Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic.

OBJECTIVE: The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management. BACKGROUND: COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk. METHOD: Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages. RESULTS: Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer. CONCLUSION: A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

Breast cancer surgery without suction drainage: the impact of adopting a 'no drains' policy on symptomatic seroma formation rates.

AIM: To determine the effect of a 'no drains' policy on seroma formation and other complications in women undergoing breast cancer surgery. MATERIALS AND METHODS: Before May 2010 drains were routinely used in our unit following mastectomy ± axillary surgery and axillary lymph node dissection (ALND) ± wide local excision (WLE). Since then, a 'no drains' policy has been adopted. Data was collected prospectively between 01/12/06 and 30/11/11 to compare symptomatic seroma, wound infection, re-admission and re-operation rates in women treated with a drain and those without. RESULTS: 596 women were included in the study. 247 women underwent modified radical mastectomy (MRM) and ALND (Group 1), 184 MRM ± sentinel lymph node biopsy (SLNB)/axillary node sampling (ANS) (Group 2) and 165 ALND ± WLE (Group 3). In group 1, 149 had a drain, in group 2, 62, and in group 3, 50. Within each group, the presence or absence of a drain did not significantly affect the rate of symptomatic seroma, number of aspirations performed, wound infection rates or the incidence of complications requiring re-admission. Having a drain was associated with lower volumes of seroma aspirated. In all three groups, the presence of a drain was associated with a longer hospital stay (p < 0.001). CONCLUSION: This study suggests that MRM ± ALND/SLNB/ANS and ALND ± WLE can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a 'no-drains' policy may also contribute to earlier hospital discharge.

Circulating levels of VEGF-A, VEGF-D and soluble VEGF-A receptor (sFIt-1) in human breast cancer.

As circulating levels of vascular endothelial growth factor (VEGF-A) are raised in malignancy, the aim of this study was to investigate whether similar changes occur in two related factors, VEGF-D and the soluble VEGF-A receptor FIt-1 (sFIt-1). Circulating levels of VEGF-A, VEGF-D and sFIt-1 were determined by ELISA in 51 patients with primary breast cancer and matched healthy controls. Results were correlated with clinicopathological data. Whilst there was a difference in VEGF-A levels between patient and control groups (p = 0.03), no such difference was observed for sFIt-1 or VEGF-D levels and there was no association between individual factors and the clinicopathological variables examined. However, there was a positive correlation between VEGF-A and sFIt-1 levels in both patient and control groups (p < 0.0001). In addition, the ratio of sFIt-1 to VEGF-A was significantly different between patients and controls (p < 0.0001) and was also associated with tumour size (p = 0.01) within the patient group. During tumour progression there is a change in the relative amounts of sFIt-1 and VEGF-A in the circulation. Measuring the sFIt-1:VEGF-A ratio may have more significance than VEGF-A alone and further studies are needed to determine whether the ratio is of use as a prognostic marker or as a means of monitoring response to anti-angiogenic therapy in cancer.

Splenic rupture as a consequence of dual malignant pathology: a case report.

A 76 year old woman presented acutely with non-traumatic splenic rupture, which was successfully treated by emergency splenectomy. Histological examination of the spleen revealed the coexistence of metastatic adenocarcinoma cells, together with low grade B cell non-Hodgkin lymphoma. Splenic rupture as a consequence of malignant disease is discussed, together with a brief review of the literature.

Co-expression of vascular endothelial growth factor C (VEGF-C) and c-erbB2 in human breast carcinoma.

Vascular endothelial growth factor C (VEGF-C) has angiogenic and lymphangiogenic properties and is associated with the development of lymphatic metastases in a number of epithelial malignancies. The aim of this study was to determine VEGF-C protein expression in a series of breast carcinomas and correlate this with axillary lymph node (LN) metastases, the presence of lympho-vascular invasion (LVI), bone marrow micro-metastases (BMM) and other clinico-pathological data including oestrogen receptor (ER) and c-erbB2 status. VEGF-C expression was determined by immunohistochemistry (IHC) in 51 tumours. ER and c-erbB2 were also assessed by IHC. Bone marrow analysis was performed using a combination of immunomagnetic separation and immunocytochemistry. Overall, 30/51 (59%) of the tumours were positive for VEGF-C. There was no significant correlation between VEGF-C expression and LN status, LVI, BMM, tumour size, grade or ER status. However, there was an association between c-erbB2 and VEGF-C expression (P=0.013). The correlation between VEGF-C and c-erbB2 suggests a functional relationship and may, in part, explain the aggressive phenotype associated with c-erbB2-positive tumours.

A prospective study of the value of axillary node sampling in addition to sentinel lymph node biopsy in patients with breast cancer.

AIMS: Limitations of sentinel lymph node biopsy (SLNB) include the occurrence of false negative (FN) results and the need to further treat SLNB positive axillae. The aims of this study were to: (1) compare the accuracy of SLNB alone to a combined SLNB and axillary sampling procedure (SLNB+AS). (2) evaluate if the additional AS could identify those SLNB positive cases with no further disease in the axilla. METHODS: Sixty-seven combined SLNB+AS procedures were performed prospectively in 66 patients, followed by Level II axillary dissection. Additionally sampled nodes were recorded if they were clinically suspicious or not at intra-operative palpation. RESULTS: The FN rate for SLNB alone was 14.3%, whilst that for SLNB+AS was reduced to 3.6%. However, the benefit of additional sampling was only seen in those cases with tumours >/=3 cm and clinically suspicious nodes (n=12). Of 12 cases with a positive SLN but negative AS, 4 (30%) were found to have disease elsewhere in the axilla. CONCLUSION: SLNB is inaccurate in the presence of suspicious nodes found at operation and careful palpation and sampling of these nodes is recommended, especially with larger tumours. In SLNB positive patients, AS is unreliable in predicting those patients with no further disease in the axilla.