Breast Cancer Management Consensus By The Society of Surgeons and Surgical Oncology Society of Pakistan.

The Society of Surgeons of Pakistan and The Society of Surgical Oncology of Pakistan with factions from various major centres comprising of surgical oncology, medical and radiation oncology collaborated to reach consensus on breast cancer management guidelines and a framework of "good practice" minimum standards of care. The aim of the task force was to enhance treatment standards, which have a direct correlation with improving patient mortality and morbidity and long-term survival whilst taking into consideration economic limitations of access to leading centers of excellence as well as minimum expertise required in health care. These multidisciplinary guidelines, whilst not exhaustive, aim to provide an algorithm of care for breast cancer patients at tertiary care centres and district level hospitals to provide most appropriate treatment.

Breast cancer treatment in high-risk elderly patients: A challenging situation and difficult decisions.

OBJECTIVE: To assess whether high-risk elderly patients with aggressive tumour biology can be offered standard treatment despite having multiple comorbid conditions. METHODS: This retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of breast cancer patients aged 65 years or above treated between 2006 and 2012,. Data was collected regarding patients' demographics, baseline clinical characteristics, comorbidities, treatment and outcomes. Stata 12 was used for data analysis. RESULTS: Of the 407 patients in the study, 399(98%) were women and 8(2%) were men. The overall mean age at diagnosis was 70±4.9 years (range: 65-90 years). Overall, 59(14.5%) participants had family history of breast cancer. Bilateral disease was seen in 17(4.2%). Invasive ductal carcinoma was seen in 299(73.5%). Besides, 101(24.8%) patients had no comorbid conditions, while 138(34%) had one, 102(25%) had two and 66(16%) had three or more comorbid conditions. There was no statistically significant difference between those receiving standard treatment including surgery or other modalities. CONCLUSIONS: Elderly patients of breast cancer may be offered treatment according to the tumour biology and their overall functional status.

Modifying Surgical Practice in the Times of Current COVID-19 Pandemic.

In the times of current coronavirus disease 2019 (COVID-19) pandemic, the surgical practice is suffering. The present report summarises the impact of this pandemic on our surgical services and the changes that have been promulgated for the resumption of services with the purpose of providing valuable information for our surgical colleagues worldwide. Almost six months have passed since this pandemic started, and the total number of confirmed cases has exceeded 7 million; and over 400 thousand lives have been claimed till now. We need to find ways to continue providing essential medical services to patients, while fighting with this pandemic since it might take longer than expected to end. Key Words: COVID-19, Pandemic, Surgery, Personal protective equipment, N95 masks.

Invasive carcinoma in accessory axillary breast tissue: A case report.

INTRODUCTION: Accessory or ectopic breast tissue is an aberration of normal breast development. It is known to be a rare entity present anywhere along the embryologic mammary streak or milk line but more common in axilla. PRESENTATION OF CASE: We report a case of 36 year old female with accessory breast carcinoma who presented with a progressive lump in her left axilla for 1 year. On examination a 2 cm solitary mass was palpable in axilla. Ultrasound confirmed a 19 mm mass with no other lesion in breast and axilla. Core biopsy showed invasive ductal carcinoma. She was discussed in multidisciplinary board meeting and was offered upfront surgery with excision of accessory breast tissue and sentinel lymph node biopsy. Axillary lymph node dissection was omitted following ACOSG Z0011 criteria. She was offered adjuvant chemotherapy and radiation post operatively along with endocrine treatment as she was hormone receptor positive. DISCUSSION: Accessory breast development is hormone dependent just like normal breast. Breast cancer in accessory breast tissue is very rare. The incidence is around 6%. Most common pathology is invasive ductal carcinoma (50-75%). The most common location is axilla (60-70%) although it can present in other less common locations like infra-mammary region (5-10%) and rarely in thighs, perineum, groin, and vulva. CONCLUSION: Since accessory axillary breast tissue is out of the image of screening breast examination, it is necessary for the oncologists to be aware of this entity and associated pathologies. Their preventive excision in high risk women can also be considered.

Association of tumor size and focality with recurrence/persistence in papillary thyroid cancer patients treated with total thyroidectomy along with radioactive-iodine ablation and TSH suppression.

