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

OBJECTIVES: Inflammatory 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. MATERIALS AND METHODS: Patients 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. RESULT: This 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. CONCLUSIONS: This 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.

Serial MRI scans help in assessing early response to neoadjuvant chemotherapy and tailoring breast cancer treatment.

BACKGROUND: Tailoring neoadjuvant chemotherapy (NAC) during breast cancer treatment is performed to improve overall tumour response, with increasing evidence to support its role. This study evaluates our breast unit's experience in MRI assessment of tumour response as an aid in tailoring NAC. MATERIALS AND METHODS: This is a retrospective study of patients treated with NAC for breast cancer between 2005 and 2009 who underwent MRI to assess tumour response. Response to NAC was monitored before NAC and after 2 and/or 4 cycles of anthracycline and cyclophosphamide (AC) chemotherapy. Taxane was substituted for AC if MRI response was deemed inadequate. Tumour response on last MRI was correlated with final pathology against different tumour subtypes and in inflammatory tumours. Strength of agreement was measured using Kappa analysis. Potential predictive factors for MRI response were assessed for significance. RESULTS: 166 tumours were assessed with serial MRI scans. MRI showed high sensitivity rate (93.1%) in predicting response to NAC particularly for tumours showing partial (PR) or complete (CR) response on pathology (p < 0.001) with fair agreement on Kappa analysis (K = 0.31). MRI seems more accurate in triple negative, HR+/HER2+ and high-grade tumours. Early identification of non-responders on MRI resulted in early tailoring of NAC, with improved rates of tumour response seen in 74.2% following switching NAC. Logistic regression showed that PR or CR observed on MRI after 2 NAC cycles significantly predicted pCR (p < 0.001). CONCLUSION: Serial MRI can be used to assess patterns of tumour response to NAC. This study shows that tailoring NAC according to pattern of response can improve overall tumour response rates.

New patient pathway using vacuum-assisted biopsy reduces diagnostic surgery for B3 lesions.

AIM: To assess the clinical impact of a new patient management pathway incorporating vacuum-assisted biopsy for lesions of uncertain malignant potential (B3). MATERIALS AND METHODS: A retrospective analysis was undertaken of all B3 lesions on core biopsy in the pathology database from April 2008 to April 2010. Outcome measures assessed included final histological diagnosis, frequency of diagnostic surgical biopsy, and impact on management. RESULTS: In the old pathway, there were 95 B3 lesions, of which 14% (13/95) were planned for vacuum-assisted biopsy and 86% (82/95) for surgical biopsy. In the new pathway, there were 94 B3 lesions, of which 68% (64/94) were planned for vacuum-assisted biopsy and 32% (30/94) for surgical biopsy. Following further sampling with vacuum-assisted biopsy, only 13% of patients required diagnostic surgical biopsy and in 25% of cases, a preoperative diagnosis of carcinoma was reached allowing patients to proceed to therapeutic surgery. CONCLUSION: The new pathway has reduced the number of benign diagnostic surgical biopsies performed and increased the preoperative diagnosis of breast cancer.

Reporting and management of breast lesions detected using MRI.

Magnetic resonance imaging (MRI) is the most accurate technique for diagnosing and delineating the extent of both invasive and in-situ breast cancer and is increasingly being used as part of the preoperative work-up to assess the local extent of disease. It is proving invaluable in providing information that allows successful single-stage surgery. An inevitable consequence of the high sensitivity of MRI is that it will identify additional lesions that may or may not represent significant extra disease. This may complicate and delay the preoperative process. This paper outlines a strategy for managing MRI-detected lesions to optimize the benefits of breast MRI as a local staging tool while minimizing the false-positive diagnoses. It discusses the importance of good technique to reduce the number of indeterminate lesions. Methods to refine the patient pathway to minimize delays are discussed. The format of MRI reporting is discussed in detail as is the usefulness of discussion of cases at multidisciplinary meetings. Illustrative cases are used to clarify the points made.

Practical advice on clinical decision making during neoadjuvant chemotherapy for primary breast cancer.

Neoadjuvant chemotherapy (NACT) is a useful approach in the treatment of many breast cancers. One of the main advantages of NACT is the possibility of breast conservation surgery in patients who would otherwise require a mastectomy. Most literature on NACT focuses on the effectiveness of different chemotherapy regimen and subsequent mastectomy rates. There is little guidance in the literature on aspects of individual patient management and decision making during NACT. This paper considers practical management advice where NACT is considered and adopted.

Measurement of pharmacokinetic parameters in histologically graded invasive breast tumours using dynamic contrast-enhanced MRI.

