High-value breast cancer care within resource limitations.

Breast cancer care is a costly global health issue where effective management depends on early detection and treatment. A breast cancer diagnosis can result in financial catastrophe especially in low- and middle-income countries (LMIC). Large inequities in breast cancer care are observed and represent a global challenge to caregivers and patients. Strategies to improve early diagnosis include awareness and clinical breast examination in LMIC, and screening in high-income countries (HIC). The use of clinical guidelines for the management of breast cancer is needed. Adapted guidelines from HIC can address disparities in populations with limited resources. Locally developed strategies still provide effective guidance in improving survival. Integrated practice units (IPU) with timely multidisciplinary breast care conferences and patient navigators are required to achieve high-value, personalized breast cancer management in HIC as well as LMIC. Breast cancer patient care should include a quality of life evaluation using ideally patient-reported outcomes (PROM) and experience measurements (PREM). Evaluation of breast cancer outcomes must include the financial cost of delivered care. The resulting value perspective should guide resource allocation and program priorities. The value of care must be improved by translating the findings of social and economic research into practice and resolving systemic inequity in clinical breast cancer research. Cancer survivorship programs must be put in place everywhere. The treatment of patients with metastatic breast cancer must require more attention in the future, especially in LMIC.

A randomised controlled trial of Pre-Operative Oncotype DX testing in early-stage breast cancer (PRE-DX study) - Study protocol.

BACKGROUND: The Oncotype DX® Breast Recurrence Score assay can guide recommendations made to patients with oestrogen receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2-) breast cancer regarding post-surgery adjuvant therapy. Standard practice is to order the test in the post-operative setting on a specimen from the excised invasive carcinoma. However, it has been shown to be technically possible to perform the test on the diagnostic core biopsy. By testing the diagnostic core biopsy in the pre-operative setting, the wait for excised invasive carcinoma Recurrence Score results could be reduced allowing patients to be more accurately counselled regarding their treatment pathway sooner with any adjuvant treatment recommendations expedited. This would allow for more efficient streaming of follow up appointments. The aim of this study is to compare the impact on the patient treatment pathway of performing the Oncotype DX® test on the diagnostic core biopsy pre-operatively (intervention) as opposed to the excised invasive carcinoma (control). METHODS AND ANALYSIS: This parallel group randomised controlled trial aims to recruit 330 newly diagnosed patients with grade 2 or grade 3, ER+, HER2-, invasive intermediate risk early-stage breast cancer. Participants will be randomised 2:1 to the preoperative testing of the diagnostic core biopsy compared to the post-operative testing of the excision specimen. The primary endpoint is number of clinical touchpoints between treating team and patient from initial approach until offer and prescription of the first adjuvant treatment. Secondary endpoints include time from diagnosis to offer and prescription of the first adjuvant treatment, patient-reported anxiety scores and health cost impact analysis collected at baseline, following the post-operative clinic and following the offer of adjuvant treatment, and number of alterations in treatment sequence from original planned surgical treatment to neoadjuvant therapy. TRIAL REGISTRATION: The study was registered on ISRCTN (ISRCTN14337451) on the 16th August 2022.

Revealing soil microbial ecophysiological indicators in acidic environments laden with heavy metals via predictive modeling: Understanding the impacts of black diamond excavation.

Appraising the activity of soil microbial community in relation to soil acidity and heavy metal (HM) content can help evaluate it's quality and health. Coal mining has been reported to mobilize locked HM in soil and induce acid mine drainage. In this study, agricultural soils around coal mining areas were studied and compared to baseline soils in order to comprehend the former's effect in downgrading soil quality. Acidity as well as HM fractions were significantly higher in the two contaminated zones as compared to baseline soils (p < 0.01). Moreover, self-organizing and geostatistical maps show a similar pattern of localization in metal availability and soil acidity thereby indicating a causal relationship. Sobol sensitivity, cluster, and principal component analyses were employed to enunciate the relationship between the various metal and acidity fractions with that of soil microbial properties. The results indicate a significant negative impact of metal bioavailability, and acidity on soil microbial activity. Lastly, Taylor diagrams were employed to predict soil microbial quality and health based on soil physicochemical inputs. The efficiency of several machine learning algorithms was tested to identify Random Forrest as the best model for prediction. Thus, the study imparts knowledge about soil pollution parameters, and acidity status thereby projecting soil quality which can be a pioneer in sustainable agricultural practices.

Evaluation of groundwater quality by adopting a multivariate statistical approach and indexing of water quality in Sagar Island, West Bengal, India.