Locoregional recurrence is common in papillary thyroid cancer PTC and an optimal surgical treatment with respect to the multifocal nature of the disease stays controversial. It is a retrospective analytical study design. 209 diagnosed PTCs managed at our institute were grouped into macro-PTC with a size of dominant focus >1 cm (unifocal n = 106 and multifocal n = 64) and micro-PTMC if size of all foci was <1 cm; (unifocal n = 16 and multifocal PTMC n = 23). The primary endpoint is recurrence and tumor free survival in each of the four groups. Secondary endpoint is an assessment of a benefit of completion total thyroidectomy in terms of assignment of true focal status to an individual's PTC. The median follow-up was 4.1 years. Upon completion thyroidectomy, the tumor focality changed to multifocal in 31.4% of macro-PTC and 60% of micro-PTMC. Multifocality was an independent risk factor for recurrence, OR 2.41 for macro (CI 1.14-5.11), and 3.48 for micro-multifocal PTMC (CI 1.19-10.2). Disease free survival patterns on Kaplan-Meier's plots were alike for micro- and macro-unifocal groups, and similarly stayed comparable among the two multifocal groups. Our analysis showed that tumor multifocality rather than size is the significant factor determining prognosis; hence, total thyroidectomy is indicated for an optimal assessment of true focality in micro-PTC.

Medullary Thyroid Carcinoma: Prognostic Variables And Tumour Markers Affecting Survival.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a relatively rare thyroid malignancy and its clinical course varies among patients due to its familial association. A number of prognostic factors have been studied, but the significance of these factors remains controversial. We evaluated the progression free survival (PFS) and overall survival (OS) of MTC and its association with tumour marker rising velocity and serum calcitonin (Ct) doubling time (DT). METHODS: Analysis of 83 (8.7%) consecutive MTC patients registered at a single centre between 1995 and 2015. The impact of tumour respectability, TNM stage, multiple endocrine neoplasia (MEN) syndrome, local recurrence, Ct DT and Ct rising velocity on PFS and OS was analysed. Median follow-up was 4.3 years (range: 1-18 years). RESULTS: Eighty-three (8.7%) of all thyroid cancers registered at our centre were MTC. Fifty-five males, 28 females. Mean age 39 years [range: 17-72 years]. Twenty-two were unresectable and 61 resectable. Five-year and 10-year OS was 84% and 77% respectively. Of 68 with follow up greater than a year; 20 (29.4%) were cured, 15 (22.1%) had biochemical evidence of disease, three (4.4%) had stable macroscopic disease and 30 (44.1%) had recurrent/progressive disease. Sixteen (23.5%) died. On multivariate analysis, T4 tumour, male gender, nodal and distant metastases, tumour resectibility, Ct DT less than two years and tumour marker rising velocity of greater than 0.05pg/ml/month were poor prognostic factors (pvalue <0.05). Age and association with MEN syndrome had no statistically significant survival impact. Radiotherapy reduced local relapse in patients with nodal disease. Total thyroidectomy with nodal clearance lessened relapses. CONCLUSION: Clinical stage and pathological aspects are predictors of disease progression. Persistent biochemical evidence of MTC does not affect OS, however, Ct DT < 2 years and rapid rate of tumour marker rise predict disease progression.

Managing the Axilla in Early Breast Cancer. Impact of ACOSOG Z0011 Trial in Changing Practices in a Low Middle Income Country

Objective: To determine the impact of the trial on surgeon practice patterns at our institution. Methodology: A comparison of patients undergoing surgery for early breast cancer before and after the implementation of the new guidelines was done. We adopted the new guidelines in April 2015. Patients meeting Z0011 inclusion criteria were identified. For group A (Pre Z0011) patients operated between Jan to Dec 2013 were studied. And for Group B (Post Z0011) patients operated between July 2014 to Jun 2015 were included. Clinicopathologic data were compared between the two groups. Results: There were 318 patients with clinical T1-2 tumors planned for breast conservation. 68% patients had T1 tumor and 32% had T2. 92% of the patients had IDCa. There were 150 patients in the pre-Z0011 group and 168 post-Z0011. 68% of the patients in Group A were ER+ve while 70% in group B. 38 (25.7 %) patients were sentinel lymph node (SLN) positive in the pre-Z0011 group versus 34 (21 %) post-Z0011 (p = 0.392). Before Z0011 100 % (38/38) of SLN-positive patients underwent axillary node dissection (ALND) versus 17 % (6/34) after Z0011 (p < 0.01). Median no of SLNs identified in group A were 1.3 and group B were 1.4. There was a decrease in median operative times of the two groups (80 vs. 60 min, p < 0.01). There was a significant decrease in the overall hospital stay of sentinel lymph node positive patients in between the two groups (2.1 days vs 1.3 days p value < 0.01). Conclusions: Implemention of Z0011 guidelines has resulted in significant short term advantages in terms of reduced axiilary dissections, shorter operative times and shoter hospital stays.

Breast Lymphoma Treatment Outcomes in a Pakistani Population: 20 Years of Experience at a Single Center.

