer size correlation with different imaging modalities and final histopathology, loco-regional recurrence and disease-free survival. A total of 334 bilateral breast MRI were performed including 72 (21.5%) MRI for ILC patients. All these MRI were carried out within 2 week of patients given the diagnosis (median 5.5 days). Age range was 24-83 (median 56.5) years. Nineteen of 72 ILC patients (26.4%) had a change in their planned operation from BCS to a different operation owing to MRI findings (seven patients with multifocal cancers, 10 with significantly larger size of the cancer and two with contralateral malignancy). Initial mastectomy rate was 31.9%, final mastectomy rate was 36.1% and re-operation rate in BCS group was 18.3%. MRI correlated better with ILC histopathology cancer size than mammogram and ultrasound scans. There was no statistically significant difference (p = 0.999) between the cancer size on histology (median 23 mm) and MRI (median 25 mm). However, mammogram (median 17 mm) and ultrasound (median 14.5 mm) scans showed cancer sizes significantly different to final histology cancer size (p = 0.0008 and p = 0.0021 respectively). Over a 44 months median follow-up (range 27-85), 95.8% disease-free survival and 98.6% overall survival have been observed. One out of every four patients (26.4%) with ILC had a change in their planned operation due to MRI findings. A relatively high disease-free survival over a medium-term follow-up proves the oncological safety of MRI in ILC. Our study provides evidence in support of the targeted use of preoperative breast MRI among patients with ILC to improve surgical planning.

Highlights Accessory breast cancer is a rare entity with incidence of around 0.2%–0.6%. Routine mammograms can miss accessory breast tissue due to its location. General lack of awareness of accessory breast cancer among clinicians has potentially dangerous implications. Accessory breast cancer does not require mastectomy unless involved by cancer.

Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients' medical records. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be recognizable to those not working within the same field. The purpose of this study was to assess whether we, the multidisciplinary team members, correctly interpret the abbreviations used in the medical records. We analysed one week of orthopaedic surgical medical records for the use of abbreviations and assessed their appreciation by other members of the multidisciplinary team by means of a standardized questionnaire. We found great variability in the understanding of these abbreviations by different groups of health care professionals. As expected, the orthopaedic surgeons produced significantly more right answers when compared to the other groups, but even they could correctly interpret just over half (57.24 per cent) of the abbreviations. There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk. Whilst abbreviations may indeed save time, the observed inter-group variation in correct interpretation of these abbreviations is unacceptable. We recommend that the abbreviations have no place in the multidisciplinary world and their continued use will only lead to eventual clinical error.

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