In the vicinity of the coast, predominantly groundwater is the sole reliable resource for potable purposes as the surface water sources are highly saline and unfit for human consumption. However, the groundwater in Sagar Island is highly vulnerable to saltwater intrusion. The majority of drinking water comes from government-owned hand pump-equipped tube wells. But during the summer season, many of these tube wells yield significantly less water. Hence, in the current scenario, water quality assessment has become important to the quantity available. Total of 31 samples of deep tube wells (groundwater) are collected at variegated locations during pre-monsoon season throughout Sagar, and then, the physical and chemical quality parameters of these water samples are analysed. Furthermore, a multivariate statistical technique is executed with the aid of the SPSS program. The hydro-chemical parameters that are taken into account for the quality analysis are pH, salinity, electrical conductivity (EC), total dissolved solids (TDS), total hardness, aluminium, arsenic, bi-carbonate, cadmium, iron, chloride, copper, chromium, cobalt, lead, magnesium, manganese, nickel, potassium, sulphate, zinc, and sodium. Then, the analysed data evaluates the water quality index (WQI). Five components are identified through the principal component analysis (PCA) technique, and 82.642% total variance is found. The outcomes of the quality assessment study illustrate that about 54.84% of collected samples come in the "excellent" water quality class when calculated by the "weighted arithmetic WQI method," and 90.32% of collected groundwater samples come in the "good" water quality class when computed using the "modified weighted arithmetic WQI method." This study helps for the interpretation of WQI to assess groundwater quality.

Understanding the exchange process between ground and surface water using mini drive point piezometer and mathematical models to identify suitable managed aquifer recharge sites.

In the current study, subsurface characteristics within the complex formation of the Shilabati basin system of West Bengal, India, extending over an area of 3888 km2, have been estimated using a cost-effective piezometer and MIKE FEFLOW package based on a steady-state numerical model. Pore size and fine particle content of streambeds are affected by two opposing flow contraptions. Such opposite flow conditions are likely to affect the hydraulic conductivity of the streambed. However, analogies of the hydraulic conductivity (Kh) of streambeds for losing and gaining streams have not been well documented in the recent past. The Kh value from the piezometer has been highest at the Dakshin Pairachali site (6.765 m/day), with the stream gaining water from the discharge of the local aquifer. Analysis of the stream-aquifer interaction using the FEFLOW model has allowed us to understand the groundwater water head of the basin ranging from 160.33 to 0.32 m.a.s.l (meters above sea level). The present study also constitutes the first attempt for the identification of suitable sites for the implementation of managed aquifer recharge (MAR) technology in West Bengal, India, to manage extreme drought events. The suitable sites have been identified by means of three fuzzy multi-criteria decision analysis based on nine criteria: river discharge, moisture content, porosity, drainage type, rainfall, land use type, geology, aquifer material, and hydraulic conductivity. To design a radial collector well and infiltration gallery for the selected site in an anisotropic, homogeneous, unconfined, and semi-infinite aquifer near a fully penetrating stream, a pumping test has been conducted to optimize a safe yield of 12.096 MLD (megaliters per day).

Iridium-Catalyzed Enantioselective Formal α-Allylic Alkylation of Acrylonitrile.

A highly enantioselective formal α-allylic alkylation of acrylonitrile is developed using 4-cyano-3-oxotetrahydrothiophene (c-THT) as a safe and easy-to-handle surrogate of acrylonitrile. This two-step process consists of an Ir(I)/(P,olefin)-catalyzed branched-selective allylic alkylation using easily accessible branched rac-allylic alcohols as the allylic electrophile followed by retro-Dieckmann/retro-Michael fragmentation and is shown to be applicable for the enantioselective synthesis of α-allylic acrylates as well as α-allylic acrolein.

Application of fuzzy C-means clustering and fuzzy EDAS to assess groundwater irrigation suitability and prioritization for agricultural development in a complex hydrogeological basin.

The current research is focused on detecting a river basin suitable for agriculture and priority for management using a new clustering tool of groundwater quality with fuzzy logic technique in R and Geographical Information System. A new fuzzy clustering-soft computing technique has been executed to determine the different hydrochemical zones considering 13 essential parameters such as electrical conductivity, hardness, chloride, sodium adsorption ratio, residual sodium carbonate, soluble sodium percent, magnesium hazard, permeability index, potential salinity, residual sodium bicarbonate, Kelly's ratio, synthetic harmful coefficient, and exchangeable sodium percentage. The derived fuzzy C-mean clustering (FCM) outperformed other available hard computing techniques like hierarchical clustering, K-means clustering, and agglomerative clustering. It divided the sampling sites into 2 clustering groups (FCM I and FCM II) which has been validated using fuzzy silhouette index (0.85), the partition coefficient (0.76), the partial entropy (0.68), and the modified partition coefficient (0.52). The hydrogeochemical analysis confirmed that the rock-water interaction, chemical weathering, and ion exchange process are predominant in the aquifer system of the study area. According to the correlation plots, the studied groundwater samples largely evolved from [Formula: see text], mixed [Formula: see text] types, and [Formula: see text] types. The spatial distribution map and the hydrochemical analysis also gives a clear depiction of the fluoride (> 1.0 mg/l) and high iron (> 0.3 mg/l) contamination in groundwater quality, making it unsuitable for both drinking and irrigation. A fuzzy EDAS priority map has been prepared based on all the irrigation suitability parameters which concludes that the groundwater at the upstream and downstream section of the basin requires the most attention. Based on the highest priority for management, five zones have been delineated: very high (5.98%), high (22.31%), medium (16.39%), low (32.30%), and very low (23.02). The findings of this study will be beneficial to planners and policymakers as they can develop schemes to solve similar problems across the country.