Dynamic contrast-enhanced MRI (DCE-MRI) has demonstrated high sensitivity for detection of breast cancer. Analysis of correlation between quantitative DCE-MRI findings and prognostic factors (such as histological tumour grade) is important for defining the role of this technique in the diagnosis of breast cancer as well as the monitoring of neoadjuvant therapies. This paper presents a practical clinical application of a quantitative pharmacokinetic model to study histologically confirmed and graded invasive human breast tumours. The hypothesis is that, given a documented difference in capillary permeability between benign and malignant breast tumours, a relationship between permeability-related DCE-MRI parameters and tumour aggressiveness persists within invasive breast carcinomas. In addition, it was hypothesized that pharmacokinetic parameters may demonstrate stronger correlation with prognostic factors than the more conventional black-box techniques, so a comparison was undertaken. Significant correlations were found between pharmacokinetic and black-box parameters in 59 invasive breast carcinomas. However, statistically significant variation with tumour grade was demonstrated in only two permeability-related pharmacokinetic parameters: k(ep) (p<0.05) and K(trans) (p<0.05), using one-way analysis of variance. Parameters k(ep) and K(trans) were significantly higher in Grade 3 tumours than in low-grade tumours. None of the measured DCE-MRI parameters varied significantly between Grade 1 and Grade 2 tumours. Measurement of k(ep) and K(trans) might therefore be used to monitor the effectiveness of neoadjuvant treatment of high-grade invasive breast carcinomas, but is unlikely to demonstrate remission in low-grade tumours.

Can the NHS Breast Screening Programme afford not to double read screening mammograms?

AIM: Rapid expansion of the National Health Service (UK) Breast Screening Programme (NHSBSP) to routinely invite women aged 50-70 years will result in many new readers undertaking screen reading. A timely method for assessing performance and preferably one that facilitates a steep learning curve will be required. MATERIALS AND METHODS: This unit screens a population of 88000 women aged 50-64 years and double reads >90% films. A record is kept of proven screen-detected cancers not recalled for assessment by either the first or second reader but correctly recalled following third-reader arbitration. Individual readers' workload and recall rates are obtained by running an annual co-writer report. The results of this 7 year prospective audit are presented. RESULTS: In total 177167 women were screened between 1/4/95 and 31/3/02 resulting in the detection of 1072 cancers. Eighty-seven cancers (8.1%) were detected after arbitration. Individual readers recall to assessment rates and percentage of cases incorrectly returned to routine recall varied. Prompt feedback of missed/misinterpreted cases allowed both experienced and inexperienced readers to modify their recall thresholds for particular mammographic abnormalities. CONCLUSION: It is recommended this audit method is adopted by all units in the NHSBSP and that the Advisory Committee for Breast Cancer Screening review the policy of single versus double reading.

Role of magnetic resonance imaging in the diagnosis and single-stage surgical resection of invasive lobular carcinoma of the breast.

BACKGROUND: Conventional imaging with mammography and ultrasonography has a low sensitivity for diagnosis and a tendency to underestimate the extent of invasive lobular carcinoma (ILC) of the breast. The aim was to determine whether magnetic resonance imaging (MRI) had any advantages for the characterization of ILC. METHODS: Twenty patients with histologically proven ILC underwent preoperative imaging with MRI. MRI was performed to aid detection of malignancy in six patients with a clinically suspicious presentation but normal or indeterminate imaging on mammography and ultrasonography. In 14 patients MRI was performed to determine tumour extent. RESULTS: MRI accurately identified malignancy in five of six patients with normal or indeterminate conventional imaging. In seven of 14 patients in whom MRI was performed to determine tumour extent, it provided significant additional information. These included four patients in whom conventional imaging grossly underestimated tumour size, two patients in whom MRI identified an unsuspected contralateral breast tumour and one patient in whom MRI predicted tumour invasion of the pectoral muscle. The correlation between tumour size on histological examination was better with MRI (r = 0.967) than with mammography (r = 0.663) and ultrasonography (r = 0.673). CONCLUSION: MRI can provide considerable additional information in the detection and characterization of ILC.

Sacroiliac arthrodesis using a posterior midline fascial splitting approach and pedicle screw instrumentation: a new technique.

