Clinical Focus
13 SEPTEMBER 2024 ausdoc . com . au
AUSDOC ’ S TOP FIVE CLINICAL ARTICLES
| THE | WOMEN ’ S AND MEN ’ S HEALTH SPECIAL
Case Report
Breast surgery
1 . Spot Diagnosis : Can you name this solitary nodule ?
Page views : 2600
2 . Clumsy feet clue to a life-changing diagnosis
Page views : 1600
3 . Lipid-based CVD score targets ‘ troubling ’ intermediate risk patients
Page views : 1600
4 . GLP-1RAs slapped with ileus warning after TGA investigation
Page views : 1400
5 . Therapy Update : A guide to persistent pelvic pain
Page views : 660
Source : AusDoc website ; 26 June to 26 Aug . breakthrough
Sensory preservation for the breast and nipple after mastectomy is now achievable for Australian women thanks to microsurgical advancements .
Dr Joe Dusseldorp Reconstructive plastic surgeon at Chris O ’ Brien Lifehouse , Camperdown , and the Mater Clinic , North Sydney , NSW ; Clinical senior lecturer in the faculty of medicine , University of Sydney .
Justine , a 54-year-old woman with no familial breast cancer history , presents with biopsy-confirmed left breast cancer . She undergoes initial left unilateral therapeutic mammoplasty for tumour excision . Histopathology reveals a hormone receptor-positive , human epidermal growth factor 2-negative primary tumour with sentinel lymph node involvement .
Multidisciplinary team review is conducted , and the team recommends that Justine undergo mastectomy , followed by adjuvant chemoradiotherapy . Justine is interested in breast reconstruction . So when the skin-sparing , nipple-sacrificing mastectomy is performed , a temporary tissue expander is placed , to preserve the pocket during radiotherapy and prepare for later definitive reconstruction with autologous tissue taken from the abdominal area . At mastectomy , additional malignancy and lymphovascular invasion are identified , albeit with no further nodal involvement . Postoperatively , Justine undergoes adjuvant chemotherapy followed by radiation therapy .
Reconstruction planning
Six weeks following the completion of radiation , it will be possible for Justine to undergo definitive reconstruction of her left breast using her own tissues . She is also contemplating simultaneous risk reducing mastectomy with immediate deep inferior epigastric perforator ( DIEP ) flap reconstruction of both breasts .
Justine is happy with the natural size and shape of her breasts , and her stated preference is to retain , or slightly enhance if possible , the size of her breasts during a reconstruction .
Following her initial mastectomy , Justine has complete loss of breast sensation , which is a common side-effect of this surgery , particularly when combined with a tissue expander and radiotherapy . She arrives at her reconstruction-planning consultation with the following goals : to consider using her own tissue to reconstruct her left breast ; to consider a risk-reducing mastectomy of her right breast and reconstruction using a right DIEP flap ; and to preserve / reconstruct as much breast sensation as possible .
With these goals in mind , Justine consents
to procedures that involve a sensation reconstruction approach , aiming to restore as much breast and nipple-areolar complex sensation as possible .
She proceeds to a bilateral DIEP flap reconstruction , with removal of the temporary tissue expander from the left breast and risk-reducing mastectomy of the right breast . Sensation reconstruction is performed in both breasts by rejoining the tiny cut ends of nerves arising from the chest wall to the tiny cut ends of nerves supplying the DIEP flap abdominal tissue that is taken to reconstruct the breasts . This process adds an additional 30 minutes to the
ESTROGEL ® PRO PRIMARY ADVERTISEMENT For her .
Medicine co-pack containing one pack of Estrogel ® ( estradiol hemihydrate ) plus one pack of Prometrium ® ( micronised progesterone ) for women with a uterus
PBS Information : These products are not available on the PBS .
