Avi Agrawal

Intraoperative assessment of sentinel lymph nodes in breast cancer.

Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node‐negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node‐positive patients.

Observational and cost analysis of the implementation of breast cancer sentinel node intraoperative molecular diagnosis

Background Accurate intraoperative sentinel lymph node (SLN) assessment enables axillary clearance to be completed immediately in node-positive breast cancer patients. This article reports a study of the introduction of intraoperative molecular SLN analysis in routine clinical practice in the Portsmouth Breast Care Centre. Design There was prospective analysis of 254 consecutive patients who underwent SLN biopsy in a single centre. Nodes were sectioned at 2 mm intervals and alternate slices were analysed using a CE-marked assay for mammaglobin (MG) and cytokeratin 19 (CK19). Remaining slices of node were sent for histological analysis, which included CK19 immunohistochemistry. While the assay was being carried out, the surgeon performed the breast tumour resection. The cost per patient was estimated retrospectively and the cost effects on the hospital and primary care trust for a typical service were also estimated. Results A total of 491 SLNs from 254 patients were evaluated. The intraoperative assay showed positivity of SLNs for metastatic cells in 78 patients. There was 100% detection of macrometastases within sentinel nodes analysed by GeneSearch. Overall concordance between histological status, including micrometastases and GeneSearch analysis, was 95% (sensitivity 96%, specificity 95%). The cost per procedure was increased for wide local excision with SLN biopsy and intraoperative assessment compared with other models, but fewer procedures were carried out. Conclusion Intraoperative assessment of SLNs in breast cancer using a molecular assay is a safe, acceptable and accurate technique that allows a reduction in the frequency of delayed axillary clearance surgery. Take-up of this method may be hampered by perverse incentives operating within healthcare funding.

The effect of introducing an in-theatre intra-operative specimen radiography (IOSR) system on the management of palpable breast cancer within a single unit

INTRODUCTION Intra-operative specimen radiography (IOSR) is used to screen specimens during breast-conserving surgery and attempt to identify incompletely excised lesions. Universal use of IOSR during surgery for impalpable breast cancer is advocated by current guidelines. This study evaluates the role of IOSR during breast-conserving surgery for palpable breast cancer. METHODS Two cohorts of patients who underwent wide local excision for palpable breast cancer were identified. Retrospective analysis of histological margins, intra-operative cavity shaves, secondary re-excision rates and specimen weight was completed comparing performance prior to the introduction of IOSR (October 2003-April 2005) with that since its introduction (April 2006-October 2007). RESULTS 224 Patients were included, 111 in the pre-IOSR cohort (PF) and 113 in the IOSR cohort (F). Patient demographics, tumour size and histology were comparable. No difference in margin involvement prior to intra-operative cavity shaving was noted, PF-26, F-31 (p=0.60). Intra-operative cavity shaves were carried out more frequently in the IOSR group, PF-9, F-32 (p=0.001). When compared with histological findings, IOSR identified margin compromise with sensitivity=58.1%, specificity=80.8%, positive-predictive value=56.25% and negative predictive value=81.9%. Re-operation rate was similar between the 2 groups, PF-26, F-31 (p=0.65). Significantly less tissue was excised following use of IOSR; PF-110g, F-70g (p=0.001). CONCLUSION Introduction of IOSR significantly reduced specimen weights without increasing re-excision rates. As volume of breast tissue removed is the most significant determinant of cosmetic outcome following breast-conserving surgery, the use of IOSR should be advocated in the surgical management of palpable breast cancer.

Oncoplastic breast conserving surgery

Oncoplastic breast conserving surgery is a fundamental component of the repertoire for the management of breast cancer. It facilitates removal of large volumes of breast tissue, and can improve cosmetic outcomes and patient satisfaction whilst maintaining good oncological principles, reducing re-excision and mastectomy rates and assisting in adjuvant radiotherapy planning. We review the various techniques for oncoplastic breast conserving surgery that have emerged over recent years and describe their utilisation in excising tumours from various locations within the breast, and the pertinent patient specific factors that must be considered in technique selection. Finally complications and the evidence for the oncological safety specific to this type of surgery are discussed.

BRAF V600 co-testing in thyroid FNA cytology: short-term experience in a large cancer centre in the UK

Aims To ascertain whether BRAF V600 mutational analysis is useful for diagnosis of thyroid cancer in thyroid fine needle aspirate (FNA). Methods Over 8 months thyroid FNAs reported as Thy 3F (neoplasm possible/suggestive of follicular neoplasm), Thy4 (suspicious of malignancy) and Thy 5 (malignant) were tested for BRAF V600 mutation and managed as malignant if mutations were present. Results Of 207 FNAs from 176 patients, 5 were Thy 5, 19 Thy 4, 36 Thy 3f, 13 Thy 3a, 84 Thy 2 and 50 Thy 1. 11 Thy 3f, 15 Thy 4 and 3 Thy 5 FNAs were tested for BRAF V600 mutation. 0 Thy 3F cases, 6 Thy 4 and 1 Thy 5 (24% of the total tested) showed evidence of mutation. Four patients with BRAF V600 mutation underwent surgery to remove all thyroid tissue, two patients received a lobectomy and one patient is awaiting thyroidectomy. All patients with BRAF V600 mutation were found to have malignancy on final histology, with a diagnostic sensitivity for malignancy excluding coincidental microcarcinoma of 43% and specificity of 100%. Conclusions BRAF V600 mutational analysis can enable single-stage total thyroidectomy for carcinoma if gene mutation is present in preoperative FNA. BRAF V600 co-testing may reduce the need for completion thyroidectomy with implied cost savings and lower patient morbidity associated with completion thyroidectomy when the cytology is inconclusive but where BRAF V600 mutation is identified in preoperative thyroid FNA.

