Raghavan Vidya

Feeling blue, going green and finding other attractive alternatives: a case of biphasic anaphylaxis to patent blue and a literature review of alternative sentinel node localisation methods.

Patent blue dye is used for sentinel lymph node localisation in order to stage the axilla in patients with breast cancer. Patent blue is one of the most common dyes used across the UK, however, the incidence of adverse effects seems to be increasing. This case highlights our experience of a biphasic anaphylactic reaction to patent blue dye, and we conduct a brief literature review of alternative and more novel methods to adequately visualise the lymphatics for sentinel lymph node biopsy.

Pre-operative axillary staging: should core biopsy be preferred to fine needle aspiration cytology?

Objective To determine the diagnostic accuracy of ultrasound guided fine needle aspiration (FNA) cytology and core needle biopsy (CNB) of axillary lymph nodes pre-operatively in newly diagnosed operable primary breast cancer. Methods An observational study for all patients who underwent pre-operative FNA cytology or CNB during September 2013–August 2014 was conducted at our institution (County Hospital, Stafford, UK). The accuracy of pre-operative axillary staging was compared to the post-operative histology. For this sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated. Results A total of 81 consecutive patients were evaluated by axillary ultrasound. Patients identified with potentially abnormal axillary lymph nodes underwent definitive surgery. Seven patients had positive cytology/histology who did not undergo definitive surgery and were excluded (N = 74) from the study. CNB had a sensitivity of 100% versus 72% (p = 0.006) for FNA cytology. Both had 100% specificity and PPV. The NPV of CNB was 100% versus 72% for FNA cytology. Among 35% of patients that underwent FNA cytology required repeat procedure versus 2.6% of patients who underwent CNB. 0/38 patients that had CNB required a second operation while 7/43 patients with negative FNA cytology had positive lymph nodes identified at sentinel lymph node biopsy (SLNB) requiring surgical re-intervention with axillary node clearance. Conclusion CNB was superior to FNA cytology when interrogating the axilla. We recommend CNB to be adopted routinely in pre-operative axillary staging to reduce surgical re-intervention.

The presentation, management and outcome of inflammatory breast cancer cases in the UK: Data from a multi-centre retrospective review.

OBJECTIVESnInflammatory Breast cancer (IBC) is a rare but aggressive form of breast cancer. Its incidence and behaviour in the UK is poorly characterised. We collected retrospective data from hospitals in the UK and Ireland to describe the presentation, pathology, treatment and clinical course of IBC in the UK.nnnMATERIALS AND METHODSnPatients with IBC diagnosed between 1997-2014 at fourteen UK and Irish hospitals were identified from local breast unit databases. Patient characteristics, tumour pathology and stage, and details of surgical, systemic and radiotherapy treatment and follow-up data were collected from electronic patient records and medical notes.nnnRESULTnThis retrospective review identified 445 patients with IBC accounting for 0.4-1.8% of invasive breast cancer cases. Median follow-up was 4.2 years. 53.2% of tumours were grade 3, 56.2% were oestrogen receptor positive, 31.3% were HER2 positive and 25.1% were triple negative. 20.7% of patients had distant metastases at presentation. Despite trimodality treatment in 86.4%, 40.1% of stage III patients developed distant metastases. Five-year overall survival (OS) was 61.0% for stage III and 21.4% for stage IV patients.nnnCONCLUSIONSnThis is the largest series of UK IBC patients reported to date. It indicates a lower incidence than in American series, but confirms that IBC has a high risk of recurrence with poor survival despite contemporary multi-modality therapy. A national strategy is required to facilitate translational research into this aggressive disease.

Techniques Used to Localise Occult Breast Lesions: An Update

With breast cancer screening programs becoming more available worldwide and covering larger age ranges, the prevalence of impalpable breast pathology is increasing. Whilst there is a tried and tested technique for localizing occult lesions, the market for alternative methods is increasing and is estimated to pass

Conservative Management of Positive Axilla After Neoadjuvant Systemic Therapy—The Need for, and Review of, Techniques Used for Lymph Node Localization

1 billion by 2024. In this article, we review the techniques currently available for localization of occult breast lesions and discuss the pros and cons of each.

Reply to: Subcutaneous implant breast reconstruction: The importance of objectively assessing the outcomes

Abstract Involvement of axillary lymph nodes is an important prognostic factor in relationship to the management of breast cancer. However, the use of neoadjuvant systemic therapy is widespread in the treatment of positive axilla and such treatment leads to downstaging of axillary disease. Hence, the role of targeted axillary lymph node biopsy appears to play a vital role after primary systemic therapy. Given that this is a relatively novel approach, we have discussed the evidence for this approach and the different techniques currently available for localization of biopsy‐proven metastatic axillary lymph nodes. We have also highlighted the need for universal guidelines for conservative management of positive axilla after systemic therapy.