Please review Product Information before prescribing , accessible at besins-healthcare . com . au / PI or 1800 BESINS ( 237 467 ), or by scanning the QR code :
Minimum Product Information Estrogel ( estradiol hemihydrate ) gel . Indications : Hormone replacement therapy ( HRT ) for estrogen deficiency symptoms in postmenopausal women . Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of , or contraindicated for , other medicinal products approved for the prevention of osteoporosis . The lowest effective dose should be used for the shortest duration . Contraindications : Known , past or suspected breast cancer ; Known or suspected estrogen-dependent malignant tumours ( e . g . endometrial cancer ); Undiagnosed genital bleeding ; Untreated endometrial hyperplasia ; Previous or current venous thromboembolism ( e . g . deep venous thrombosis , pulmonary embolism ); Known thrombophilic disorders ( e . g . protein C , protein S , or antithrombin deficiency ); Active or recent arterial thromboembolic disease ( e . g . angina , myocardial infarction ); Acute liver disease , or a history of liver disease as long as liver function tests have failed to return to normal ; Known or suspected pregnancy ; Lactation ; Known hypersensitivity to the active substances or to any of the excipients ; Porphyria . Precautions : Appraisal of the risks and benefits should be undertaken at least annually . Refer to full Product information ( PI ) for conditions which require supervision during treatment with Estrogel . Treatment should be withdrawn if the following occur , jaundice or deterioration in liver function ; significant increase in blood pressure ; new onset of migraine type headache ; pregnancy . Caution : endometrial hyperplasia and carcinoma , breast cancer , ovarian cancer , venous thromboembolism , coronary artery disease ( CAD ), ischaemic stroke , thyroid function , elderly , ALT elevations , paediatric use ( see full PI ). Interactions : use of concomitant skin medications , surface active agents or strong skin cleansers and detergents should be avoided at site of application , metabolism of estrogens may be increased by concomitant use of inducers of hepatic enzymes such as anticonvulsants ( phenobarbital , phenytoin , carbamezapine ) and anti-infectives ( rifampicin , rifabutin , nevirapine , efavirenz , ritonavir and nelfinavir ) and some herbal preparations ( St John ’ s wort ) reducing the effectiveness of estrogen . Estrogel as a transdermal administration might be less affected than other oral hormones by enzyme inducers . Concomitant use of estrogens with lamotrigine may decrease lamotrigine plasma concentrations . Caution is warranted for co-administration with hepatitis C virus ( HCV ) combination regimens ombitasvir / paritaprevir / ritonavir with or without dasabuvir and the regimen glecaprevir / pibrentasvir may cause greater than usual ALT elevations . Pregnancy Category B3 ; not for use in lactation . Adverse Effects : headache , nausea , abdominal pain , breast swelling / pain , breast enlargement , dysmenorrhea , menorrhagia , metrorraghia , leucorrhoea , endometrial hyperplasia , weight gain ( increase or decrease ), water retention with peripheral edema ( see full PI ). Dosage and Administration : Estrogel should be used daily on a continuous basis . Estrogel as an estrogen only product is indicated only for women without a uterus . In women with an intact uterus it is recommended to add a progestogen for at least 12 days of each month . Although some women will respond to 1.25 g daily ( 1 pump ), the usual starting dose is 2.5 g per day ( 2 pumps ). If after one month of treatment , effective relief of menopausal symptoms is not obtained the dosage may be increased to a maximum of 5 g ( 4 pumps ) ( see full PI ). The lowest effective dose should be used for maintenance therapy . The optimal daily maintenance dose needs to be reevaluated regularly ( e . g . annually ). Estrogel should only be continued for as long as the benefit outweighs the risk . The correct dose of gel should be dispensed and applied to clean , dry , intact areas of skin e . g . on the arms and shoulders , and / or inner thighs . The area of application should be as large as possible . Refer to Full Product Information before prescribing .
Minimum Product Information Prometrium ( oral , micronised progesterone ) Indications : menstrual irregularities ; adjunctive use with an estrogen in postmenopausal women with an intact uterus . Contraindications : known allergy / hypersensitivity to progesterone or excipients ; severe hepatic dysfunction ; undiagnosed vaginal bleeding ; known missed abortion / ectopic pregnancy ; mammary / genital tract carcinoma ; thromboembolic disorders ; thrombophlebitis ; cerebral haemorrhage ; porphyria . Clinically Significant Precautions : not a treatment for premature labour ; not a contraceptive ; discontinue if unexplained visual loss / changes , proptosis , diplopia , papilloedema , retina vascular lesions or migraine ; use caution in conditions affected by fluid retention and history of depression , diabetes , hepatic dysfunction , migraine , photosensitivity and during lactation ; increased risk of breast cancer and venous thromboembolism with estrogen concomitant therapy ( refer estrogen PI ); may cause drowsiness ; may affect laboratory test results . Clinically Significant Interactions : caution with P450 enzyme inducers and inhibitors ; may increase antidiabetic medication ; bioavailability may be reduced by smoking and increased by alcohol abuse . Very Common and Common Adverse Effects : menstrual disturbances ; headache . d1 – d25 . Secondary amenorrhoea : 400mg / d for 10d . Ovulation disorders / anovulation : 200 – 300mg for 10d ( d17 – d26 , inclusive ).
Estrogel ® and Prometrium ® are registered trademarks of Besins Healthcare . Besins Healthcare Australia Pty Ltd ABN 68 164 882 062 . Suite 5.02 , 12 Help Street , Chatswood NSW 2067 . Office phone ( 02 ) 9904 7473 . For medical information call 1800 BESINS ( 237 467 ). www . besins-healthcare . com . au EPR-EST-PRM-1969 January 2024