Kylie Snook

Increasing breast reconstruction rates by offering more women a choice

Breast reconstruction (BR) following mastectomy for breast cancer is safe and has high rates of patient satisfaction, yet only around 12% of Australian women undergo BR. This study presents BR rates and outcomes from a specialist practice that discusses reconstruction options with all women medically suitable for BR.

High discordance rates between sub-areolar and peri-tumoural breast lymphoscintigraphy

OBJECTIVE To test the hypothesis that sub-areolar (SA) lymphoscintigraphy (LSG) identifies the same sentinel node as peri-tumoural (PT) injections. BACKGROUND It is commonly believed that all LSG techniques will identify the same sentinel lymph nodes (SLN) draining the breast. Hybrid imaging technology (SPECT/CT) allows accurate identification of the exact location of SLNs. Using SPECT/CT SA and PT LSG techniques were compared. METHOD In a multi-centre trial 39 patients sequentially underwent LSG (SA followed by PT) separated by 2-7 days. Patients were referred by 4 surgeons to 3 LSG centres, with standardization of isotope (99mTc-antimony sulfide colloid), LSG and SPECT/CT evaluation techniques. LSG were evaluated for SLN concordance and degree of discordance in the axilla and internal mammary nodes (IMN). RESULTS 39 eligible patients, median age 62 years, were recruited. Successful axillary SLN mapping for SA and PT injection techniques was 87% and 95% respectively. Successful internal mammary SLN mapping occurred with SA and PT LSG in 5% and 36% respectively. Discordance was identified in the IMN (39%) and axilla (21%), with an overall rate of discordance between SA and PT LSG of 56%. CONCLUSIONS There is a high level of discordance in the localization of SLN by these commonly used LSG injection techniques. This discordance has implications for accuracy of axillary and extra-axillary staging and could impact on patient outcome.

Utility of neoadjuvant chemotherapy in the treatment of operable breast cancer

Neoadjuvant chemotherapy (NAC) is a legitimate alternative to first‐line surgical therapy for the treatment of breast cancer patients, as level one evidence shows the effect on overall survival is equivalent to that of adjuvant chemotherapy. In the treatment of women with operable breast cancer, NAC provides a number of potential advantages including: improving the chance of achieving breast‐conserving surgery, improving cosmesis after breast‐conserving surgery, downstaging the breast and axilla, allowing time to fully consider surgical options, time for genetic testing and facilitating breast reconstruction in otherwise high‐risk patients. However, in Australia, NAC is poorly utilized with less than 3% of women with operable breast cancer receiving NAC. This review discusses the potential harms and benefits of NAC, discusses areas of controversy in the use of NAC and describes how we have used NAC in our own practice. We conclude that if it is obviously necessary for the newly presenting breast cancer patient to have chemotherapy as part of the treatment, it is worth considering NAC. In many patients, the potential benefits of NAC outweigh the harms. However, maximizing these benefits is closely aligned with appropriate patient selection and timely multidisciplinary team communication.

An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high-risk breast cancer.

Women with locally advanced breast cancer face many conflicting issues affecting their choice of immediate versus delayed versus no breast reconstruction (BR). This single‐centre pilot study assessed high‐risk womens reasons and priorities in choosing the timing and type of BR in a setting where all clinically feasible options were discussed with all women.

Patient-reported outcomes of breast reconstruction in older women: Audit of a large metropolitan public/private practice in Sydney, Australia

Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. This study compared patient‐reported outcomes between women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

Single-Arm Longitudinal Study to Evaluate a Decision Aid for Women Offered Neoadjuvant Systemic Therapy for Operable Breast Cancer

Background: Neoadjuvant systemic therapy (NAST) is an increasingly used treatment option for women with large operable or highly proliferative breast cancer. With equivalent survival outcomes between NAST and up-front surgery, the situation-specific preference-sensitive nature of the decision makes it suitable for a decision aid (DA). This study aimed to develop and evaluate a DA for this population. Methods: A DA booklet was developed according to international standards, including information about adjuvant and neoadjuvant treatment, outcome probabilities, and a values clarification exercise. Eligible women, considered by investigators as candidates for NAST, were enrolled in a multi-institutional, single-arm, longitudinal study. Patient-reported outcome measure questionnaires were completed pre- and post-DA, between chemotherapy and surgery, and at 12 months. Outcomes were feasibility (percentage of eligible patients accessing the DA); acceptability to patients (percentage who would recommend it to others) and clinicians (percentage who would use the DA in routine practice); and decision-related outcomes. Results: From 77 eligible women, 59 were enrolled, of whom 47 (79.7%; 95% CI, 69.4-89.9) reported having read the DA; 51 completed the first post-DA questionnaire. Of these 51, 41 participants (80.4%; 95% CI, 69.5-91.3) found the DA useful for their decision about NAST. Of 18 responding investigators, 16 (88.9%; 95% CI, 74.4-103.4) indicated they would continue to use the DA in routine practice. Post-DA, decisional conflict decreased significantly (P<.01); anxiety and distress decreased significantly; and 86.3% (95% CI, 73.7-94.3) achieved at least as much decisional control as they desired. Conclusions: This DA was feasible and acceptable to patients and clinicians, and improvement in decision-related outcomes was demonstrated when used in combination with clinical consultations. This DA could safely be implemented into routine practice for women considering NAST for operable breast cancer.

