Prediction of nipple involvement in breast cancer after neoadjuvant chemotherapy: Should we rely on breast MRI to preserve the nipple?

BACKGROUND: Indications for nipple sparing mastectomy (NSM) is extending to post-neoadjuvant chemotherapy (NAC) setting. Eligibility for NSM with an optimum tumor-nipple distance (TND) after NAC is unclear. We examined predictive factors for nipple tumor involvement in patients undergoing total mastectomy following NAC. METHODS: Clinical and pathological data from prospectively collected medical records of women with invasive breast carcinoma, who were undergone NAC and total mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection were analyzed. PreNAC and postNAC magnetic resonance imaging (MRI) views were examined and a cut-off TND value for predicting the negative nipple tumor status was determined. RESULTS: Among 180 women, the final mastectomy specimen analysis revealed that 12 (7%) had nipple involvement as invasive carcinoma. Patients with nipple involvement had more postNAC multifocal/multicentric tumors (p: 0.03), larger tumors on preNAC and postNAC images (p: 0.002 and p < 0.001), shorter median TNDs on preNAC and postNAC images (7 mm-IQR 1.5-14, p: 0.005 and 8.5 mm-IQR 3-15.5, p < 0.001, respectively), more nipple retraction on preNAC and postNAC images (p: 0.007 and p: 0.006) and more nipple areola complex skin thickening (> 2mm) on preNAC and postNAC images (p < 0.001 and p: 0.01). The best likelihood ratios (LR) belonged to the postNAC positivity of the < 20 mm TND, with a + LR of 3.40, and - LR of 0.11 for nipple involvement. PreNAC positivity of the < 20 mm TND also had a similar - LR of 0.14. CONCLUSION: A TND-cut-off  ≥ 2 cm on preNAC and postNAC MRI was shown to be highly predictive of negative nipple tumor involvement.

Assessment of extracorporeal photopheresis related cell damage.

AIM: Extracorporeal photochemotherapy (ECP) is emphasized chiefly as it has a high safety profile. However, the genotoxic effects of ECP are not known. This experimental study aimed to assess the potential genotoxic impact of ECP treatment by the AKLIDES system, a new generation standardized and automated evaluation method. MATERIALS AND METHODS: Buffy coats were obtained from the blood of 26 healthy volunteers, and ECP was applied to 2 j/cm2 UV-A for two hours. After the DNA isolation procedure, all slides were stained with DAPI to visualize lymphocytes, FITC for visualization of damage foci marker (γH2AX), and APC for visualization of repair foci marker (53BP1). With the AKLIDES imaging system, all parameters were evaluated. RESULTS: Median damage marker Foci γ-H2AX before and after ECP were 11.42 and 18.65 arbitrary units, respectively (p = 0.153). Median repair marker foci 53BP1 (repair biomarker) before and after ECP were measured as 4.17 and 6.7 arbitrary units. The difference was also not statistically significant (p = 0.088). Although 58 % of cells were affected by ECP irradiation, as shown by FITC fluorescent staining, no statistical difference was found in any genotoxicity parameters. CONCLUSION: We found an increase in the foci γ-H2AX parameter, one of the objective indicators of DNA breaks, and an increase in the foci 53BP1 parameter, which indicates the post-damage repair mechanisms after ECP. However, further in vitro, and in vivo studies are needed with large sample volumes to demonstrate the significance.

The role of loco-regional treatment in long-term quality of life in de novo stage IV breast cancer patients: protocol MF07-01Q.

