James French

Ductal Carcinoma in Situ at Core-Needle Biopsy: Meta-Analysis of Underestimation and Predictors of Invasive Breast Cancer

PURPOSE To perform a meta-analysis to report pooled estimates for underestimation of invasive breast cancer (where core-needle biopsy [CNB] shows ductal carcinoma in situ [DCIS] and excision histologic examination shows invasive breast cancer) and to identify preoperative variables that predict invasive breast cancer. MATERIALS AND METHODS Studies were identified by searching MEDLINE and were included if they provided data on DCIS underestimates (overall and according to preoperative variables). Study-specific and pooled percentages for DCIS underestimates were calculated. By using meta-regression (random effects logistic modeling) the association between each study-level preoperative variable and understaged invasive breast cancer was investigated. RESULTS Fifty-two studies that included 7350 cases of DCIS with findings at excision histologic examination as the reference standard met the eligibility criteria and were included. There were 1736 underestimates (invasive breast cancer at excision); the random-effects pooled estimate was 25.9% (95% confidence interval: 22.5%, 29.5%). Preoperative variables that showed significant univariate association with higher underestimation included the use of a 14-gauge automated device (vs 11-gauge vacuum-assisted biopsy, P = .006), high-grade lesion at CNB (vs non-high grade lesion, P < .001), lesion size larger than 20 mm at imaging (vs lesions ≤ 20 mm, P < .001), Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5 (vs BI-RADS score of 3, P for trend = .005), mammographic mass (vs calcification only, P < .001), and palpability (P < .001). CONCLUSION About one in four DCIS diagnoses at CNB represent understaged invasive breast cancer. Preoperative variables significantly associated with understaging include biopsy device and guidance method, size, grade, mammographic features, and palpability.

Aorto‐enteric fistula following endoluminal abdominal aortic aneurysm repair

An aortoenteric fistula (AEF) is a communication between the aorta and an adjacent loop of bowel, and is classified as being primary or secondary. Primary fistulae occur without a prior history of aortic intervention or repair and typically result from erosion of an infected aorta into the posterior wall of the duodenum. Secondary fistulae develop after aortic intervention and typically involve the proximal suture line 1 and/or prosthetic graft material. Secondary AEF are more common, with a reported incidence of between 0.36% 2 and 4% 3 of patients who have undergone open aortic surgery. In 1999 the first case of an aortoduodenal fistula (ADF) following an endoluminal aortic graft repair was reported. Four other cases 4–6 have been reported since then. We report a sixth case, believed to be the first in Australia (Table 1).

Intraoperative sentinel lymph node assessment in breast cancer: a comparison of rapid diagnostic method based on CK19 mRNA expression and imprint cytology

Sentinel lymph node biopsy in breast cancer is a routine technique for staging the axilla. The two most common methods of intraoperative histopathological assessment, imprint cytology and frozen section, are hampered by poor sensitivity and lack standardized methodology. The one‐step nuclei acid amplification (OSNA) assay is a rapid quantification of cytokeratin 19 mRNA. This prospective study compared an existing intraoperative imprint cytology protocol with the OSNA system.

Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the Breconda Randomized Controlled Trial

Background: Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making. Methods: Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants’ decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret. Results: Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants’ ratings for BRECONDA demonstrated high user acceptability and overall satisfaction. Conclusions: Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision.

Relevance of the American College of Surgeons Oncology Group Z0011 Trial to breast cancer in the Australian setting.

Conventional wisdom suggests that a patient with a positive sentinel node requires a completion axillary clearance to obtain full staging and durable regional control. However, this dictum has been challenged by the recent American College of Surgeons Oncology Group Z0011 Trial demonstrating that women with node‐positive breast cancer who underwent sentinel node biopsy only, and were treated with breast conserving surgery and radiation, had equivalent locoregional recurrence and survival rates to those who had a completion axillary clearance. The aim of our study was to determine what the clinical impact of the Z0011 findings might be if patients were managed according to the Z0011 criteria in an Australian teaching hospital setting.

