The role of guideline reinforcement in improving quality of referrals to a specialist breast clinic
Authors: S. Davis, A. Lannigan, J. Murray
Journal: International Journal of Surgery (2015)

s / International Journal of Surgery 23 (2015) S15eS134 S30 Aim: To demonstrate the role of human fibrin sealant glue for mastectomy flap adherence. Methods: We audited the use of ARTISS fibrin sealant glue versus surgical drain placement for six months at a District General Hospital, looking at two primary endpoints; discharge within 23 hours and post-operative complications. All mastectomy patients were included and complications were identified up to 60 days. Data was collected prospectively from physical and electronic records. Results: Complete data was collected for 18/19 patients who underwent mastectomy in the study period. The rate of discharge within 23 hours using fibrin sealant glue was 6/7 patients compared with 5/8 with surgical drains. For the four patients who had neither drain nor glue, two were discharged within 23 hours. The rate of seroma with fibrin glue was 1/7 versus 4/8 with a drain. Using neither drain nor glue 2/4 patients developed seromas and one was re-admitted. Conclusion: The use of fibrin sealant glue resulted in reduced complications and earlier discharge compared with surgical drains for mastectomy patients in this small sample. Larger scale studies are required to demonstrate statistical significance, but fibrin sealant glue may negate the use of drains, expedite discharges and reduce costs from community nursing, prolonged admissions, drain complications and delays starting adjuvant treatment. 0700: THE ROLE OF GUIDELINE REINFORCEMENT IN IMPROVING QUALITY OF REFERRALS TO A SPECIALIST BREAST CLINIC S. Davis, A. Lannigan, J. Murray. Wishaw General Hospital, UK Aim: To assess the effect of redistributing Scottish Cancer Referral Guidelines to primary care in improving the quality of referrals to a specialist breast clinic in a Scottish DGH. Methods: A previous audit showed 36% referrals from general practice were either inappropriate or of incorrect level of urgency. The Scottish Cancer Referral Guidelines were re-distributed to primary care physicians and referrals were re-audited over a 2 week period. Results: 231 referrals were made in the study period. 33% were referred as routine. Of these, 65% were correct and 35% incorrect. Incorrect routine referrals should have been urgent according to guidelines (54%); the remainder should have been managed in primary care (46%). This was a 17% improvement over the previous audit. 67% patients were referred as urgent. Of these, 73% were correct while 27% were incorrect. 86% incorrect referrals should have been routinewhile 14% should have beenmanaged in primary care. This was a 6% improvement over the previous audit. Conclusion: Redistribution of the guidelines did improve the quality of referrals. Other methods of reinforcement are needed to further improve standards of referral from primary care and to give general practitioners the confidence to manage conditions not needing specialist care. 0728: A REVIEW OF THE MANAGEMENT OF AXILLARY MICROMETASTASES IN BREAST CANCER M. Green, H. Ingle. Good Hope Hospital, UK Aim: Our local protocol suggests undertaking axillary node clearance (ANC) if a micrometastasis is found at sentinel lymph node biopsy (SLNB). With recent reports suggesting this may not be necessary, we reviewed our data between January 2012 and August 2014 (30 months) Methods: A case note review was performed on all patients undergoing axillary surgery for breast cancer over a three year period. The form of axillary surgery, as well as the number of nodes retrieved was noted. We also noted whether there were micrometastases or macrometastases. Results: 163 of a total of 358 patients (45.5%) underwent axillary node clearance (ANC). Of those, 87 (53.4%) were primary, and 76 (46.6%) following SLNB. From the 76 secondary ANCs, 21 (27.6%) only had micrometastases on SLNB. All underwent ANC. Out of the 21 ANCs for micrometastasis, only 2 patients (9.5%) had further nodal involvement. One with a further solitary micrometastasis, another had 2 involved nodesone micrometastasis, one macrometastasis. Conclusion: ANC with solitary micrometastases has been called into question, especially with improving adjuvant therapies. This data supports that view and suggests that in almost 28% (21/76) of cases we may be unnecessarily increasing potential morbidity and cost by advocating ANC. 0741: USE OF THE LATISSIMUS DORSI FLAP IN BREAST RECONSTRUCTION: THE PATIENT PERSPECTIVE E. Snashall, P. Wadsworth, C. Harding-MacKean, E. Redmond. Countess of Chester Hospital, UK Aim: The latissimus dorsi (LD) flap is one of many available methods of breast reconstruction following mastectomy. All methods carry key strengths and potential pitfalls; no method can exactly replace the lost breast. This study aims to assess patient perspective of outcome following breast reconstruction with LD flap. Methods: 29 patients completed satisfaction surveys assessing aesthetic, pain and functional outcomes. Results: Mean overall satisfaction score was 8.9/10 and 28/29 (96.6%) would recommend the procedure. The most important factors in aesthetic outcome were symmetry (10/29, 34.5%) and shape (10/29, 34.5%). Eight (27.6%) reported mild/moderate restrictions in activities and six (20.6%) reported moderate pain; none reported significant limitation or pain. Conclusion: LD flap reconstruction was associated with high overall patient satisfaction comparable to DIEP which is considered as the gold standard, and little functional or aesthetic compromise. The most important factor for patients was symmetry. Patient expectations and priorities should be a key point to address in a reconstruction consultation. The ultimate aim should be for an outcome which has addressed the factors most important to that individual patient. 0763: EFFICACY OF TRIPLE ASSESSMENT IN COMPARISON WITH SURGICAL BIOPSY IN BREAST CANCER M.I. Aslam , M.O. Karim , A. Khan , P.K. Arora . a South Warwick NHS Foundation Trust, UK; b John Radcliffe Oxford University Hospital, UK; c Tameside General Hospital, UK Aim: To examine, combined and individual predictive values regarding Palpation (P), Mammogram (M), Ultrasound (U) and FNAC (C)/Core biopsy (B) in Breast cancer diagnosis in relation to surgical biopsy. Methods: 124 breast cancer patients reviewed between 1st April’09e30th March'10. For diagnostic potential of combination of the modalities (P, M and FNAC), we considered cases with score of 4 (Probablymalignant) and 5 (malignant) in any of the modalities were considered positive for malignancy. All Patients diagnosed with breast cancer with triple assessment were found having breast cancer on surgical biopsy. 12 were excluded, unfit for intervention. Results: (P) alone relatively accurate, confirmed by surgical biopsy. PPV 58.9% when compared with surgical biopsy, PPV 66.1% after ultrasound scan, the over Radiological grading (R) gives a PPV 81.3%, reflecting important role of ultrasound. FNAC 73.2%, comparable with other studies. Core biopsy diagnostic in 107 (95.5%). combination of the modalities (P, M, U, R, FNAC) is more accurate than any one modality, alone. Conclusion: Cases with positive three modalities for breast malignancy; surgical biopsy confirms the breast cancer with a PPV 100%, sensitivity 95.5%. Results showed improvement when compared to previous audit. Furthermore, practice was in line with NICE guidelines and performance was well above standard required. 0798: PRIMA: Y INVASIVE BREAST TUMOUR SIZE WITH AXILLARY METASTASIS IN ETHNICITIES X.Y. Kowa, M.F. Anwar, F. Mihaimeed. Newham University Hospital, UK Aim: To explore the correlation between breast cancer tumour size and axillary lymph node metastasis in new presentations, amongst an ethnically diverse patient population in an east London hospital. Methods: A total of 131 patients were identified as first presentations of breast cancer over a two-year period based on the Trust's electronic database (excluding recurrent breast disease or histological anomalies). Tumour size was based on TNM staging and status of the axilla derived