BACKGROUND/OBJECTIVE: Since more solid evidence has emerged supporting the effectiveness of loco-regional treatment (LRT), clinicians consider LRT a treatment option for selected de novo stage IV breast cancer (BC) patients. This is the first report on long-term quality of life (QoL) in a cohort of patients who were randomized to receive either LRT and then systemic treatment (ST) or ST alone in the protocol MF07-01. We aimed to evaluate QoL in patients living at least 3 years since randomization using scores from the SF-12 health survey. METHODS: SF-12 (V2) forms were completed during visits of patients who were living 36 months after the randomization. We first calculated PCS-12 (Physical Health Composite Scale) and MCS-12 (Mental Health Composite Scale) scores from de novo stage IV BC patients and compared them with the scores of patients diagnosed with stage I-III BC who lived more than 3 years. Further, PCS-12 and MCS-12 scores were compared between the LRT and ST groups with de novo stage IV BC. Additionally, general health, physical functioning, role functioning, bodily pain, vitality, mental health, and social functioning were evaluated and compared between the groups. Considering age-related changes in QoL, we also compared PCS-12 and MCS-12 scores of patients below or above 55 and 65 years of age. Responses to four additional questions (compare your physical health, mental health, daily activities, and energy currently vs. at diagnosis of BC) were recorded, considering cultural differences. RESULTS: There were 81 patients in this analysis; 68% of patients (n = 55) had LRT, and 32% (n = 26) received ST. General health was good or very good in 62% (n = 34) in the LRT group and 66% (n = 17) in the ST-only group (p = 0.63). Mean PCS-12 score was 40.8 + 1.6, and mean MCS-12 score was 43.4 + 2.0 (p = 0.34 and p = 0.54, respectively). PCS-12 and MCS-12 score difference was lower than that of the general Turkish population (PCS-12 = 49.3 + 12.8 and MCS-12 = 46.8 + 13.0) and stage I-III BC patients (PCS-12 = 51.1 ± 0.5, MCS-12 = 45.7 ± 0.6). PCS-12 and MCS-12 scores were similar between the LRT and ST-only groups in patients younger and older than 55 and 65, but QoL scores were much better in stage I-III BC patients younger than 65 when compared to the scores of those with de novo stage IV BC. Although treatment with or without LRT did not affect physical health, mental health, daily activities, and energy at 3 years vs. at diagnosis of BC in de novo stage IV BC patients (p > 0.05), these variables were significantly better in stage I-III BC patients (p < 0.001). CONCLUSION: The current MF07-01Q study demonstrates that patient who had LRT has similar physical and mental health outcomes compared to ST only in a cohort of patients who lived longer than 3 years. Trial registration This study is registered on clinicaltrials.gov with identifier number NCT00557986.

The relative importance of factors influencing the surgeons' choice between mastectomy and breast-conserving surgery for women with breast cancer.

The authors' aim is to provide breast surgeons' perspectives on the relative importance of the criteria for choosing an appropriate surgery method between mastectomy (total removal of a breast) and breast-conserving surgery (removal of a breast cancer tumor and some of the normal tissue that surrounds it) for women with breast cancer by using the multicriteria decision-making method (MCDM). The Analytic Hierarchy Process (AHP), the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS), and Vise Kriterijumska Optimizacija I Kompromisno Resenje (VIKOR) methods are utilized. A decision hierarchy is set with a goal, criteria, and alternatives. We developed our model based on three main criteria, tumor-related, patient-related, and post-operative process-related factors and nineteen sub-criteria, as well as two alternatives, mastectomy and breast-conserving surgery (BCS). An online questionnaire was sent to the breast surgeons; we showed that the most important criteria are post-operative process-related factors, especially the demand for esthetic appearance based on 39 breast surgeons. Conversely, the least significant criteria are tumor-related factors. Furthermore, breast-conserving surgery is selected as the most appropriate surgery method for breast cancer patients using the AHP, TOPSIS, and VIKOR.

Idiopathic granulomatous mastitis with erythema nodosum: Is it a variant of clinical presentation indicating treatment resistance? A retrospective cohort study.

Idiopathic granulomatous mastitis (IGM) rarely occurs with erythema nodosum (EN) as a systemic finding. However, the impact of their coexistence on disease severity and response to steroids has not been investigated yet. Patients diagnosed with IGM between September 2014 and October 2018 were divided into two groups according to the presence or absence of EN during the first admission retrospectively. The IGM was more severe in patients with EN as it was presented more often as bilateral and diffuse involvement of the breast. Findings of mastitis did not resolve with steroids in 50% of this group. Repetitive excisions and mastectomy with reconstructions were required to control the disease. Coexistence of EN and IGM was found to be related to bilateral and aggressive involvement, which could be associated with insufficient response to steroids. Associated patients should be informed in terms of the aggressive course, and surgery can be highlighted as a first-line treatment.