BACKGROUND: Breast lymphomas constitute a rare disease entity. To date, limited relevant data have been reported. We therefore here present a review of breast lymphoma patients treated at a single center over a 20 year period, focusing on histological types, treatment modalities and outcomes. MATERIALS AND METHODS: We identified patients who were diagnosed and treated for breast lymphoma at a single center from January 1995 to January 2014 and extracted data regarding patient demographics and clinical data. RESULTS: Twenty-seven patients with breast lymphoma were identified, of which 3 were males. The median age at diagnosis was 37 years (range: 22-76 years). Chemotherapy was the main stay of treatment and 55.6% patients also received radiation to the affected breast. At our institute, only 3 patients, all with progressive disease, had surgery performed to achieve local palliation. Complete response after chemotherapy was seen in 63% patients and partial response in 7.4%, while 26% patients demonstrated disease progression. The mean follow up was 46.8 months. Seven patients (33.3%) who were alive at last follow up, as well as 1 patient who died, survived more than 5 years after diagnosis. CONCLUSIONS: Patients with breast lymphoma should receive aggressive treatment, with combination of chemotherapy and radiation therapy. Surgery should be limited for diagnosis and palliation of local symptoms in cases of progressive disease.

Outcomes of triple-negative versus non-triple-negative breast cancers managed with breast-conserving therapy.

BACKGROUND: Triple negative breast cancer is associated with aggressive behavior and high risk of local and regional failure. Aggressive surgical intervention is considered suitable. This makes role of breast conserving therapy (BCT) debatable in these patients. The objective of this study was to compare outcome of BCT for triple negative versus non-triple negative breast cancer. MATERIALS AND METHODS: Medical records of patients who underwent breast conserving therapy from 1999 to 2009 at Shaukat Khanum Cancer Hospital and had complete receptor status information were extracted. Patients were divided into triple negative breast cancer (TNBC) and non-TNBC. Patient characteristics, medical treatment modalities and adverse events were compared. Expected five year locoregional recurrence free, disease free and overall survival was calculated. The Cox proportional hazard model was used to identify independent predictors of outcome. RESULTS: A total of 194 patients with TNBC and 443 with non-TNBC were compared. Significant difference was present for age at presentation (p<0.0001), family history (p=0.005), grade (p<0.0001) and use of hormonal therapy (p<0.0001). The number of locoregional failures, distant failures and mortalities were not significantly different. No significant difference was present in 5 year locoregional recurrence free (96% vs 92%, p=0.3), disease free (75% vs 74%, p=0.7) and overall survival (78% vs 83%, p=0.2). On multivariate analysis, tumor size, nodal involvement and hormonal treatment were independent predictors of negative events. CONCLUSIONS: Breast conserving therapy has comparable outcomes for triple negative and non-triple negative breast cancers.

Judicious use of recombinant TSH in the management of differentiated thyroid carcinoma.

OBJECTIVE: To evaluate the feasibility of using recombinant human TSH (rhTSH) in conjunction with ¹³¹I to treat patients with differentiated thyroid carcinoma. METHODS: Between July 2003 and April 2009, 14 patients [mean age, 39.1 years (range 14-71 years)], of whom seven were treated for remnant ablation and seven for irresectable or metastatic disease, received rhTSH-aided ¹³¹I therapy. None had an adequate rise in TSH. The mean ¹³¹I dosage administered was 5206.3 MBq. Baseline thyroglobulin/anti-thyroglobulin (Tg/anti-Tg) and TSH levels were documented. rhTSH (0.9 mg) was given intramuscularly on days 1 and 2, and TSH levels were recorded. ¹³¹I was given when the TSH level rose to >30 µIU/ml. Tg/anti-Tg levels were measured at 3-month intervals. A ¹³¹I whole-body scan (¹³¹I scan) was performed 6 or 12 months after treatment. RESULTS: The baseline median valid Tg and TSH levels were 76.2 ng/ml (range 14.1 to >30000) and 3.63 µIU/ml (range 1.36-11.0), respectively. The rise in TSH level was 34.8-96.9 µIU/ml after the first rhTSH injection and 33.1 to >75 µIU/ml after the second injection. The post-therapy ¹³¹I scan showed uptake at disease sites in all patients, indicating the initial empirical adequacy of treatment. Follow-up ¹³¹I scan was positive for four patients, but negative for three of these patients after subsequent therapy. Complete resolution of disease was seen in eight patients and partial resolution in four after 3 months of therapy; one had stable disease; and in one patient with progressive disease, complete resolution was achieved after repeated ¹³¹I doses with thyroxine withdrawal. After a median follow-up of 39.2 months, all patients were alive and no disease recurrence was observed. The overall response rate at 3 months was 86% and had improved to 93% at the time of this review. The final ablation rate in seven patients was 100%. Apart from notable neck swelling in four patients, which was responsive to medication, and headache in two patients, no significant short-term side-effects of therapy were seen. CONCLUSION: In our setting, the use of rhTSH-aided ¹³¹I ablation and treatment was safe and effective.