Dimitri Hadjiminas

Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies

Objectives:To evaluate differences in outcomes of breast cancer patients undergoing either conventional mastectomy without reconstruction (NSSM) or skin-sparing mastectomy (SSM) with immediate reconstruction. Data Sources:All comparative studies published between 1997 and 2009 were used to evaluate local recurrence and distant relapse in the 2 study groups. Review Methods:Meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, was carried out to evaluate the robustness of the pooled estimates and assess the between-study heterogeneity. Results:Nine studies, comprising of 3739 patients (1104 SSM and 2635 NSSM) were included in the analysis. There were no significant differences in the disease stage or the proportion of invasive cancers between groups (73.9% vs. 83.8%, P = 0.65). There was no significant difference in local recurrence between the SSM versus NSSM groups (7 studies, 3436 patients, 6.2% vs. 4.0%, odds ratio = 1.25, 95% CI: 0.81–1.94) and there was no significant heterogeneity between the studies. The SSM group had a lower proportion of distant relapses compared with the NSSM group (5 studies, 2122 patients, 10.0% vs. 12.7%, odds ratio = 0.67, 95% CI: 0.48–0.94) but this should be interpreted with caution since the grade of the tumors was not adequately reported in the studies considered. Conclusions:Our results suggest that in breast cancer patients, SSM was not significantly different from NSSM, in terms of rates of local recurrence. As no randomized control trial has addressed this question to date, the present meta-analysis reports the best evidence on the subject.

Optimising preoperative diagnosis in phyllodes tumour of the breast

The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. However, reliable differentiation of phyllodes tumour from cellular fibroadenoma remains difficult. Preoperative diagnostic accuracy allows correct surgical treatment, avoiding the pitfalls of reoperation because of inadequate excision, or surgical overtreatment. Specific clinical indices may arouse diagnostic suspicion but are unreliable for confirmation, as with current imaging modes. Fine needle aspiration cytology has a high false negative rate. Few studies have evaluated the role of core needle biopsy, but it may prove a useful adjunct. Both diagnostic and prognostic information may in future be gained from application of immunohistochemical and other techniques assessing the expression of proliferative markers including p53, Ki-67, and others.

Diagnostic Accuracy of Intraoperative Techniques for Margin Assessment in Breast Cancer Surgery: A Meta-analysis.

Objective: The aim of this study was to conduct a systematic review and meta-analysis to clarify the diagnostic accuracy of intraoperative breast margin assessment (IMA) techniques against which the performance of emerging IMA technologies may be compared. Summary of Background Data: IMA techniques have failed to penetrate routine practice due to limitations, including slow reporting times, technical demands, and logistics. Emerging IMA technologies are being developed to reduce positive margin and re-excision rates and will be compared with the diagnostic accuracy of existing techniques. Method: Studies were identified using electronic bibliographic searches up to January 2016. MESH terms and all-field search terms included “Breast Cancer*” AND “Intraoperative*” AND “Margin*.” Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included. A bivariate model for diagnostic meta-analysis was used to attain overall pooled sensitivity and specificity. Results: Eight hundred thirty-eight unique studies revealed 35 studies for meta-analysis. Pooled sensitivity (Sens), specificity (Spec), and area under the receiver operating characteristic curve (AUROC) values were calculated per group (Sens, Spec, AUROC): frozen section = 86%, 96%, 0.96 (n = 9); cytology = 91%, 95%, 0.98 (n = 11); intraoperative ultrasound = 59%, 81%, 0.78 (n = 4); specimen radiography = 53%, 84%, 0.73 (n = 9); optical spectroscopy = 85%, 87%, 0.88 (n = 3). Conclusions: Pooled data suggest that frozen section and cytology have the greatest diagnostic accuracy. However, these methods are resource intensive and turnaround times for results have prevented widespread international adoption. Emerging technologies need to compete with the diagnostic accuracy of existing techniques while offering advantages in terms of speed, cost, and reliability.

Atypical Anaphylactic Reaction to Patent Blue During Sentinel Lymph Node Biopsy for Breast Cancer

INTRODUCTION We present an unusual case of severe anaphylaxis to Patent Blue dye with atypical clinical features during sentinel lymph node biopsy (SLNB). The medical personnel involved with sentinel node biopsies should be alert, and familiar with this unusual entity. We also present current data from the literature. CASE REPORT During a wide local excision for primary breast cancer and SLNB, and early during the operation, the patient became severely tachycardic and hypotensive without any signs of urticaria, rash, oedema, or bronchospasm. Resuscitation required the addition of noradrenaline infusion followed by an overnight admission to the intensive care unit. Raised serum tryptase levels supported the diagnosis of anaphylactic shock while skin tests showed a severe reaction to Patent Blue dye. CONCLUSIONS Severe, life-threatening anaphylaxis to Patent Blue dye may present without obvious previous exposure to the dye and without the cardinal signs of oedema, urticaria and bronchospasm making the diagnosis and management of such cases challenging. Correct diagnosis and identification of the causative factor is important and requires a specific set of laboratory tests that are not commonly requested in every-day medical practice. It is not clear from the literature whether the condition is common enough to justify pre-operative prophylactic or diagnostic measures.