Isoflurane hepatitis-induced liver failure: a case report

A case of fulminant hepatic failure two days following an uneventful operation during isoflurane anesthesia is presented. Investigations included elevated bilirubin and serum transaminases in the absence of any other cause of hepatic dysfunction. The patient died on the fourth postoperative day. Subsequent postmortem examination showed centrilobular coagulative necrosis consistent with drug toxicity, with isoflurane as the most likely toxic agent.

Staging Investigations in Breast Cancer: Collective Opinion of UK Breast Surgeons

Introduction. Certain clinicopathological factors are associated with a higher likelihood of distant metastases in primary breast cancer. However, there remains inconsistency in which patients undergo formal staging for distant metastasis and the most appropriate investigation(s). Aims. To identify UK surgeon preferences and practice with regard to staging investigations for distant metastases. Methods. A survey was disseminated to members of the Association of Breast Surgery by e-mail regarding surgeon/breast unit demographics, use of staging investigations, and local policy on pre/postoperative staging investigations. Several patient scenarios were also presented. Results. 123 of 474 (25.9%) recipients completed the survey. Investigations routinely employed for patients diagnosed with early breast cancer included serological/haematological tests (72% respondents), axillary ultrasound (67%), liver ultrasound (2%), chest radiograph (36%), and computed tomography (CT) (1%). Three areas contributed to decisions to undertake staging by CT scan: tumour size, axillary nodal status, and plan for chemotherapy. There was widespread variation as to criteria for CT staging based on tumour size and nodal status, as well as the choice of staging investigation for the clinical scenarios presented. Conclusions. There remains variation in the use of staging investigations for distant disease in early breastcancer despite available guidelines.

Mastectomy skin flap necrosis: challenges and solutions

Introduction Mastectomy skin flap necrosis (MSFN) has a reported incidence of 5%–30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions. Methods A MEDLINE search was performed using the search term “mastectomy skin flap necrosis”. Titles and abstracts from peer-reviewed publications were screened for relevance. Results MSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited. Conclusion MSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

Breast-conserving surgery in patients with Paget's disease

Pagets disease of the breast is a rare condition that is associated with underlying breast cancer in the majority of patients. The conventional treatment for Pagets disease has been mastectomy, but there is an increasing trend to consider breast‐conserving surgery (BCS) in selected patients. Owing to the uncommon nature of the disease, research studies tend to be small and retrospective. This systematic review presents the published evidence regarding BCS for patients with Pagets disease with a focus on patient selection and oncological safety.

Repeat surgery following breast conservation and intra-operative sentinel lymph node analysis for breast cancer

INTRODUCTION Intra-operative sentinel node analysis (IOA) for breast cancer reduces the need for a second operation by revealing metastasis intra-operatively, allowing immediate axillary clearance. Critics argue that the number of patients deriving benefit is limited, as further surgery is often required for reasons other than nodal status. AIM To identify the proportion of women avoiding further surgery by using IOA excluding those who require further surgery for reasons other than axillary node metastasis. PATIENTS AND METHODS All patients undergoing sentinel node biopsy with IOA over one year were reviewed. Patient demographics, margin positivity, sentinel node metastasis, requirement for further surgery, and cavity shave involvement were analysed. RESULTS 322 patients were analysed: 253 undergoing breast-conserving surgery [BCS] and 69 undergoing mastectomy). IOA revealed metastasis in 81 (25.2.%) patients [25 undergoing mastectomy and 56 undergoing BCS], who underwent immediate axillary clearance. 43 BCS patients (17%) did not require further surgery other than for sentinel node involvement. 39 patients required further oncological surgery: 16 excision of margins; 13 completion mastectomy; 6 excision of margins followed by mastectomy; 3 completion axillary clearance; and 1 excision of recurrence. 20.6% had involvement of any circumferential histological margin. Cavity shaves were performed in 28.5% patients at initial surgery, the majority of which were clear of malignancy. 20 mastectomy patients had concordant definitive histology, avoiding a second operation. In total, 19.6% of this cohort avoided a second operation through the use of IOA. DISCUSSION Approximately 15% of patients undergoing breast conservation surgery for breast cancer require further surgery. However, a further 17% were saved subsequent surgery by utilising IOA, since they had immediate axillary clearance. When also considering patients undergoing mastectomy, this proportion is even higher.