Comparison of Topical, Systemic, and Combined Therapy with Steroids on Idiopathic Granulomatous Mastitis: A Prospective Randomized Study.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a benign disorder of the breast, for which the optimal treatment modality remains missing. METHODS: A total of 124 patients with a histopathologically proven diagnosis of IGM were enrolled in a prospective, randomized parallel arm study. Patients were treated with topical steroids in Group T (n: 42), systemic steroids (0.8 mg/kg/day peroral) in Group S (n: 42), and combined steroids (0.4 mg/kg/day peroral + topical) in Group C (n: 40). Compliance with the therapy, response to the therapy, the duration of therapy, side effects and the recurrence rates were compared. RESULTS: Sixteen patients did not comply with the treatment, and the highest ratio of compliance with therapy was seen in Group T (p < 0.05). Complete clinical regression (CCR) was observed in 90 (83.3%) patients. Response to the treatment (RT) was evaluated radiologically and observed in 89.8% of the patients. There was no statistically significant difference between groups regarding CCR, RT and the recurrence rate. The longest duration of therapy was observed in Group T (22 ± 9.1-week), whereas the shortest was observed in Group S (11.7 ± 5.5-week) (p < 0.001). The systemic side effects were significantly lower in Group T in comparison with Groups S and C (2.4% vs. 38.2% and 30.3%, respectively) (p < 0.001). CONCLUSIONS: The efficiency of the treatment was similar for all groups, both clinically and radiologically. Although the duration of therapy was longer in Group T, the lack of systemic side effects increased the compliance of the patients with the therapy. Therefore, topical steroids would be among first-line treatment options of IGM.

Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01.

BACKGROUND: The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients. METHODS: At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor. RESULTS: The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04). CONCLUSION: In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Comparison of telomere length and insulin-like growth factor-binding protein 7 promoter methylation between breast cancer tissues and adjacent normal tissues in Turkish women.

BACKGROUND: Both insulin-like growth factor-binding protein 7 (IGFBP7) and telomere length (TL) are associated with proliferation and senescence of human breast cancer. This study assessed the clinical significance of both TL and IGFBP7 methylation status in breast cancer tissues compared with adjacent normal tissues. We also investigated whether IGFBP7 methylation status could be affecting TL. METHODS: Telomere length was measured by quantitative PCR to compare tumors with their adjacent normal tissues. The IGFBP7 promoter methylation status was evaluated by methylation-specific PCR and its expression levels were determined by western blotting. RESULTS: Telomeres were shorter in tumor tissues compared to controls (P<.0001). The mean TL was higher in breast cancer with invasive ductal carcinoma (IDC; n=72; P=.014) compared with other histological type (n=29), and TL in IDC with HER2 negative (n=53; P=.017) was higher than TL in IDC with HER2 positive (n=19). However, telomeres were shortened in advanced stages and growing tumors. IGFBP7 methylation was observed in 90% of tumor tissues and 59% of controls (P=.0002). Its frequency was significantly higher in IDC compared with invasive mixed carcinoma (IMC; P=.002) and it was not correlated either with protein expression or the other clinicopathological parameters. CONCLUSION: These results suggest that IGFBP7 promoter methylation and shorter TL in tumor compared with adjacent tissues may be predictive biomarkers for breast cancer. Telomere maintenance may be indicative of IDC and IDC with HER2 (-) of breast cancer. Further studies with larger number of cases are necessary to verify this association.

Sentinel lymph node biopsy and aberrant lymphatic drainage in recurrent breast cancer: Findings likely to change treatment decisions.

