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The breast can be affected by a wide range of dermatological conditions. Some conditions are unique to the skin of the breast, whereas others occur elsewhere on the body. General practitioners (GPs) will see both benign and malignant skin conditions of the breast; a nuanced approach to assessing and managing these conditions is required. This paper gives an overview of the breast skin changes commonly seen in a GP practice, with aetiology, symptoms and guidance on treatment and management. The symptoms of breast skin conditions might overlap. Failure to resolve with adequate treatment could indicate a serious underlying aetiology and the patient needs to be seen by a specialist for further investigation. Early referral decreases morbidity and, in malignant disease, mortality.

We previously reported the 5-year results of the phase 3 IBCSG 23-01 trial comparing disease-free survival in patients with breast cancer with one or more micrometastatic (≤2 mm) sentinel nodes randomly assigned to either axillary dissection or no axillary dissection. The results showed no difference in disease-free survival between the groups and showed non-inferiority of no axillary dissection relative to axillary dissection. The current analysis presents the results of the study after a median follow-up of 9·7 years (IQR 7·8–12·7). In this multicentre, randomised, controlled, open-label, non-inferiority, phase 3 trial, participants were recruited from 27 hospitals and cancer centres in nine countries. Eligible women could be of any age with clinical, mammographic, ultrasonographic, or pathological diagnosis of breast cancer with largest lesion diameter of 5 cm or smaller, and one or more metastatic sentinel nodes, all of which were 2 mm or smaller and with no extracapsular extension. Patients were randomly assigned (1:1) before surgery (mastectomy or breast-conserving surgery) to no axillary dissection or axillary dissection using permuted blocks generated by a web-based congruence algorithm, with stratification by centre and menopausal status. The protocol-specified primary endpoint was disease-free survival, analysed in the intention-to-treat population (as randomly assigned). Safety was assessed in all randomly assigned patients who received their allocated treatment (as treated). We did a one-sided test for non-inferiority of no axillary dissection by comparing the observed hazard ratios (HRs) for disease-free survival with a margin of 1·25. This 10-year follow-up analysis was not prespecified in the trial's protocol and thus was not adjusted for multiple, sequential testing. This trial is registered with ClinicalTrials.gov, number NCT00072293. Between April 1, 2001, and Feb 8, 2010, 6681 patients were screened and 934 randomly assigned to no axillary dissection (n=469) or axillary dissection (n=465). Three patients were ineligible and were excluded from the trial after randomisation. Disease-free survival at 10 years was 76·8% (95% CI 72·5–81·0) in the no axillary dissection group, compared with 74·9% (70·5–79·3) in the axillary dissection group (HR 0·85, 95% CI 0·65–1·11; log-rank p=0·24; p=0·0024 for non-inferiority). Long-term surgical complications included lymphoedema of any grade in 16 (4%) of 453 patients in the no axillary dissection group and 60 (13%) of 447 in the axillary dissection group, sensory neuropathy of any grade in 57 (13%) in the no axillary dissection group versus 85 (19%) in the axillary dissection group, and motor neuropathy of any grade (14 [3%] in the no axillary dissection group vs 40 [9%] in the axillary dissection group). One serious adverse event (postoperative infection and inflamed axilla requiring hospital admission) was attributed to axillary dissection; the event resolved without sequelae. The findings of the IBCSG 23-01 trial after a median follow-up of 9·7 years (IQR 7·8–12·7) corroborate those obtained at 5 years and are consistent with those of the 10-year follow-up analysis of the Z0011 trial. Together, these findings support the current practice of not doing an axillary dissection when the tumour burden in the sentinel nodes is minimal or moderate in patients with early breast cancer. International Breast Cancer Study Group.

The rates of lactational mastitis are variable in the literature with the World Health Organization (WHO) review giving rates of between 5% and 50% of breastfeeding women2 and a Cochrane report suggesting rates up to 33%.3 Australian data suggest a lactational mastitis rate of 20%, which is most common in the first six weeks of breastfeeding. The most common causative organism is Staphylococcus aureus, and first-line antibiotic recommendations are flucloxacillin or dicloxacillin 500 mg qid for five days.4 Studies show that treating mastitis with antibiotics shortens the episodes and reduces the progression to abscess formation.2 Patients should keep breastfeeding or expressing milk during treatment to reduce milk stasis in the breast. The clinical presentation can mimic other breast conditions, such as breast cancer, requiring thorough diagnostic work-up, including mammography and ultrasound, to exclude malignancy. First-line antibiotic therapy often includes oral antibiotics such as dicloxacillin; however, anaerobic cover with metronidazole is also recommended, especially in smokers.8 In cases of chronic or recurrent periductal mastitis, surgical interventions, including duct excision (ductectomy), might be necessary in severe cases.

Cerebral reperfusion following carotid endarterectomy occasionally causes cerebral hyperperfusion syndrome. This is a rare but important complication and this case report acted as a stimulus for a literature review of this problem. A 60-year-old businessman had a right carotid endarterectomy for a severe stenosis which had caused recurrent attacks of amaurosis fugax. The left internal carotid artery had occluded asymptomatically. The operation and his immediate postoperative recovery were entirely uneventful but he developed right-sided headaches and focal sensory motor seizures. He subsequently recovered. Hemodynamically compromised patients appear to be at greater risk and as the mortality of the operation is reduced and more complex patients are treated, it is likely that this unusual complication will increase in incidence.