Munir Ahmed

Development and implementation of centralized simulation training: evaluation of feasibility, acceptability and construct validity

A competent urologist should not only have effective technical skills, but also other attributes that would make him/her a complete surgeon. These include team‐working, communication and decision‐making skills. Although evidence for effectiveness of simulation exists for individual simulators, there is a paucity of evidence for utility and effectiveness of these simulators in training programmes that aims to combine technical and non‐technical skills training. This article explains the process of development and validation of a centrally coordinated simulation program (Participants – South‐East Region Specialist Registrars) under the umbrella of the British Association for Urological Surgeons (BAUS) and the London Deanery. This program incorporated training of both technical (synthetic, animal and virtual reality models) and non‐technical skills (simulated operating theatres).

Meta-analysis of superficial versus deep injection of radioactive tracer and blue dye for lymphatic mapping and detection of sentinel lymph nodes in breast cancer

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye.

Systematic review of axillary reverse mapping in breast cancer

Axillary reverse mapping (ARM) assesses the lymphatic drainage of the arm simultaneously with that of the breast, enabling preservation of arm lymphatics during axillary surgery for breast cancer. This article systematically reviews the evidence on the lymphoedema rate and oncological safety of the ARM technique.

High intensity focused ultrasound in the treatment of breast fibroadenomata: results of the HIFU-F trial

Abstract Objectives: Breast fibroadenomata (FAD) are the most common breast lumps in women. High intensity focused ultrasound (HIFU) is a non-invasive ablative technique that can be used to treat FAD but is associated with prolonged treatment times. In the HIFU-F trial, we evaluated the change in volume over time with circumferential HIFU treatment of FAD and compared this to no treatment. Methods: Patients ≥18 years, diagnosed with symptomatic, palpable FAD, visible on ultrasound (US) were recruited. Twenty patients were treated using US-guided HIFU under local anaesthesia. Another 20 participants underwent an US 6 months after diagnosis. Outcome measures included: reduction in treatment time compared to whole lesion ablation; feasibility to achieve a 50% reduction in volume after 6 months; decrease in volume compared to a control group and reduction in symptoms. Results: Circumferential ablation reduced the mean treatment time by 37.5% (SD 20.1%) compared to whole lesion ablation. US demonstrated a significant mean reduction in FAD volume of 43.5% (SD 38.8%; p = 0.016, paired t-test) in the HIFU group compared to 4.6% (SD 46.0%; p = 0.530) in the control group after 6 months. This mean reduction in FAD volume between the two groups was significant in favour of the HIFU group (p = 0.002, grouped t-test). Pre-treatment pain completely resolved in 6 out of 8 patients 6 months post-treatment. Conclusion: Circumferential HIFU ablation of FAD is feasible, with a significant reduction in pain and volume compared to control participants. It provides a simple, non-invasive, outpatient-based alternative to surgical excision for FAD.

Meta‐analysis of sentinel lymph node biopsy in breast cancer using the magnetic technique

The standard for sentinel lymph node biopsy (SLNB), the dual technique (radiolabelled tracer and blue dye), has several drawbacks. A novel magnetic technique without these drawbacks has been evaluated in a number of clinical trials. It uses a magnetic tracer and a handheld magnetometer to identify and excise sentinel lymph nodes. A systematic review and meta‐analysis was performed to assess the performance and utility of the magnetic in comparison to the standard technique.

Magnetic guidance for cancer surgery

.ThestandardforSLNBstill remains the dual technique,although this has major drawbacks.Radioisotopes expose patients andhealthcare workers to radiation, andtheiruseisheavilycontrolledbylegi-slation.Thebluedyecanobscurethesurgical field and frequently leaves ablueskinstain,whichcantakemonthsto fade or can be permanent. Thereisalsoariskofupto0.9percent

Radioactive seed localization for non-palpable breast cancer (Br J Surg 2013; 100: 582-588).

Sir I read with much interest the article by Barentsz and colleagues. An area of interest was the brief description of the financial benefits of radioactive seed localization (RSL). Barentsz et al. have quoted figures, derived from the article by McGhan and co-workers1, of ¤46 for the total cost of image-guided localization with the iodine-125-labelled seed compared with ¤130 for wire-guided localization (WGL). I find these figures very surprising. The article by Rao and colleagues2 states that the costs of materials for RSL versus WGL are comparable at ¤13. Each procedure requires radiological input via ultrasound-guided or stereotactic localization to allow seed and wire positioning, so the difference in these costs is not sensible. No detailed cost–benefit analysis has been performed on RSL, unlike the case in radioguided occult lesion localization (ROLL). Postma et al.3, in a cost–benefit analysis of their previous randomized controlled trial of ROLL versus WGL4, found that there was no cost benefit for ROLL over WGL when considered overall. Interestingly, they found that ROLL cost ¤0 in terms of localization costs because it allowed radioisotope injection for sentinel lymph node biopsy to be performed simultaneously with localization, whereas WGL required a separate procedure in addition to localization. RSL does not offer this benefit of ROLL. Therefore, I believe it unlikely that RSL provides a cheaper localization procedure, although a full cost-benefit analysis is required.

Report from the 37th San Antonio Breast Cancer Symposium, 9–13th December 2014, Texas, USA

The 37th San Antonio Breast Cancer Symposium (SABCS) was held at the Henry B. Gonzalez Conference Centre in San Antonio, Texas, USA between the 9 and 13th of December 2014. It brought together an interaction between basic scientists and clinicians involved in the management of breast cancer. The symposium included six general sessions, poster discussion, and poster sessions. The most important highlights in the fields of advancing endocrine therapy; hormone receptor positive advanced breast cancer and hormonal resistant therapy; targeted therapies; genetics and genomics; supportive (adjunct) care; chemotherapy treatments; breast screening and risk stratification; male breast cancer and future potential directions were included here.

Margins in breast conserving surgery: A practice-changing process.

Margins in breast conserving surgery (BCS) have been a long standing subject debate. This largely arises from the absence of a consensus on what constitutes an adequate margin width, resulting in re-excision rates of 25-40% for close or positive margins and its consequent impact upon cosmesis, economic costs, patient dissatisfaction and lack of bearing on survival. Accepting that the increased risk of local recurrences (LR) has its influence on survival, the decrease in LR in BCS in the last decade have been motivated by better surgical techniques for assessing negative margins, use of targeted therapies and in general with the multimodal treatment in the management of breast cancer patients. Since the publication of the consensus guidelines on margins there has evolved a trend of changing attitudes towards re-excision. Surgeons are considering margins in the context of all factors including not only patient and tumor characteristics but also the regional and systemic treatment the patient is receiving.

Meta‐analysis of aberrant lymphatic drainage in recurrent breast cancer

Sentinel node biopsy (SNB) in recurrent breast cancer offers targeted axillary staging compared with axillary lymph node dissection (ALND) or no treatment. The evidence for lymphatic mapping in recurrent breast cancer is reviewed, focusing on aberrant drainage and its implications for patient management.