BACKGROUND AND OBJECTIVES: It is not clear whether sentinel lymph node biopsy (SLNB) can be applied to patients with a second breast cancer or recurrence occurring at previously treated breast. The purpose of this study was to assess the feasibility of SLNB procedure in patients with recurrent breast cancer. METHODS: Patients with non-metastatic recurrent N0 breast cancer at ipsilateral breast were included. Patients were grouped according to their initial breast, axilla, and overall surgery. Presence of drainage and its pattern as well as SLNB success rate and overall axillary involvement rates were assessed. Findings were compared. RESULTS: Out of 75 patients, mean age was 52.5 years and disease-free interval was 82 (9-312) months. Lymphatic drainage was successful in 42 (56%) patients. Drainage positivity was more frequent in patients who were previously treated with SLNB (82.6%) than in patients who underwent axillary lymph node dissection (ALND) (44.2%; P = 0,002). Aberrant lymphatic drainage was detected in 64.3% of drainage positive patients. Success rate of reoperative SLNB was 92.9%. Adjuvant treatment plan was altered in 12 (16%) patients. In 15 patients, negative SLNB prevented axillary dissection. CONCLUSIONS: Reoperative SLNB seems to be technically feasible in N0 recurrent breast cancer patients. It may further avoid unnecessary ALND and lead changes in adjuvant treatment plans. J. Surg. Oncol. 2016;114:796-802. © 2016 2016 Wiley Periodicals, Inc.

Impact of cyclooxygenase-2 over-expression on the prognosis of breast cancer patients.

OBJECTIVE: The aim of this present study was to assess the impact of COX-2 over-expression on breast cancer survival. MATERIAL AND METHODS: Non-metastatic invasive breast cancer patients who received adequate loco-regional and systemic treatments were evaluated. Patients' demographic, clinical, pathologic, and treatment-related and survival data were retrieved from their hospital files. COX-2, estrogen/progesterone receptor (ER/PR), HER-2/neu expression and Ki67 index of the tumors were determined immunohistochemically. As the primary objective, COX-2 positive and negative patients were compared in terms of overall (OS), disease-free (DFS) and breast cancer-specific survival (BCSS). Secondary objectives were to assess the independent prognostic factors for survival. In addition, the correlation of COX-2 expression with conventional prognostic and predictive factors of breast cancer was assessed. RESULTS: Two hundred and seventeen patients who underwent adequate breast cancer treatment between November 2004 and December 2013 were included in the study. The median follow-up was 37 months (range: 5-107). Eighty-one (37%) patients were COX-2 positive. OS, DFS, and BCSS were similar in COX-2 positive and negative patients. Ki67 index and age were significantly correlated with COX-2 expression (r=-0.116; p=0.02; r=0.159; p=0.02). PR expression was found to be the only independent factor for predicting OS, tumor size and molecular subtype classification were found to be the only independent factors for predicting DFS, and PR expression was found to be the only independent factor for predicting BCSS. CONCLUSION: Among the independent predictive and prognostic factors of breast cancer, COX-2 over-expression was only correlated with Ki67 index and age.

Radiofrequency ablation of benign symptomatic thyroid nodules: prospective safety and efficacy study.

BACKGROUND: Radiofrequency ablation (RFA) is a relatively novel procedure in the management of benign nodular goiter. This study was conducted to evaluate the safety and efficacy of ultrasound (US)-guided percutaneous RFA for benign symptomatic thyroid nodules as an alternative to surgery. METHODS: The study involved patients for whom a fine needle aspiration biopsy had proved a diagnosis of benign nodular goiter and had nodule-related symptoms such as dysphagia, cosmetic problems, sensation of foreign body in the neck, hyperthyroidism due to autonomous nodules or fear of malignancy. Percutaneous RFA was performed as an outpatient procedure under local anesthesia. The primary outcome was an evaluation of the changes in symptom scores (0-10) for pain, dysphagia and foreign body sensation at the 1st, 3rd, and 6th months after the RFA procedure. Secondary outcomes were assessing volume changes in nodules, complication rates, and changes in thyroid function status. RESULTS: A total of 33 patients (24% female, 76% male) and a total of 65 nodules were included into the study. More than one nodule was treated in 63.6% of the patients. We found a statistically significant improvement from baseline to values at the 1st, 3rd, and 6th months, respectively, as follows: pain scores (2.9 ± 2.7, 2.3 ± 2.01, 1.8 ± 1.7, and 1.5 ± 1.2, p 0.005), dysphagia scores (3.9 ± 2.7, 2.6 ± 1.9; 1.7 ± 1.6, and 1.1 ± 0.3, p 0.032), and foreign body sensation scores 3.6 ± 3, 2.5 ± 2.2; 1.6 ± 1.5, and 1.1 ± 0.4, p 0.002).The mean pre-treatment nodule volume was 7.3 ± 8.3 mL. There was a statistically significant size reduction in the nodules at the 1st, 3rd, and 6th months after RFA (3.5 ± 3.8, 2.7 ± 3.4, and 1.2 ± 1.7 mL, p 0.002). The volume reduction was found to be 74% at 6th months following the RFA (p 0.005). 8 patients had autonomously functioning nodules in the pre-treatment period, 50% (n: 4) became euthyroid at the 6th month after RFA. There were no complaints other than pain (12%). CONCLUSION: RFA can be an alternative treatment modality in the management of benign symptomatic thyroid nodules. The results showed that it is a safe and effective procedure.