Trends in Immediate Postmastectomy Breast Reconstruction in the United Kingdom.

Background: The study aimed to evaluate local and national trends in immediate breast reconstruction (IBR) using the national English administrative records, Hospital Episode Statistics. Our prediction was an increase in implant-only and free flap procedures and a decline in latissimus flap reconstructions. Methods: Data from an oncoplastic center were interrogated to derive numbers of implant-only, autologous latissimus dorsi (LD), LD-assisted, and autologous pedicled or free flap IBR procedures performed between 2004 and 2013. Similarly, Hospital Episode Statistics data were used to quantify national trends in these procedures from 1996 to 2012 using a curve fitting analysis. Results: National data suggest an increase in LD procedures between 1996 (n = 250) and 2002 (n = 958), a gradual rise until 2008 (n = 1398) followed by a decline until 2012 (n = 1090). As a percentage of total IBR, trends in LD flap reconstruction better fit a quadratic (R2 = 0.97) than a linear function (R2 = 0.63), confirming a proportional recent decline in LD flap procedures. Conversely, autologous (non-LD) flap reconstructions have increased (1996 = 0.44%; 2012 = 2.76%), whereas implant-only reconstructions have declined (1996 = 95.42%; 2012 = 84.92%). Locally, 70 implant-assisted LD procedures were performed in 2003 -2004, but only 2 were performed in 2012 to 2013. Conclusions: Implants are the most common IBR technique; autologous free flap procedures have increased, and pedicled LD flap procedures are in decline.

Breast conserving surgery with preservation of the nipple-areola complex as a feasible and safe approach in male breast cancer: a case report

IntroductionBreast cancer in men is rare. The evidence about treatment has been derived from data on the management of the disease in women. The usual treatment is for male patients to undergo modified radical mastectomy. There is insufficient experience of breast conserving surgery with preservation of the nipple. The management of patients who demand such an approach for personal reasons remains a challenge for both the surgeon and oncologist.Case presentationA 50-year-old man with a breast cancer was successfully managed with breast conserving surgery with nipple preservation combined with axillary clearance and postoperative radiotherapy, chemotherapy and hormone treatment. Since there are no similar cases in the literature, we discuss the feasibility, safety and possible indications of such an approach.ConclusionDespite the limited indications and evidence about the safety and efficacy of breast conserving surgery with nipple preservation in men with breast cancer, it is a feasible approach if other options are declined by the patient. More studies are necessary to reach firm conclusions about the safety of such an approach.

Sentinel lymph node biopsy after neo-adjuvant chemotherapy in patients with breast cancer: Are the current false negative rates acceptable?

The advent of sentinel lymph node biopsy has revolutionised surgical management of axillary nodal disease in patients with breast cancer. Patients undergoing neo-adjuvant chemotherapy for large breast primary tumours may experience complete pathological response on a previously positive sentinel node whilst not eliminating the tumour from the other lymph nodes. Results from 2 large prospective cohort studies investigating sentinel lymph node biopsy after neo-adjuvant chemotherapy demonstrate a combined false negative rate of 12.6-14.2% and identification rate of 80-89% with the minimal acceptable false negative rate and identification rate being set at 10% and 90%, respectively. A false negative rate of 14% would have been classified as unacceptable when compared to the figures obtained by the pioneers of sentinel lymph node biopsy which was 5% or less.