Factors Affecting the Preoperative and Postoperative Extracellular Fluid in the Arm on the Side of Breast Cancer: A Cohort Study

BACKGROUND To explore what factors affect volume of extracellular fluid (ECF) in the arm on the side of surgery pre- and postoperatively and to determine the value of knowing preoperative ECF volume for diagnosis of lymphedema postoperatively. METHODS AND RESULTS Women (N=516) with early breast cancer were assessed preoperatively and within 4 weeks postoperatively. Baseline measures included inter-arm ECF ratio, side of cancer, number of nodes involved, and other individual characteristics. Postoperative assessment included inter-limb ECF ratio and details from surgery. The postoperative ECF ratio was categorized as to whether it exceeded previously established thresholds, and the change in ECF was categorized as to whether it exceeded 0.1. Linear regression identified which factors explained the variance for preoperative ECF ratio and the change in ratio. Chi square analysis compared whether women categorized using thresholds were the same as those whose ratio increased >0.1 postoperatively. Postoperative ECF ratio was significantly higher than the preoperative ratio (p<0.001). Women whose ECF ratio exceeded previously established thresholds were not the same as those whose ratio increased >0.1 postoperatively (p<0.001). Only the side of surgery explained the preoperative ECF measure; extent of surgery and actual weight explained the change in ECF ratio. CONCLUSION The ECF ratio preoperatively is not affected by nodal involvement. The change in ECF ratio is affected by the extent of surgery and body mass. Change from preoperative ECF ratio did identify more women at risk for lymphedema than reliance postoperatively on thresholds, supporting preoperative measures.

Nipple-sparing mastectomy with implant reconstruction: the Westmead experience.

Nipple‐sparing mastectomy (NSM) involves the removal of all breast tissue with preservation of the breast skin envelope and nipple‐areola complex (NAC). The objective of this study was to report the outcomes from our initial experience with NSM.

Body image and psychological distress in nipple-sparing mastectomy: the roles of self-compassion and appearance investment

Women with breast cancer face threats to body image following surgery. Nipple‐sparing mastectomy with immediate breast reconstruction (NSM + IBR) may minimise body image disturbance as this preserves the womans skin and areola complex. We assessed levels of body image disturbance and psychological distress in women undergoing NSM + IBR. To further understand the body image–distress relationship, we investigated the potential moderating effect of self‐compassion and appearance investment on this relationship.

Patient reported outcomes of autologous fat grafting after breast cancer surgery

INTRODUCTION Autologous fat grafting (AFG) can be used as an adjunct in breast cancer surgery to improve contour defects. Few previous studies have assessed patient reported outcomes (PROs) for AFG. This study analysed AFG use and assessed PROs in terms of physical and psychosocial well-being. MATERIALS AND METHODS All patients undergoing AFG were identified from a prospective database and asked to complete the validated BREAST-Q questionnaire and a tool to assess patient-perceived change after AFG (5-point Likert-type scale). Descriptive statistics were computed for all BREAST-Q and perceived change subscales. Independent sample t-tests were conducted to compare scores on each of the BREAST-Q and perceived change subscales by type of breast cancer surgery and radiotherapy status. RESULTS 156 AFG sessions were performed over 4 years on 119 breasts in 88 patients. Fifty-seven patients received AFG after reconstruction and 19 after breast conserving surgery. Forty-six patients (52%) completed the questionnaire. BREAST-Q scores (out of 100) and patient-perceived change after AFG (out of 5) were respectively: 54 and 4.0 for Breast satisfaction, 69 and 3.3 for Physical well-being and 60 and 3.6 for Psychosocial well-being. Radiotherapy status and type of surgery made little difference. Number of AFG procedures positively correlated with perceived improvement. DISCUSSION Autologous fat grafting was associated with improved patient satisfaction despite small volumes transferred. BREAST-Q scores were comparable with previously published series on reconstructive breast surgery. Perceived change after AFG was no different in patients receiving radiotherapy.

Implant salvage in breast reconstruction with severe peri-prosthetic infection.

Although treatment of mild peri‐prosthetic infection in implant‐based breast reconstruction results in high rates of resolution, successful management of severe peri‐prosthetic infection remains a significant challenge.