Should we consider topical silver nitrate irrigation as a definitive nonsurgical treatment for perianal fistula?

BACKGROUND: Surgery is currently the sole treatment modality for anal fistulas. However, surgery is associated with complications such as permanent incontinence, which reduces quality of life. OBJECTIVE: To determine the rate of complete clinical healing of anal fistulas after irrigation of the fistula tract with silver nitrate solution as a nonsurgical treatment. DESIGN: Prospective single arm study. SETTING: Tertiary university hospital PATIENTS: : Adult patients with symptomatic perianal fistula presenting between June 2012 and January 2013. INTERVENTION: Irrigation of the fistula tract with 1% silver nitrate solution. Irrigation was repeated every 2 weeks when necessary. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of complete clinical healing. RESULTS: Fifty-six consecutive patients with anal fistula were analyzed. Of those, 29 (52%) had complete clinical healing without recurrence for a median of 10 months. The median number of irrigations needed for complete clinical healing was 4 (1-10). The level of satisfaction was excellent in patients with complete clinical healing. The frequency of complaints was the only independent factor that had an impact on healing; patients with intermittent discharge had a significantly higher rate of complete clinical healing (67%) than those with continuous discharge (40%). There were no notable complications. LIMITATIONS: Short follow-up, small sample size, and no comparisons. CONCLUSION: This study demonstrates that the application of silver nitrate solution often produces a favorable outcome in the treatment of anal fistula. This method may be considered as a first-line treatment for the disease because it is simple, performed on an outpatient basis, minimally invasive, and lacks the complications encountered with current conventional surgical modalities.

The emerging role of national academies in surgical training: an inspiring environment for increasing the quality of health care in breast cancer management.

Medical education, both graduate and postgraduate, is given at medical schools and affiliated teaching hospitals. The training at these institutions is necessary and valuable. In each field of the medical profession, the relevant science is being developed and changed constantly. Training of medical staff and auxilliary professionals must be adaptable to changes in the field. Also, the development of standards for the diagnosis and treatment of diseases is important. Independent institutions, called academies, serve an extremely useful task in the continuing further training that needs to be adjusted according to individual needs. Academies are independent and free from bureaucracies. Standardized records are uniform and comparable at these institutions. Both patients and medical staff receive training from these institutions. In this way, a high standard is provided in medicine, error rates are decreased and patient satisfaction is increased. Breast cancer, the most common tumor in women, is a serious cause of morbidity and mortality. The European Institute of Oncology (EIO) in Milan, Italy and the European Academy of Senology in Duesseldorf, Germany play important roles in establishing the standards of breast care. They provide substantial training for physicians to achieve high quality in breast cancer management. SENATURK (Senoloji Akademisi, Turkish Academy of Senology) was established in 2010 in Istanbul, Turkey. Both national and international scientists and physicians including eminent senologists are currently faculty members of this young organization. SENATURK collaborates with other institutions in Europe. Its missions include developing training programs for each level of the profession, as well as developing data recording systems and electronic learning tools for breast cancer prevention, diagnosis, treatment, rehabilitation and palliation. Briefly, SENATURK plays a significant role as the opinion leader on every aspect of health care related to conditions and diseases of the breast.

Imposter Phenomenon in Pediatric Residency: An Empirical Simulation-Based Educational Study.