Many techniques for sacroiliac arthrodesis have been described. No single technique is universally accepted as the standard. The current report describes a new technique using a midline fascial-splitting approach and pedicle screw instrumentation. Four consecutive patients with nontraumatic disorders of the sacroiliac joint who have undergone successful arthrodesis by the described technique are presented. One patient had a spontaneous sacroiliac disruption secondary to rheumatoid arthritis, and was returned to her previous ambulatory status after fusion of the disrupted joint. Her fusion remained stable for 9 years postoperatively. The others had degeneration of the sacroiliac joint that was symptomatically improved by arthrodesis. The described method of sacroiliac arthrodesis may be an attractive option for surgeons who are familiar with pedicle screw instrumentation techniques.

Lateral intertransverse process single-level fusion for salvage of the unstable failed posterior lumbar interbody fusion.

Our study was an attempt to salvage severely unstable posterior lumbar interbody fusions (PLIFs) by using the lateral bilateral intertransverse single-level (floating) fusion. A retrospective review of six patients with failed L4-L5 PLIFs was carried out. These patients underwent reoperation between 2 weeks and 2 years after the initial surgery. All patients had persistent symptoms, including low back pain and sciatica, interfering with activities of daily living. Computed tomography (CT) scans revealed extrusion of the bone plug into the spinal canal in five patients. All six had a nonunion of the PLIF, and three patients had grade 3 or 4 iatrogenic spondylolisthesis caused by the PLIF. The operation involved decompression followed by lateral intertransverse process fusion with autogenous bone graft. All patients were placed in external immobilization after the procedure for 3 months. Follow-up averaged 38.5 months (range, 21-55), at which time five had substantial pain improvement. Five were radiographically fused. One had a second nonunion, which subsequently healed after reoperation with repeat lateral fusion and Luque plate hardware. Our fusion rate was 83% without the use of instrumentation. In conclusion, we recommend the simplistic procedure of lateral bilateral intertransverse process single-level fusion along with liberal external immobilization for the difficult problem of salvage of failed PLIFs.

Complications associated with harvesting autogenous iliac bone graft.

The harvesting of an autogenous iliac bone graft is a frequently performed orthopedic procedure. Although often regarded as the simple or routine part of bone graft requiring surgery, complications are not necessarily uncommon. Documented donor-site complications include nerve, arterial, or urethral injury; chronic donor-site pain; cosmetic deformity; herniation of abdominal contents; sacroiliac joint instability; pelvic fractures; gait disturbances; hematoma; infection; peritoneal perforation; and hip subluxation. Most of these complications are avoidable when the surgeon is aware of their possibility and is familiar with the involved anatomy and preferred surgical approaches.

Midline fascial splitting approach to the iliac crest for bone graft. A new approach.

The midline fascial splitting approach is a modified midline approach to the iliac crest for bone graft that takes advantage of the anatomic planes between layers of the dorsal lumbar fascia. Two hundred consecutive grafts were taken by this technique with one superficial infection, two cases of serous hematoma, and three patients with significant postoperative pain at the harvest site, for an overall complication rate of 3%. In comparison, bone grafts were harvested from 200 consecutive patients by the midline subcutaneous approach to the iliac crest with 2 deep infections, 1 cluneal nerve injury, 15 patients with severe and disabling pain at the harvest site, and 12 patients with a serous hematoma, for an overall complication rate of 15%. The midline fascial splitting approach significantly reduced the incidence of postoperative serous hematoma (P < 0.007) as well as the incidence of significant and disabling pain (P < 0.001). In addition, the approach is simple, straightforward, anatomic, and decreases trauma to soft tissues.

Fracture-dislocation of the thoracic and lumbar spine: advantages of halo-bifemoral traction.

Thoracic and lumbar fracture-dislocations with 100% spinal column displacement are uncommon injuries that usually have associated neurologic injury. Severe spinal malalignment and instability can result in blood loss, tenting of skin and, severe pain. Four patients with thoracic or lumbar fracture-dislocations were initially treated and reduced with halo-bifemoral traction. Fracture reduction with halo-bifemoral traction decreased pain, controlled instability, relieved skin pressure, and prevented the need for acute surgical intervention. In addition, use of halo-bifemoral traction allowed for the resolution of spinal shock, allowed time for complete presurgical planning, and simplified the reduction portion of the operative procedure, thereby reducing operative time and blood loss.

Use of the pantaloon cast for the selection of fusion candidates in the treatment of chronic low back pain.

Forty-five patients with low back pain (LBP) of longer than six months' duration and for whom all conservative therapies failed were placed in a pantaloon cast for a two- to four-week trial period. Significant pain relief occurred in 31 (69%) of these patients. Of these 31, 23 patients were treated with spinal arthrodesis using lateral, intertransverse process fusions with iliac bone grafts. Before fusion, the painful lumbar segments were determined by facet analgesic blocks or the normal saline acceptance test. After an average follow-up period of 14 months, 17 (74%) had significant pain relief. The pantaloon cast may be an effective tool for identifying those chronic LBP patients who might benefit from spinal stabilization procedure.