Aesthetic breast surgery: putting in context-a narrative review.

OBJECTIVE: This review article summarises the latest evidence for commonly undertaken procedures in aesthetic breast surgery with a focus on key principles of breast augmentation, reduction, and mastopexy. The paper also outlines various approaches and controversies as well as complications such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII) which are increasingly being recognised and becoming a challenge to manage. BACKGROUND: Changing trends of aesthetic breast surgery over the decades has warranted a continuous evolution of this field. The ability to deliver safe and appropriate care is dependent upon sound reconstructive principles and proper training. The lack of uniformity in either is a cause of concern. The impact of social media and changing perception of body image can also no longer be overlooked in the field of aesthetics and reconstruction. METHODS: Review of literature including recent journals, textbook chapters, online databases like PubMed, and current government and surgical society guidelines. CONCLUSIONS: Breast reconstruction is based on sound surgical principles and it is imperative to follow these for the practice of this speciality. There are two important issues that revolve around this aspect of surgery. First relates to the urgent need to invest time and effort in improving regulations and outcomes in the cosmetic surgery industry. Second, it is crucial to promote and prioritize the development and training in this field as the principles of aesthetic breast surgery underpins oncoplastic breast surgery for management of cancer.

Oncoplastic breast-conserving surgery for women with primary breast cancer.

BACKGROUND: Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques. OBJECTIVES: Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer. DATA COLLECTION AND ANALYSIS: Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures. MAIN RESULTS: We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation. AUTHORS' CONCLUSIONS: The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Effect of Immediate Implant-Based Breast Reconstruction After Mastectomy With and Without Acellular Dermal Matrix Among Women With Breast Cancer: A Randomized Clinical Trial.

Importance: The use of acellular dermal matrix (ADM) in implant-based breast reconstructions (IBBRs) is established practice. Existing evidence validating ADMs proposed advantages, including improved cosmetics and more single-stage IBBRs, is lacking. Objective: To evaluate whether IBBR with ADM results in fewer reoperations and increased health-related quality of life (HRQoL) compared with conventional IBBR without ADM. Design, Setting, and Participants: This was an open-label, multicenter, randomized clinical trial of women with primary breast cancer who planned for mastectomy and immediate IBBR, with a 2-year follow-up for all participants. Participants were enrolled at 5 breast cancer units in Sweden and the United Kingdom between 2014 and May 2017. Exclusion criteria included previous radiotherapy and neo-adjuvant chemotherapy. Data were analyzed until August 2017. Interventions: Participants were allocated to immediate IBBR with or without ADM. Main Outcomes and Measures: The primary trial end point was number of reoperations at 2 years. HRQoL, a secondary end point, was measured as patient-reported outcome measures using 3 instruments from the European Organization for Research and Treatment of Cancer Quality of life Questionnaire. Results: From start of enrollment on April 24, 2014, to close of trial on May 10, 2017, a total of 135 women were enrolled (mean [SD] age, 50.4 [9.5] years); 64 were assigned to have an IBBR procedure with ADM and 65 to the control group who had IBBR without ADM. There was no statistically significant difference between groups for the primary outcome. Of 129 patients analyzed at 2-year follow-up, 44 of 64 (69%) had at least 1 surgical event in the ADM group vs 43 of 65 (66%) in the control group. In the ADM group, 31 patients (48%) had at least 1 reoperation on the ipsilateral side vs 35 (54%) in the control group. The overall number of reoperations on the ipsilateral side were 42 and 43 respectively. Within the follow-up time of 24 months, 9 patients (14%) in the ADM group had the implant removed compared with 7 (11%) in the control group. We found no significant mean differences in postoperative patient-reported HRQoL domains, including perception of body image (mean difference, 3; 99% CI, -11 to 17; P = .57) and satisfaction with cosmetic outcome (mean difference, 8; 99% CI, -6 to 20; P = .11). Conclusions and Relevance: Immediate IBBR with ADM did not yield fewer reoperations compared with conventional IBBR without ADM, nor was IBBR with ADM superior in terms of HRQoL or patient-reported cosmetic outcomes. Patients treated for breast cancer contemplating ADM-supported IBBR should be informed about the lack of evidence validating ADM's suggested benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT02061527.