The imposter phenomenon (IP) may have a negative impact on the ability of healthcare providers to make difficult and accurate decisions. This study presents an empirical approach, segregating the real imposters based on a simulation, and aims to investigate the prevalence and severity of IP and evaluate the attitude in the decision-making process of pediatric residents with impostorism. A simulation-based case study with the 113 pediatric residents was performed with the Clance Imposter Phenomenon Scale to identify IP scores and appropriate management skills for the case. The collected data were divided and combined into different categories based on the IP scale scores and the success of case management to further detect how real imposters were affected. Our study revealed that 24 (21.2%) of residents have moderate, 33 (25.7%) of residents have frequent, and 29 (29.2%) of residents have intense impostorism feelings. The imposter scores were found to be higher among female participants (P = .006). However, when considering the prevalence of significant impostorism (defined as both frequent and intense), there was no statistically significant difference between females and males (P = .088). The data indicated that an increase in IP scores was associated with a higher likelihood of delayed pressing the help button for both the overall and post-exclusion groups (P < .001). The analysis also revealed a significant correlation and a monotonic-linear trend between IP scores and the decision-making process, even after excluding the unsuccessful participants (P < .001). This is the first study to demonstrate the prevalence of IP among pediatric residents, potentially leading to challenges in patient care and resulting in delayed decisionmaking and self-doubt with feelings of inadequacy. The findings support the claim that higher imposter scores are associated with a greater tendency to seek help from more experienced individuals, even when fully capable of managing cases independently. This emphasizes the importance of awareness about the IP, as these factors can directly impact both the well-being of trainees and patient care outcomes.

Treatment of Granulomatous Mastitis With Steroids: Should the Decision to End the Treatment be Made Radiologically?

Objective: Idiopathic granulomatous mastitis (IGM) is a benign inflammatory breast disease of unknown etiology that affects women in their reproductive period. The most commonly preferred option as first-line treatment is steroids, but the lack of a standard treatment protocol and high recurrence rate after treatment constitutes a recurring challenge during its management. The aim of this study was to investigate whether the decision to end the treatment should be made radiologically or clinically. Materials and Methods: This retrospective cohort study included IGM patients who had complete clinical recovery with steroids and were followed for a minimum of 30 months. Patient demographics, disease severity and findings, treatment regimens and duration, and magnetic resonance imaging (MRI) findings at clinical recovery were assessed for their relation to recurrence. Results: Eighty-nine patients who were clinically completely healed after steroid treatment for IGM were included in the study. At the time of clinical healing, 51 (57.3%) patients had a complete radiological response and 38 (42.7%) had a partial radiological response (PRR) on MRI. Overall, recurrence developed in 22 (24.7%) patients after a median 38.6-month follow-up. Patients who experienced recurrence were significantly older and had PRR when their treatment was stopped upon clinical healing. Conclusion: During the process of clinical healing, the imaging findings revealed that the remaining disease seems to be a significant predictor for recurrence in IGM patients. In patients with PRR, extending the treatment with either prolonged steroid therapy or by surgical excision of the occult residual disease may prevent recurrences in IGM patients.

Efficacy of prophylactic antibiotic administration for breast cancer surgery in overweight or obese patients: a randomized controlled trial.

OBJECTIVE: To assess the impact of prophylactic antibiotics on the prevention of surgical site infection (SSI) and the cost-effectiveness of this prophylaxis for breast cancer surgery in overweight or obese women. BACKGROUND DATA: SSI is higher than expected after breast surgery. Obesity was found to be one of the risk factors. METHODS: The trial was designed as a phase IV randomized, controlled, parallel-group efficacy trial. It was conducted at a tertiary university hospital. Overweight or obese women with clinically early-stage breast cancer who had been assigned to undergo surgery were eligible. Patients were randomly allocated to either a prophylaxis or a control group by using a computer-generated list. The prophylaxis group received 1 g ampicillin-sulbactam intravenously at anesthesia. The control group received no intervention. Patients and observers were blinded to the assignments. The primary outcome was the comparison of SSI incidences of the 2 groups. Patients were monitored for 30 days. RESULTS: A total of 369 patients were included in final analysis, out of which 187 were allocated for prophylaxis and 182 were randomly assigned to the control group. Analysis was done according to the intention-to-treat principle. Prophylaxis significantly reduced the SSI rate (4.8%) in the prophylaxis group when compared with that in the control group [13.7%; relative risk (RR) 0.35; 95% CI: 0.17-0.73]. No adverse reaction was observed. The mean SSI-related cost (20.26 USD) was found to be significantly higher in the control group when compared with that (8.48 USD) in the prophylaxis group. CONCLUSION: Antibiotic prophylaxis significantly decreased SSI incidence after elective surgery and was shown to be cost-effective in obese breast cancer patients. ClinicalTrials.gov Identifier: NCT00356148.