Platinum multidisciplinary breast cancer care or platinum breast reconstruction

functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 2004; 136: 1310–22. 6. Thomusch O, Machens A, Sekulla C et al. Multivariate analysis of risk factors for postoperative complications in benign goitre surgery: prospective multicentre study in Germany. World J. Surg. 2000; 24: 1335– 41. 7. Serpell JW, Yeung MJ, Grodski S. The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch. Ann. Surg. 2009; 249: 648–52. 8. Sancho JJ, Pascual-Damieta M, Pereira JA, Carrera MJ, Fontane J, Sitges-Serra A. Risk factors for transient vocal cord palsy after thyroidectomy. Br. J. Surg. 2008; 95: 961–7. 9. Chiang FY, Wang LF, Huang YF, Lee KW, Kuo WR. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery 2005; 137: 342–7. 10. Snyder SK, Lairmore TC, Hendricks JC, Roberts JW. Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy. J. Am. Coll. Surg. 2008; 206: 123–30. 11. Randolph GW, Dralle H, Abdullah H et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope 2011; 121 (Suppl. 1): S1–16. 12. Randolph GW, Kobler JB, Wilkins J. Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation. World J. Surg. 2004; 28: 755–60. 13. Dionigi G, Van Slycke S, Boni L, Rausei S, Mangano A. Limits of neuromonitoring in thyroid surgery. Ann. Surg. 2013; 258: e1–2. 14. Barczynski M, Konturek A, Cichon S. Randomised clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br. J. Surg. 2009; 96: 240–6. 15. Dralle H, Sekulla C, Lorenz K, Nguyen Thanh P, Schneider R, Machens A. Loss of the nerve monitoring signal during bilateral thyroid surgery. Br. J. Surg. 2012; 99: 1089–95. 16. Goretzki PE, Schwarz K, Brinkmann J, Wirowski D, Lammers BJ. The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort? World J. Surg. 2010; 34: 1274–84. 17. Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT. Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: a meta-analysis. Laryngoscope 2011; 121: 1009–17.

Intraoperative molecular sentinel node analysis: the way of the future or great technology with limited indication?

The axillary lymph node status is a powerful prognostic factor for predicting breast cancer distant metastases. Detecting lymph node involvement often necessitates instigating adequate therapy to eradicate the regional disease. In the past, this has typically meant full axillary lymph node dissection (ALND). In more recent times, sentinel lymph node biopsy has become standard of care for staging the axilla as it has low morbidity and detects lower volume disease than ALND. Several recent studies have shown that low risk/low volume sentinel lymph node disease does not require ALND to improve regional control or overall survival. The quandary thus exists for the breast surgeon – when doing sentinel lymph node biopsy, should intraoperative assessment of the sentinel nodes be performed and immediate ALND if positive or should the surgeon wait for formal pathology and discuss the results with the patient and the multidisciplinary team before recommending ALND or axillary radiotherapy? There are strongly differing opinions on how to manage patients in this situation. The challenges for the protagonists of routine immediate intraoperative assessment are increased by the inadequacies of intraoperative assessment using either frozen section or touch imprint cytology (TIC). Failure to detect a significant sentinel lymph node metastasis intraoperatively can be a huge disappointment for the patient (and treating clinician), often resulting in a second operation to clear the axilla with subsequent delays starting adjuvant treatments, as well as psychological, financial and logistic implications. In this issue, the first two Australian studies of ‘One Step Nucleic Acid Amplification’ (OSNA) are presented, examining the feasibility and accuracy of this automated molecular diagnostic technique as an alternate intraoperative method of sentinel lymph node analysis. In both studies, OSNA has been compared with each institution’s usual method of intraoperative analysis (TIC) and results compared with the ‘gold standard’ final histopathology result. Both studies have shown that OSNA is superior to TIC in sensitivity and overall accuracy, consistent with previous studies. OSNA involves skeletonizing the lymph node, preparing the whole (or a designated part of the) node into a lysate and placing it into an automated instrument. After 16 min, a copy number of cytokeratin 19 mRNA, found in most breast cancer cells, is produced which, based on predetermined cut-off values, reflects a macrometastasis, micrometastasis or no metastasis/isolated tumour cells. The entire process takes median times of 32–62 min for one to four node samples. OSNA has clear advantages over TIC and frozen section. It is more accurate and able to detect smaller volume disease. Being fully automated, a dedicated pathologist need not be present. For breast units who previously have not had access to intraoperative pathology services, OSNA is an attractive option that enables the clinical and financial advantages of avoiding a second operation. In the Australian and international experience, there has been a small percentage of ‘false positive results’ inferring that these patients progress to an unnecessary axillary clearance. The difficulty with interpreting the results of OSNA is that it is compared with a ‘gold standard’ (histology), which despite informing our current treatment protocols, has well-known flaws itself. Furthermore, in studies making a comparison, each technique requires specific lymph node preparation such that differing parts of the lymph node are used for OSNA and histology. A meta-analysis concluded that the false positive results are almost always attributable to ‘tissue allocation bias’. The OSNA system should be a better reflection of the tumour burden of the lymph node as the entire sentinel lymph node specimen is prepared into a lysate for the molecular analysis, unlike histology where sampling error can occur. As tumour deposits are not always equally distributed throughout a lymph node, sentinel lymph node protocols with 2 mm slices detect most macrometastases but multiple smaller deposits may not be accurately detected with histology. Having said this, our conventional treatment recommendations and protocols are based on histology, and therefore probable underestimation of the true tumour burden in lymph nodes. Thus concerns exist that patients may be ‘over treated’ if OSNA is used or potentially undertreated by using current histology protocols. There is no long-term data yet to resolve this issue, the answer may come from those who have already adopted OSNA into routine clinical practice. In conclusion, OSNA is a reliable technique but its place in future breast practice is controversial as less ALND is being done in the settings described and only high volume centres may be able to justify the expense and learning curve of introducing the technology.