Ines Buccimazza

Colorectal foreign bodies.

Objective  A pictorial review of colorectal foreign bodies and their extraction.

Oncoplastic Breast Surgery: A Global Perspective on Practice, Availability, and Training

Oncoplastic surgery is the seamless joining of the extirpative and reconstructive aspects of breast surgery that is performed by a single surgeon. A symposium was held at ISW 2007 in Montreal with a prearranged aim to publish an article on the current and historical record of the developing specialty of oncoplastic breast surgery. The presenters and authors are well-known breast surgeons from Australia, Croatia, India, Sweden, and South Africa.

Improving outcomes in breast cancer for low and middle income countries.

Abstract Breast cancer is the most common cancer in women world-wide. Incidence rates in low- and middle-income countries (LMICs) are lower than in high income countries; however, the rates are increasing very rapidly in LMICs due to social changes that increase the risk of breast cancer. Breast cancer mortality rates in LMICs remain high due to late presentation and inadequate access to optimal care. Breast Surgery International brought together a group of breast surgeons from different parts of the world to address strategies for improving outcomes in breast cancer for LMICs at a symposium during International Surgical Week in Helsinki, Finland in August 2013. A key strategy for early detection is public health education and breast awareness. Sociocultural barriers to early detection and treatment need to be addressed. Optimal management of breast cancer requires a multidisciplinary team. Surgical treatment is often the only modality of treatment available in low-resource settings where modified radical mastectomy is the most common operation performed. Chemotherapy and radiotherapy require more resources. Endocrine therapy is available but requires accurate assessment of estrogen receptors status. Targeted therapy with trastuzumab is generally unavailable due to cost. The Breast Health Global Initiative guidelines for the early detection and appropriate treatment of breast cancer in LMICs have been specifically designed to improve breast cancer outcomes in these regions. Closing the cancer divide between rich and poor countries is a moral imperative and there is an urgent need to prevent breast cancer deaths with early detection and optimal access to treatment.

The challenges of managing breast cancer in the developing world - a perspective from sub-Saharan Africa

Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer,and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.

An unusual complication of intestinal amoebiasis

Corresponding author: thomson@ukzn.ac.za hemicolectomy with a primary restorative anastomosis was performed. Figs 1 and 2 demonstrate the resected specimen. Histological examination revealed extensive amoebiasis involving the caecum and intussusceptum. We postulated that the amoebic focus served as a lead point for the development of this intussusception. Traditionally it was thought that intestinal amoebiasis confined itself to the colon and spared the terminal ileum. Certainly the doyen of the surgical complications of amoebiasis, the late Professor Luvuno, never reported ileal amoebiasis in his extensive reviews on the topic. Although our institution has subsequently reported on the existence of ileal amoebiasis, amoebiasis as a cause of ileo-colic and colocolic intussusception has only previously been described on the Asian subcontinent. It would appear that ileal amoebiasis as a cause of ileocolic intussusception is something of a unique complication in KwaZulu-Natal, and worthy of documentation.

Prevalence of breast tuberculosis: Retrospective analysis of 65 patients attending a tertiary hospital in Durban, South Africa

BACKGROUND Breast tuberculosis (BTB) is uncommon, but not rare. Knowledge of the ways in which it can present can prevent unnecessary invasive procedures and delay in diagnosis. OBJECTIVES To describe the clinical and radiological findings in patients with BTB, including evaluation of current treatment methods. METHODS We retrospectively analysed 65 patients diagnosed with BTB at Addington and King Edward VIII hospitals, Durban, South Africa, between 2000 and 2013. Demographic, clinical and radiological findings and treatment outcomes were noted. RESULTS A total of 11,092 patients underwent breast investigations between 2009 and 2013, with a prevalence of BTB for the period of 0.3% (30 patients). Of the 65 patients diagnosed between 2000 and 2013, 64 were female (98.5%) and one was male (1.5%). The age range was 23-69 years (mean 38.5). The most common mammographic pattern was density (39.4%) and the least common a mass (6.1%). Isolated axillary lymphadenitis was found in 12.1%. Abscess was the commonest ultrasound pattern (39.0%). Of the 47 patients with a known history of pulmonary tuberculosis (TB), 68.1% (n=32) did not have radiological evidence of previous or concurrent pulmonary TB, nor was there evidence of TB elsewhere. Of 47 patients with known HIV status, 34 were HIV-positive. Fine-needle aspiration cytology had sensitivity of only 28% compared with 94% for histology. Of those treated, 72.7% obtained full resolution following 9 months of TB treatment; 25.0% did not complete treatment, and 2.3% (n=1) died while on treatment. Follow-up data on relapse rates after treatment completion and disease resolution are scanty. CONCLUSION Understanding and being aware of the various presentations of BTB make it possible to treat most patients successfully.