New Media Platforms for Teaching and Networking: Emerging Global Opportunities for Breast Surgeons.

Background: The framework of breast care is changing rapidly due to the increasing success of systemic therapies for breast cancer, and consequently, surgeons need to adapt themselves to the changing role of surgery in its management. Real-world evidence indicates that breast cancer patient-related outcomes are better if they are managed by specialized physicians and surgeons. On the other hand, the curriculum for the training of breast surgeons is expanding and includes skills that involve newer surgical techniques and nonsurgical technologies. De-escalation of surgery and also the fact that quality of life is becoming one of the priorities in breast cancer management require breast surgeons to be competent in all aspects of multidisciplinary management. Classical teaching including master-apprentice relation-based training is no more sufficient to satisfy the expectations of the trainees. However, on the other hand, the sources for contemporary postgraduate education are relatively scarce when considering these fast changes in the field. Therefore, there is a continuing quest among breast surgeons for finding ways to maintain their professional development. Summary: Classrooms and operating theaters without walls that came with the internet boom brought substantial opportunities for breast surgeons. Platforms such as BreastGlobal, Breastics24 h, Global Breast Hub, Oncoplastic Academy-Brazil, ibreastbook, Virtual Breast Oncoplastic Surgical Simulator, and CluBreast helped surgeons who needed to get contemporary training and interaction for their professional continuous development. Networking sites such as YouTube, Facebook, and Twitter are also among the social media platforms for professional groups to interact. National and global breast surgery societies also provide periodical online meetings and congresses for their members in order to satisfy the ongoing demand for training, interaction, and networking. Therefore, web-based platforms helped many surgeons from different parts of the world who could not afford to travel or did not have time to attend the necessary meetings due to their limited time and resources. Moreover, these online programs may have also encouraged surgeons to pursue specialized training in breast surgery which in turn should be expected to increase the quality of breast care in their countries. Key Messages: The platforms have downsides such as practical training and role modeling are limited and the opportunity of receiving real-time feedback on skills requirements lacks and networking would not be productive as expected. Nevertheless, web-based platforms require certain technology and infrastructure which still could not be provided everywhere.

Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411).

BACKGROUND: Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics. METHODS: We performed a systematic review on localization techniques for non-palpable breast cancer. RESULTS: For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques. CONCLUSIONS: Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.

Uncertainties and controversies in axillary management of patients with breast cancer.

The aims of this Oncoplastic Breast Consortium and European Breast Cancer Research Association of Surgical Trialists initiative were to identify uncertainties and controversies in axillary management of early breast cancer and to recommend appropriate strategies to address them. By use of Delphi methods, 15 questions were prioritized by more than 250 breast surgeons, patient advocates and radiation oncologists from 60 countries. Subsequently, a global virtual consensus panel considered available data, ongoing studies and resource utilization. It agreed that research should no longer be prioritized for standardization of axillary imaging, de-escalation of axillary surgery in node-positive cancer and risk evaluation of modern surgery and radiotherapy. Instead, expert consensus recommendations for clinical practice should be based on current evidence and updated once results from ongoing studies become available. Research on de-escalation of radiotherapy and identification of the most relevant endpoints in axillary management should encompass a meta-analysis to identify knowledge gaps, followed by a Delphi process to prioritize and a consensus conference to refine recommendations for specific trial designs. Finally, treatment of residual nodal disease after surgery was recommended to be assessed in a prospective register.