Specimen Orientation in Breast Conserving Surgery: An Argument for using Specimen Kits

We would like to thank Onesti et al. for their interest in our publication in EJSO [1]. Pre-pectoral implant breast reconstruction is an emerging technique with promising results and potential advantages and it is gaining popularity among breast reconstructive surgeons and patients. Our comprehensive literature review showed that the quality of the available data is still not optimal based mainly on small, single centre cohorts with short follow-up. As highlighted in our paper and also by Onesti et al. in their Letter to the Editor, another important issue is the limited use of validated tools for the objective evaluation of aesthetic and functional outcomes including post-operative pain and recovery and also for the assessment of patients’ satisfaction and quality of life after pre-pectoral implant breast reconstruction. We would like to encourage all efforts to address these significant issues and emphasize the importance to conduct well-designed studies using validated tools including the questionnaires used by Onesti et al. (EORTC QLQ C-30 and EORTC QLQ BR-23) [2,3] as well as the more recently validated BREAST-Q questionnaire [4] that has been specifically developed to capture patient satisfaction and quality of life data after breast surgery. These questionnaires should ideally be used both at baseline and following treatment to allow more reliable evaluation of the results. In conclusion, we agree with Onesti et al. that there is need for a more structured and coherent approach to evaluating the results of novel techniques always having as guide our duty to ensure patient safety. It is also important to work collaboratively to advance our knowledge and contribute in the rapid dissemination of results of proven improved techniques for the benefit of our patients.

Infection prevention in breast implant surgery – A review of the surgical evidence, guidelines and a checklist

Breast cancer becoming a major threat now a day. About 45,000 women are diagnosed with breast cancer in the UK each year and about 60% have breast conserving surgery. The rate of re-excision rates following breast conserving surgery varies between 12% to 30%across the UK. The use of margin status and re-excision rate as a measure of quality is controversial. Specimen orientation kits are important as they can influence the re-excision rates. Here in this study, there is used a new specimen orientation kit called Klin tray and assessed its impact on margins and re-excision rate.

A poetic story: lessons learnt from the world's largest breast cancer window of opportunity study

We read the review article by Barr et al. with interest. Firstly, we would like to congratulate the Northwest Breast Surgical Research Collaborative on their work on the important topic of infection prevention in breast implant surgery. At present there are no clear guidelines to help decide the role of antibiotic prophylaxis and further doses after breast cancer surgery. There is variability in practice with some patients not getting any prophylaxis and on the other end of the spectrum, patients receiving prolonged antibiotics with no specific indication. The ‘UK Five Year Antimicrobial Resistance Strategy 2013 to 2018’ highlights the inappropriate use of antibiotics leading to development of resistance and increasing risk of C diff. colitis. As responsible healthcare professionals, we need to address this issue and ensure that our patients receive the most appropriate antibiotics. It is clear from the recent Cochrane review that there is no Level 1 evidence regarding the practice of antibiotic prophylaxis in breast reconstruction. Most of the data is based on small cohort studies or data extrapolated from cosmetic procedures (augmentation). Therefore, the recommendation with regards to antibiotics in the Theatre Implant Checklist of the review paper is not supported by Level 1 evidence. To address this issue, we propose to conduct a National Audit of Antimicrobial use in Breast Surgery and Surgical Site Infections. Its intended aims include:

Breast lumps: a rare site for rheumatoid nodules

Hormone sensitive breast cancer (BC) is a common disease in postmenopausal women. Generally seen as less aggressive than other BC subtypes patients have a continued risk of relapse for 15+ years (EBCTCG, 2011) thus the cumulative risk is not insubstantial. Efforts continue to identify patients who are at continued residual risk of relapse in order to develop new treatment strategies. Previous trials (IMPACT, 2007) suggested that aromatase inhibitor (AI) treatment for 2 weeks in the peri-surgical window-of-opportunity results in detectable biomarker changes (Ki67) and predicts long term outcome. Gene expression profiling offers opportunities to identify patients demonstrating early resistance to endocrine therapy. n nPOETIC was a UK-wide RCT devised to provide definitive results on the role of perioperative (AI) treatment. Biopsies were taken at diagnosis and 2 weeks later at surgery thus allowing an in vivo assessment of AI sensitivity. To succeed, POETIC needed to overcome substantial barriers in relation to compliance with cancer wait times, recruitment of women at diagnosis, varied clinical practice and to ensure receipt of sufficient quality tissue samples for analysis of biomarker endpoints. Patient advocates were involved from inception. n nPOETIC succeeded in recruiting 4486 women from 130 UK centres. Paired tissue samples were received for 96% patients. Lessons learnt in rolling out the worlds largest window-of-opportunity BC trial illustrate the viability and potential of this experimental model as a vehicle for testing early biological effects of novel agents and to identify women most likely to be at long term residual risk of relapse.