South African Breast Cancer and HIV Outcomes Study: Methods and Baseline Assessment

Purpose In low- and middle-income, HIV-endemic regions of sub-Saharan Africa, morbidity and mortality from the common epithelial cancers of the developed world are rising. Even among HIV-infected individuals, access to antiretroviral therapy has enhanced life expectancy, shifting the distribution of cancer diagnoses toward non–AIDS-defining malignancies, including breast cancer. Building on our prior research, we recently initiated the South African Breast Cancer and HIV Outcomes study. Methods We will recruit a cohort of 3,000 women newly diagnosed with breast cancer at hospitals in high (average, 20%) HIV prevalence areas, in Johannesburg, Durban, Pietermaritzburg, and Empangeni. At baseline, we will collect information on demographic, behavioral, clinical, and other factors related to access to health care. Every 3 months in year 1 and every 6 months thereafter, we will collect interview and chart data on treatment, symptoms, cancer progression, comorbidities, and other factors. We will compare survival rates of HIV-infected and uninfected women with newly diagnosed breast cancer and their likelihood of receiving suboptimal anticancer therapy. We will identify determinants of suboptimal therapy and context-specific modifiable factors that future interventions can target to improve outcomes. We will explore molecular mechanisms underlying potentially aggressive breast cancer in both HIV-infected and uninfected patients, as well as the roles of pathogens, states of immune activation, and inflammation in disease progression. Conclusion Our goals are to contribute to development of evidence-based guidelines for the management of breast cancer in HIV-positive women and to improve outcomes for all patients with breast cancer in resource-constrained settings.

Implementing Sentinel Lymph Node Biopsy Programs in Developing Countries: Challenges and Opportunities

Not all malignancies in developing countries present at an advanced stage. In countries with unique economic maps and heterogeneous populations the spectrum of presentation is the same as that seen in developed countries. Globally, there has been a paradigm shift in the management of cancers: treatment has become more patient specific and tumor specific. It is therefore incumbent on surgeons, including those in developing countries, to be familiar with the vagaries of surgical practices in the treatment of malignancies. Sentinel lymph node biopsy (SLNB) is a technique used worldwide to detect lymphatic spread from a variety of tumors. In the treatment of breast cancer, SLNB is the standard of care in clinically node-negative breast cancer and the preferred staging procedure. The largest and most important trial of SLNB for melanoma conducted to date has also firmly established the concept of SLNB. Results support SLNB as a standard of care staging procedure in patients with intermediate-thickness (1.2–3.5 mm) melanoma [1]. In their masterful article included in the current issue of World Journal of Surgery, Keshtgar et al. [2] provide a pragmatic approach to the implementation of SLNB programs in under-resourced settings. The authors, who collectively represent a distinguished panel of experts on this subject, are to be commended on a thoroughly researched, appropriately referenced, and authoritative paper on the philosophy, physics, techniques, and implications of this form of nodal staging for both breast cancer and melanoma. The wealth of practical information provided is useful in any resource setting. The article is important for many reasons: it highlights the reality that most patients in developing countries do not receive established standard care, even though they may qualify; it mentions some of the obstacles hindering the effective implementation of SLNB programs in developing countries; and it embraces the principle of devising training programs suitable to local circumstances yet consistent with international standards and recommendations Although the concept is not original (the successful UK NEW START model [3] was adapted for the purpose of training clinicians in developing countries) these authors have recognized that there are specific difficulties that need to be considered when developing global training programs. They extensively discuss some of the difficulties that can compromise the effective implementation of SLNB programs in under-resourced areas. There are, however, other difficulties that pose obstacles to the initiation of any new endeavor. Although these obstacles is highly prevalent in developing countries, there have also been reports from first world countries outlining such difficulties. For example, it is well known that a fair and egalitarian health system with open access for all is not a high priority in developing countries. Health care is characterized by overburdened, under-resourced public facilities staffed with borderline work forces and large, medically underserved rural communities. However, similar problems have been reported from maximally resourced countries. A 2006 article by Newman revealed that minority-ethnicity women and those residing in geographically remote regions within the United States are less likely to have access to the most advanced surgical techniques for breast cancer. This I. Buccimazza (&) Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa e-mail: ines@orthoserve.co.za

