Let us cut to the core: is core biopsy enough for subcentimeter breast cancer?

BACKGROUND: Breast conservation therapy has become a preferred method of treating early-stage breast cancer. As care continues to evolve, certain lesions allowed less invasive treatment options. A simplified explanation of early breast cancer care is detection, biopsy, surgery, and adjuvant therapy. The authors look to challenge that algorithm for a specific type of disease. METHODS: A retrospective review was performed to identify all subcentimeter breast cancer that underwent surgery after core biopsy. These cases (n = 115) were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found on final pathology, potentially rendering the surgical resection an unneeded procedure. RESULTS: The authors found that 17 of 115 patients (14.8%) who underwent biopsy for subcentimeter breast cancer had no residual disease found on final surgical resection. Although the subsets were small, the largest core needle resulted in negative pathology two of three times, while the smallest gauge, never resulted in negative resection at time of surgery. CONCLUSIONS: Nearly, fifteen percent of patients were found to have no residual disease on final surgical pathology. These results were obtained when the radiologist was simply trying to get tissue diagnosis. The authors postulate that this percentage could be even higher if protocols were initiated to biopsy these small lesions with larger core biopsies and possibly alleviate the need for formal surgery in these specific, small lesion.

Does routine use of indocyanine green fluorescence angiography prevent anastomotic leaks? A retrospective cohort analysis.

BACKGROUND: Insufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. METHODS: This was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. RESULTS: The anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p < 0.05). CONCLUSIONS: No significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience.

BACKGROUND: Ureteral injuries during colorectal surgery are a rare event, ranging in the literature from 0.28-7.6%. Debate surrounds the use of prophylactic lighted ureteral stents to help protect the ureter during laparoscopic surgery. It has been suggested that they help to identify injuries but do not prevent them. The authors look to challenge this. METHODS: Over 66 months, every laparoscopic or colectomy involving ureteral stents was recorded. Researchers documented any injury to the ureter intraoperatively. The chart was also reviewed for the complications of urinary tract infection (UTI) and urinary retention post-operatively. RESULTS: During the 66 months, 402 laparoscopic colon resections were done. There were no ureteral injuries. The lighted ureteral stent was identified during every case in the effort to prevent injury during dissection and resection. No catheter associated UTIs were identified, while 14 (3.5%) suffered from post-operative urinary retention. CONCLUSIONS: The authors of this study present a large series of colon resections with no intraoperative ureteral injuries. In addition, these catheters were not associated with any UTIs and a rate of urinary retention similar to that of the at large data. This series provides compelling data to use lighted ureteral stents during laparoscopic colon surgery.

Intraoperative indocyanine green fluorescence angiography--an objective evaluation of anastomotic perfusion in colorectal surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0-256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPY provides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.