Acute renal vein thrombosis in renal allografts: new Doppler ultrasonic findings.

We report two cases of renal vein thrombosis in renal transplants, both diagnosed by Doppler ultrasound. In both cases Doppler ultrasound showed complete absence of venous flow. In addition, the arterial signal showed a sharp systolic peak with a notch on the reverse diastolic component resembling an 'inverted M', a finding previously undescribed. This arterial waveform was present at both hilar and interlobar level. We postulate that this 'inverted M' sign may be more specific for renal vein thrombosis in that it may represent non-occlusive thrombus, despite the lack of detectable venous flow, whereas the previously described plateau-like reverse diastolic flow seen in some cases of renal vein thrombosis, also occurs in severe allograft rejection and is therefore a non-specific sign.

Does lymphangiography have any role in the management of early non-seminomatous germ cell tumours?

Since 1980, 51 patients with non-seminomatous testicular germ cell tumours (NSGCT) and normal or equivocal initial computed tomography (CT) imaging have also had lymphography performed. Radiological records of these patients were reviewed to determine the extent to which lymphography (LAG) contributed to patient management. Forty-nine patients were retrospectively confirmed to have normal CT but of these 14 (29%) were considered to have nodal metastatic disease on lymphography. These patients and seven others with marker only evidence of tumour received chemotherapy and all remain disease-free. Six of thirty-six patients relapsed, but the incidence was not significantly higher in patients who did not undergo LAG (2 of 8:25%) than among those whose initial LAG was normal (4 of 28: 14%). All relapsing tumours achieved a complete remission with chemotherapy. We conclude that although LAG may have resulted in earlier treatment for some patients, several may have been overtreated on the basis of radiological abnormalities which did not represent metastatic disease. We believe that the success of salvage chemotherapy means that LAG may be safely abandoned as a staging procedure for NSGCT.

Neurologic injury and recovery patterns in burst fractures at the T12 or L1 motion segment.

Fourteen consecutive patients with burst fractures at T12 or L1, partial paralysis, and more than 30% canal compromise were prospectively evaluated pretreatment and posttreatment with roentgenograms to determine the initial fracture pattern, CT scans to determine the percent canal compromise and subsequent improvement, and a quantitative motor trauma index scale and bladder sphincter evaluation to determine neurologic recovery. The follow-up period averaged 32 months (range, 12-50 months). Treatment was as follows: nonoperative (three patients), Harrington rods and fusion (seven patients), and Harrington rods and fusion followed by anterior decompression and fusion (four patients). The initial severity of paralysis did not correlate with the initial fracture roentgenographic pattern or the amount of initial CT canal compromise. Neurologic recovery did not correlate with the treatment method or amount of canal decompression. Subsequent recovery did correlate with the initial fracture pattern. If the patient had a Type I or Type II fracture (both greater than 15 degrees kyphosis), greater than 90% neurologic recovery occurred, regardless of treatment. If the patient had a Type III fracture (less than 15 degrees kyphosis and the maximal canal compromise where bone encircles the canal) less than 50% neurologic recovery occurred. If the patient had a Type IV fracture (less than or equal to 15 degrees kyphosis and the maximal canal compromise at the level of the ligamentum flavum), the neurologic recovery was variable. Prognosis for neurologic recovery can be made based on initial roentgenograms. If greater than 15 degrees kyphosis is present, there is a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative discitis. Diagnosis and management.

Postoperative discitis (POD) continues to be a diagnostic challenge and its management remains variable. This article raises the following questions and presents new observations. What is the current role of the CT scan in POD? Is a uniform pathogen involved and is there a basis for the duration of intravenous antibiotics? What is the expected long-term functional result? In a retrospective analysis of 12 consecutive patients with POD followed for an average of 29 months (17-42 months), the CT scan was extremely sensitive in showing a pathogen was present. The CT scan was misread in over one-third of the cases. Gram-positive cocci were the only organisms cultured (10 of 13 cultures, 8 of 12 patients). The erythrocyte sedimentation rate (ESR) invariably fell predictably to normal within 90 days when patients were treated with IV antibiotics for more than 40 days. Most patients were clinically improved and subjectively better at follow-up examination. No correlation existed between the patient's subjective result and preexisting medical conditions, the type of antibiotic, or the length of treatment, the ESR, or the follow-up roentgenograms.