Invited Commentary: The Impact of Neoadjuvant Chemotherapy on Patients with Locally Advanced Breast Cancer in a Nigerian Semiurban Teaching Hospital: A Single-Center Descriptive Study

Locally advanced breast cancer (LABC) is a common occurrence in developing countries. Guidelines for the treatment of LABC, with particular reference to lowresource countries, have been published [1]. These state, inter alia, that neoadjuvant chemotherapy (NACT) should be standard treatment for LABC in all resource settings; and that multidisciplinary teams should be available for the management of breast cancer patients, irrespective of resource setting. Two important points were highlighted. First that all the trials demonstrating the efficacy of NACT (response rates and improved survival rates) have been conducted in developed countries. Second very little is published on the impact of NACT for LABC in developing countries; and although scientific advances drive management guidelines, the implementation is limited by local resources and expertise. In developing countries NACT with an anthracyclinecontaining regimen is administered to downsize lesions and render them resectable via mastectomy. Clinical response rates of between 60% and 80% can be achieved, but less than 20% of patients achieve a complete pathologic response, which is considered an important prognostic factor [2] and a critical determinant of outcome. The patient profile in the article by Arowolo et al. [3] documenting the impact of NACT in patients with LABC in their center mirrors that reported from other developing countries. This suggests a different spectrum of the disease when compared to developed countries [4]. Patients are approximately one decade younger and, for a panoply of sociocultural reasons, presentation is late [5]. Further compounding factors are inadequacies in healthcare standards and infrastructure, as well as a prevailing culture of poor follow-up. The poorer outcomes are largely attributable to the advanced disease stage at diagnosis and the lack of comprehensive multimodal treatment opportunities. Nevertheless, the impact of NACT and the outcome in the cohort of patients reported in this article by Arowolo et al. is different from that reported from other resource-limited countries [3]. The most striking differences in the study by Arowolo et al. are the tumor response rates and survival [3]. There was a clinical response rate of 51%, with no patient achieving a complete pathological response. The authors postulate that the large size of the tumors may account for the poor response rates. However, studies by Deo [6] and Chow [7], who used similar chemotherapy regimes in patients with LABC, revealed clinical response rates of 66% and 75% and complete pathological response rates of 4% and 13.2%, respectively. Average tumor size was [5 cm in 92% and 65% of patients, respectively. In both studies, response rate was unaffected by tumor size. It is conceivable that, despite similar patient profiles and challenges, there is variability, even within developing countries. This possibility raises interesting questions regarding possible chemoresistant clones or even the use of generic chemotherapy agents with less active ingredients. The 5-year survival rate of 11.9% in this study is also in stark contrast with that reported from other developing countries, where 5-year survival rates in excess of 50% have become the norm [2]. Two factors may have contributed to this difference: margin status and the lack of comprehensive multi-modal therapy. Clear margins were obtained in only 80.6% of patients. It has been shown in studies of patients with early breast I. Buccimazza (&) Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa e-mail: ines@orthoserve.co.za