Patient attitudes towards undergoing additional breast biopsy for research

BACKGROUND Acquisition of additional breast tissue has become integral to breast oncology research. This questionnaire study examines patient willingness to undergo research-dedicated breast biopsies either at time of diagnostic biopsy (T1) or after carcinoma diagnosis has been confirmed and eligibility for a specific study established (T2), and influencing factors thereof. METHODS Prior to consultation, patients attending breast clinics were recruited to complete a questionnaire examining willingness to undergo an extra fine needle aspirate (FNA) and/or core needle biopsy (CNB) for research either at T1 or T2. Descriptions of FNA and CNB procedures were supplied to those with no prior experience. Patient perspectives towards donating surplus tissue remaining from a diagnostic procedure and/or surgery for future research were also explored. FINDINGS A total of 100 patients were recruited, 42% with prior history of breast carcinoma (BC), 22% with family history of BC (FHBC) and 65%/42% with previous experience of CNB/FNA respectively. Overall, 57% were willing to undergo additional biopsy at one or both time points. Willingness to undergo additional biopsy was greater for T1 than T2, but equivalent for CNB and FNA (willingness CNB T1, 50% vs T2, 26%, willingness FNA T1 50% vs T2 29%). A statistically significant increase in willingness to undergo CNB and/or FNA at T1 and/or T2 was seen in association with prior diagnosis of BC, FHBC, previous visit to breast clinic and prior experience of breast biopsy. 83% of patients expressed a willingness to allow surplus tissue to be stored in a biobank for future research. INTERPRETATION Where possible patients should be approached to undergo baseline research biopsies at time of diagnostic process rather than subsequently. Patients do not find FNA more acceptable than core biopsy. Prior exposure to the biopsy procedure increases willingness to undergo research-dedicated biopsies.

Should we manage all cases of granulomatous mastitis conservatively? A 14 year experience.

To the Editor: Granulomatous mastitis (GLM) is a rare localized benign inflammation of the breast, presenting commonly as a painful mass in young women with a history of recent breast-feeding (1,2). It can often mimic breast carcinoma both radiologically and clinically. The histologic presence of non caseating granulomas confined within breast lobules together with negative microbiologic finding, including mycobacteria and fungal cultures often confirms diagnosis (1,2). Steroids, surgery, and antibiotics have been used with varying degrees of success as recurrence and a chronic clinical course are deemed to be more likely without intervention (2,3). We present our experience of managing GLM conservatively over the last 14 years. We identified all patients presenting with GLM retrospectively from the histopathologic archival data base between 1996 and 2010. Hospital records were reviewed, patient demographics, presenting complaint and history, relevant obstetric history, initial treatment, recurrence, length of follow-up, and discharge from clinic were recorded. The radiologic and microbiologic results including tuberculosis and fungal infections were also compiled for each patient. For those patients that had been discharged from clinic, a telephone questionnaire was conducted inquiring specifically if there had been further recurrence of disease with treatment being sought at another hospital. A total of 17 patients were identified with GLM. One patient was excluded due to inaccessible hospital records. Telephonic consultation was possible for 13 patients. The median age of presentation was 37 (21–50) years. Patients were of multiethnic origin, mostly being Africo-Carribean or Asian (n = 9, 56.3%). Three (18.8%) of the patients had previously been treated for benign breast lumps affecting the other breast. There were 13 parous patients (81.3%) with only one patient being pregnant, three patients had delivered less than 12 months and eight patients had been pregnant more than 3 years before presentation. None of the patients were breast-feeding, but a majority of the patients (n = 10, 60%) had breast-fed previously with two having breast-fed within the last 4 months from presentation. The left breast was affected in 10 of 16 patients and there was no bilateral breast involvement. The presented complaints were lump (n = 16), pain (n = 12), erythema (n = 4), and a discharging sinus in five patients. Mammography and ultrasound were done for 11 patients with three patients having only an ultrasound and two patients having a mammogram alone. Ultrasound suggested a suspicious lesion, meriting further investigations, in nine (81.8%) patients. The mammogram showed a nonspecific density in six patients with one showing suspicious microcalcifications. All patients (n = 16) underwent diagnostic core biopsy confirming GLM on histology. Excisional biopsy was not performed in any of the patients. After the diagnosis of GLM was made further core biopsies were taken. Core biopsies from three patients yielded mycobacteria tuberculosis after culture and from one patient it was Aspergillus Fumigatus. All patients received up to 2 weeks of antibiotics initially prior to diagnosis. No further treatment was given to any of the patients until TB and fungal cultures were reported after 12 weeks. At that point, three patients were commenced on anti-tuberculosis treatment and one on oral systemic anti-fungal therapy. The remaining 12 patients were diagnosed with idiopathic GLM. Two patients who had substantial discharging sinuses were then treated with 50–60 mg of Prednisolone for 6 months and then reducing dose over a further 6 months. The remaining 10 patients were advised to have no medical treatment and attended our follow-up clinic at 6–12 weekly intervals till complete regression of the disease. Symptoms resolved within 6–12 months in seven patients. The Address correspondence and reprint requests to: Ms Parveen Jayia, Apartment 30 The School House, 69 Tollington Road, Islington, N7 6DW, UK, or e-mail: parveenjayia@gmail.com.

Validation of an oncoplastic breast simulator for assessment of technical skills in wide local excision.

Simulation enables safe practice and facilitates objective assessment of technical skills. However, simulation training in breast surgery is rare and assessment remains subjective. The primary aim was to evaluate the construct validity of technical skills assessments in wide local excision (WLE).