The uptake of contralateral prophylactic mastectomy is rising with increasing trends that are possibly highest in the USA. Whilst its role is generally accepted in carriers of recognized high-risk predisposition genes such as BRCA1 and BRCA2 when the affected individual is premenopausal, controversy surrounds the benefit in less understood risk-profile clinical scenarios. This comprehensive review explores the current evidence underpinning the role of contralateral prophylactic mastectomy and its impact on contralateral breast cancer risk and survival in three distinct at-risk groups affected by unilateral breast cancer: known genetic carriers, those with strong familial risk but no demonstrable genetic mutation and women who are of young age at presentation. The review supports the role of contralateral prophylactic mastectomy in “high risk” groups where the evidence suggests a reduction in contralateral breast cancer risk. However, this benefit is less evident in women who are just young at presentation or those who have strong family history but no demonstrable genetic mutation. A multidisciplinary and personalized approach to support individuals in a shared-decision making process is recommended.

Introduction This case involved a 15-year-old boy, who slipped and impaled his left hand on a wooden beam. An initial anterior–posterior radiograph was obtained prior to referral to plastic surgery for further management (figure 1). Clinical photographs and initial X-ray taken of the impalement injury. Clinical examination was restricted due to access. The patient reported general pain on limited movement of all digits but normal neurology. He received appropriate initial treatment of broad-spectrum antibiotics and tetanus care in the emergency department. His medical and social history were unremarkable. Question What is the next most appropriate intervention? Immediate removal of the impaled structure under tourniquet control in an operating theatre. Immediate removal of the impaled structure in the emergency department under nerve block. Further imaging is needed. Urgent surgical consultation. Question

We read with great interest the article entitled, “Neoadjuvant Radiotherapy: Changing the Treatment Sequence to Allow Immediate Free Autologous Breast Reconstruction” by Hughes et al.[1] It provides a unique and innovative perspective on how to best integrate radiotherapy into the treatment pathway for women with locally advanced breast cancer who need mastectomy and want breast reconstruction. In the era of multidisciplinary management of breast cancer, it is important for all involved specialties to collaborate with regards to the optimal timing of treatment delivery with the aim of maximizing oncological and cosmetic outcomes. In their study, the authors provide data that could support, along with anticipated data from ongoing clinical trials (PRADA NCT 02771938),[2] a change in paradigm regarding the sequence of treatment modalities. The reported data are very encouraging. While the focus is on the technical feasibility and short-term outcomes of immediate free autologous reconstruction, it would be educational to have more information from the oncological perspective. The authors reported a high pathological complete and near-complete response rate (57%) following neoadjuvant chemotherapy (NACT). It would be interesting to establish further details on the tumor phenotypes in evaluating these outcomes and clarifying whether the study controlled for pathological subtype. Overall, this may support the rationale for response-adapted surgery where some patients with pathologic complete response (pCR) may avoid mastectomy, with no detriment to overall survival.[3] Deciding the radiotherapy regimen in patients receiving NACT can be the subject of controversy. It is debated whether this should be based on clinical stage at presentation or the residual tumor burden (size and number of involved axillary lymph nodes). It would be interesting to know the policy and rationale adopted by the radiation oncologists in this study. It is well established that nodal burden, in addition to pathologic complete response, is an important prognostic factor. It would, therefore, be interesting to have more information on nodal staging to more reliably evaluate the oncological outcomes. The authors acknowledge the relatively short follow-up time of 19.7 months and we would anticipate an update with longer term outcomes. Balancing the timing of surgery with the completion of radiotherapy can be challenging in these cases, to allow sufficient time for pathological downsizing and downstaging, while minimizing the risk of tumor regrowth and metastatic potential. The authors reported an average time of 6.4 weeks between neoadjuvant radiotherapy and surgery. Our institutional experience is to consider surgery at a median time of 2 to 4 weeks following neoadjuvant radiotherapy, prior to the peak inflammatory phase of wound healing which may increase the inherent surgical challenges. Finally, one of the theoretical benefits in delivering radiotherapy in the neoadjuvant setting is shortening the duration of the overall treatment protocol and streamlining the patient journey. It would be helpful if the authors could comment on the total duration of treatment and its objective impact on patient-reported outcome measures and quality of life, as it may further strengthen the drive to adopt a change in practice.

Ongoing fiscal limitations continue to restrict the opportunity to perform aesthetic procedures within the National Health Service (NHS). This, in conjunction with shift-pattern surgical training due to the advent of the European Working Time Directive, has resulted in declining training exposure in this subspecialty. Various modalities have been proposed to address this shortfall, including in-built ‘aesthetic rotations’ during the training period,1 pre-Certificate of Completion of Training (CCT) and post-CCT aesthetic fellowships, British Association of Plastic Reconstructive and Aesthetic Surgeons–approved instructional courses and simulation training.