James Kollias

Psychological impact and cosmetic outcome of surgical breast cancer strategies

Background:  Current surgical treatment modalities for breast cancer include breast conserving surgery, mastectomy alone and mastectomy with breast reconstruction. There are recognized benefits of breast conservation and breast reconstruction over mastectomy but there are few studies assessing this area in Australia. The aim of the present study was to compare the various surgical strategies for breast cancer treatment in terms of quality of life, cosmesis and patient satisfaction.

Thyroid surgery and voice-related outcomes

Background: Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles. Methods: Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire. Results: Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow-up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively. Conclusions: Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre-operative voice status.

COMPARISON OF VOLUME DISPLACEMENT VERSUS CIRCUMFERENTIAL ARM MEASUREMENTS FOR LYMPHOEDEMA: IMPLICATIONS FOR THE SNAC TRIAL

Background:  The Royal Australasian College of Surgeons Sentinel Node versus Axillary Clearance trial is a randomized controlled trial comparing sentinel node biopsy with axillary clearance in breast cancer patients. Primary study end‐points include arm volume differences with time, which may indicate the development of lymphoedema. The RACS SNAC trial uses circumferential arm measurements in the estimation of arm volume. This study aimed to assess the accuracy of circumferential volume estimation in comparison with water displacement.

Computer simulations of lymph node metastasis for optimizing the pathologic examination of sentinel lymph nodes in patients with breast carcinoma

Many empiric protocols are used to detect metastases in sentinel lymph nodes (SLNs), but comparison of the efficacy of these methods is impractical because tissue is lost in processing, making reassessment with another policy difficult. Consequently, performance indicators of this test are largely unknown.

QUALITATIVE ASSESSMENT OF BREAST RECONSTRUCTION IN A SPECIALIST BREAST UNIT

Background:  Breast reconstruction is an integral part of the surgical management of women with breast cancer. It is often performed by plastic surgeons but, in some centres, it is performed by breast surgeons trained in breast reconstruction and oncoplastic surgery. We evaluated the objective and subjective outcomes of reconstruction for breast cancer at the Royal Adelaide Hospital Breast Unit (Adelaide, Australia) between 1990 and June 2002.

Breast volume replacement using the latissimus dorsi miniflap

Background:  Mastectomy is often recommended to women with early breast cancer who have large tumours or where the breast volume requiring resection to achieve adequate tumour clearance is too great to allow for a satisfactory cosmetic result after breast conservation surgery. The use of a latissimus dorsi muscular flap (latissimus dorsi miniflap (LDMF)) to replace the volume loss after major breast sector resection is an option where the tumour to breast volume ratio is large. The present study describes the technique and evaluates the experience of the LDMF at Royal Adelaide Hospital, Adelaide, Australia.

Removal of two sentinel nodes accurately stages the axilla in breast cancer.

Assessment of lymph node status in breast cancer is still necessary for staging. Sentinel lymph node biopsy (SNB) may provide accurate staging with less morbidity than axillary clearance. The aim of this study was to assess the effect of the number of sentinel nodes removed on the false‐negative rate.

Factors predictive of treatment by Australian breast surgeons of invasive female breast cancer by mastectomy rather than breast conserving surgery

BACKGROUND The National Breast Cancer Audit Database of the Society of Breast Surgeons of Australia and New Zealand is used by surgeons to monitor treatment quality and for research. About 60% of early invasive female breast cancers in Australia are recorded. The objectives of this study are: (1) to investigate associations of socio-demographic, health-system and clinical characteristics with treatment of invasive female breast cancer by mastectomy compared with breast conserving surgery; and (2) to consider service delivery implications. MATERIALS AND METHODS Bi-variable and multivariable analyses of associations of characteristics with surgery type for cancers diagnosed in 1998-2010. RESULTS Of 30,299 invasive cases analysed, 11,729 (39%) were treated by mastectomy as opposed to breast conserving surgery. This proportion did not vary by diagnostic year (p>0.200). With major city residence as the reference category, the relative rate (95% confidence limits) of mastectomy was 1.03 (0.99, 1.07) for women from inner regional areas and 1.05 (1.01, 1.10) for those from more remote areas. Low annual surgeon case load (<10) was predictive of mastectomy, with a relative rate of 1.08 (1.03, 1.14) when compared with higher case loads. Tumour size was also predictive, with a relative rate of 1.05 (1.01, 1.10) for large cancers (40+ mm) compared with smaller cancers (<30 mm). These associations were confirmed in multiple logistic regression analysis. CONCLUSIONS Results confirm previous studies showing higher mastectomy rates for residents of more remote areas, those treated by surgeons with low case loads, and those with large cancers. Reasons require further study, including possible effects of surgeon and womans choice and access to radiotherapy services.

Patterns of Surgical Treatment for Women with Breast Cancer in Relation to Age

Abstract:  Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged ≤40 years (OR = 1.140; 95% CI: 1.004–1.293) compared to women aged 51–70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455–0.545). Significantly more women aged ≤50 years underwent more than one operation for breast conservation (20.4–24.8%) compared with women aged >50 years (11.4–17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0–1.3% in all other age groups (≤40, 41–50 51–70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age ≤40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.

Intraoperative imprint cytologic assessment of the sentinel node for early breast cancer

Abstract An increasing number of patients are undergoing sentinel node biopsy alone for axillary staging of early breast cancer. A reliable method for evaluating the status of the sentinel node intraoperatively would allow patients with sentinel node metastases to undergo immediate rather than delayed axillary clearance. Sentinel nodes in 53 consecutive patients were examined by intraoperative imprint cytology. When compared with subsequent analysis by hematoxylin-eosin staining and immunohistochemistry, the accuracy of imprint cytology for the detecting nodal metastases was 81.1%; the false negative rate was 47.0%, and there were no false positives. Results were made available to the operating surgeon within a mean time of 25 minutes. All but one of the false negatives involved micrometastatic deposits of less than 0.1 mm. Intraoperative imprint cytologic examination of the sentinel node is a useful technique that can be performed efficiently and without loss of nodal tissue for subsequent analysis. With the use of this technique, more than 50% of lymph node-positive patients would potentially be spared a second operation.