M. Keshtgar

Current status and advances in management of early breast cancer

Breast cancer is the most common female cancer. Worldwide, more than a million women are diagnosed every year. However despite this increase, the mortality rate is declining. This is due to combination of factors including early diagnosis and effective treatment. This manuscript which is presented in two sections outlines the current status in management of early breast cancer. Section 1 focuses on the advances in diagnosis and surgical treatment of breast cancer and give an overview of the histopathological aspects. The focus of section 2 is on advances on adjuvant treatment of breast cancer including radiotherapy, chemotherapy and endocrine treatment.

Assessment of Radio-Guided Occult Lesion Localization Associated with Sonography in Non-Palpable Breast Lesions

To the Editor: Currently detection of nonpalpable breast lesions has been improved due to screening imaging programs (1). Several methods are applied for localization of lesions prior to excision, the most common is wire replacement under ultrasonography guidance, which has some disadvantages such as interference with surgery field, wire movement, pneumothorax, high expenses of wire, and logistical constraints (2–4). Radio-guided occult lesion localization (ROLL) for nonpalpable breast masses is a relatively new method with more advantages and less complications. In this method liquid radiotracer, Tc-99m labeled colloid particles of human serum albumin is injected into the lesion (4) and the surgeon identifies the accurate location of target lesion based on the maximum radioactivity signal by a handheld gamma-probe (3,5). Being a new method in Iran, we applied ROLL in our institution and investigated its accuracy in localization and consequently complete excision of nonpalpable breast lesions. In this study, 42 patients with the mean age of 44 (26–70) years with nonpalpable breast lesions were enrolled. Inclusion criteria were an indication for excisional surgery based on either ACR BI-RADS standard system 2012, or physician and patient preference for resection. First, an experienced interventional radiologist injected 0.1–0.2 mL of Tc99m labeled sodium Phytate into the center of the lesion by a 20G needle under ultrasonography guidance, equivalent to 0.5–1 mCi, 1–10 hours before surgery. About 0.1 mL of air was injected with the radiotracer for better visualization and ensuring accurate localization and complete injection of the tracer (Fig. 1). The site of incision was determined by an experienced breast surgeon according to preoperative images and the point of intense radioactivity signal during surgery, and then the lesion was excised. The excision bed was then explored by the gamma probe for any residual radioactivity and if detected, excision was repeated. Accurate localization of lesion occurred in 38 patients (90.5%), which was lower than previous studies (5). Inaccurate localization was performed in four patients (9.5%) which was higher than previous researches (2,5–8), including spreading of radiotracer into subcutaneous tissue in two cases and adjacent ducts in another two patients, which made the surgeon confused. So in these four patients we had reexcision (9.5%) with larger volumes of specimen, and one of them underwent secondary surgery (2.4%) which was lower than other studies with larger sample size (2,6,7). Margin status after excision was clear in all patients (100%) which was lower than some studies with larger sample size (2,4,7,8). In one patient (2.4%) with atypical ductal hyperplasia, in spite of clear margin, pathologic involvement was extended near the margin. As the majority of histologic results were benign with a few number of malignant lesions (benign in 38 patients (90.5%) and malignant in four patients (9.5%)), margin status could not be accurately investigated in our practice. Mean excised tissue volume was 28.59 27.96 cm in all patients and 23.54 23.46 cm in patients with accurate localization which was higher than previous investigations (7,8). Our patients’ satisfaction level about postoperative cosmetic results was excellent in 33.3% and good in 66.6% of patients, which was lower than previous studies (2,8). Pain score was 3.21 0.6 (2–5) which was higher relative to previous studies (8). Mean duration of localization (1.80 0.42 minutes) and surgical procedure (26.78 8.10 minutes) were significantly lower and similar to previous studies, respectively (1,2,4,7,8). Mean duration of hospital stay Address correspondence and reprint requests to: Samaneh Sajjadi, MD, Assistant Professor, Department of Internal Medicine, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, or e-mail: sajjadis@mums.ac.ir

A Novel Evidence-Adaptive Computerised Decision Support System for Breast Cancer Multidisciplinary Meetings: Results of an Evaluation Study.

Background: Multidisciplinary meetings (MDM) also known as multidisciplinary cancer conferences are a forum for providing evidence-based care and are widely accepted as a part of standard cancer care worldwide. In United Kingdom, it is a mandatory requirement that the care of all breast cancer patients is managed through breast MDMs. However the lack of required support for conducting MDM is documented in many recent reviews. Advanced Computerised Decision Support (CDS) technology can play an important role in supporting MDMs and improving its functioning. We present a novel breast MDM support tool which integrates a CDS system into an electronic patient record to assist breast Multi Disciplinary Team (MDT) in making an evidence based, transparent treatment decisions during MDM. To the best of our knowledge there are no published studies of implementing computerised decision support systems for breast MDM. Methods: The Multi-disciplinary meeting Assistant and Treatment sElector (MATE) is a tool designed to assist breast clinicians in making management decisions for their patients in MDM. MATE is developed using a PRO forma CDS technology which is funded by the Cancer Research UK. The tool is implemented in the breast unit of Royal Free hospital, London for its pilot testing. MATE evaluates patient9s clinical facts and suggests optimal management options according to incorporated national and international clinical guidelines. The evidence base used in MATE can be updated as and when new evidence is published. MATE recommendations are not binding and the final decision is taken by breast MDT. MATE facilitates the flexible conduct of MDM. Additionally, it highlights if the patient is eligible to take part in any local, national or international clinical trials. In the evaluation study, the data of 300 consecutive breast patients presented at the Royal Free breast MDM along with their documented MDM recommendations are entered in MATE. MDM recommendations and MATE suggestions are analysed. Results: MATE system is able to suggest the treatment recommendations in concordance with breast MDT in most of the cases (91 %). MATE suggested more management options per patient than the documented MDT recommendations (3.4% vs. 1.2 %). MATE also identified 65% more patients suitable for ongoing clinical trials. Deviations that occur specially in unaided MDMs can be minimised using electronic data capture and decision support system like MATE. Conclusion: This evaluation study has shown the feasibility of implementing MATE into MDM and its potential to improve certain aspects of MDM by helping overburdened clinicians. The evidence adaptive decision support component of MATE can improve the guideline-compliance and transparency in the decision-making and also identify more patients to be considered for recruitment in clinical trials. Another important benefit could be completeness of documentation. Further evaluations of MATE in a randomised controlled trial are under way. If found beneficial, the system could easily be adapted for other cancers. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5118.