Study of water productivity model on wetlands: a case study of Bhagirathi-Hooghly sub-catchment basin, Southern West Bengal, India.

In this article, we explored how to determine the water productivity of wetlands in a compact and evolving basis with geographic information systems and agro-climatic models. Our research aimed to use the AquaCrop model to determine the extent to which the wetlands in the Bhagirathi-Hooghly Basin in South West Bengal, India, have used their water productivity to meet human needs. The wetland capacity and productivity are declining over time due to pressure from the growing population with declining land area. Various statistical data obtained from the field are calibrated based on the AquaCrop model. The validity of the information collected from the model depends on the prediction error (Pe), coefficient of determination (R2), index of agreement (d) and model efficiency (ME) and based on which the goodness of fit develops. It is concluded that the economic dependence of the people living along the wetland has shifted from rice production to fishing and other aquatic plant production. The water productivity of aquatic resources is 7% higher than the water productivity of rice. The study marks the success of a future strategy for wetland development and urges the state government to undertake management policies to create a healthy wetland environment.

A quality evaluation of the clinical practice guidelines on breast cancer using the RIGHT checklist.

BACKGROUND: Breast cancer is the most frequent type of cancer in women. The methodological quality of clinical practice guidelines (CPGs) on breast cancer has been shown to be heterogeneous. The aim of our study was to evaluate the quality of breast cancer CPGs published in years 2018-2020, using the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. METHODS: We searched Medline (via PubMed), Chinese National Knowledge Infrastructure (CNKI), Wanfang and Chinese Biomedical Literature (CBM) as well as websites of guideline organizations for CPGs on breast cancer published between 2018 and 2020. We used the RIGHT checklist to evaluate the reporting quality of the included guidelines by assessing whether the CPGs adhered to each item of the checklist and calculated the proportions of appropriately reported RIGHT checklist items. We also presented the adherence reporting rates for each guideline and the mean rates for each of the seven domains of the RIGHT checklist. RESULTS: A total of 45 guidelines were included. Eighteen (40.0%) guidelines had an overall reporting rate below 50% and only three (6.7%) reported more than 80% of the items. The domains "Basic information" and "Background" had the highest reporting rates (75.9% and 62.5%, respectively). The mean reporting rates of the domains "Evidence", "Recommendation", "Review and quality assurance", "Funding and declaration and management of interests" and "Other information" were 42.7%, 53.0%, 33.3%, 45.0%, and 44.4%, respectively. CONCLUSIONS: The reporting quality varied among guidelines for breast cancer, showing the need for improvement in reporting the contents. Guideline developers should pay more attention to reporting the evidence, review and quality assurance, and funding and declaration and management of interests in future.

Efficacy of surgical masks or cloth masks in the prevention of viral transmission: Systematic review, meta-analysis, and proposal for future trial.

OBJECTIVE: Recommendations for widespread use of face mask, including suggested type, should reflect the current published evidence and concurrently be studied. This review evaluates the preclinical and clinical evidence on use of cloth and surgical face masks in SARS-CoV-2 transmission and proposes a trial to gather further evidence. METHODS: PubMed, EMbase, and the Cochrane Library were searched. Studies of SARS-CoV-2 and face masks and randomized controlled trials (RCTs) of n ≥ 50 for other respiratory illnesses were included. RESULTS: Fourteen studies were included in this study. One preclinical and 1 observational cohort clinical study found significant benefit of masks in limiting SARS-CoV-2 transmission. Eleven RCTs in a meta-analysis studying other respiratory illnesses found no significant benefit of masks (±hand hygiene) for influenza-like-illness symptoms nor laboratory confirmed viruses. One RCT found a significant benefit of surgical masks compared with cloth masks. CONCLUSION: There is limited available preclinical and clinical evidence for face mask benefit in SARS-CoV-2. RCT evidence for other respiratory viral illnesses shows no significant benefit of masks in limiting transmission but is of poor quality and not SARS-CoV-2 specific. There is an urgent need for evidence from randomized controlled trials to investigate the efficacy of surgical and cloth masks on transmission of SARS-CoV-2 and user reported outcomes such as comfort and compliance.

Partial Breast Reconstruction with Lateral Chest Wall Perforator Flap to Facilitate Breast Conservation in Breast Cancer: First 100 Cases with Cancer Outcomes at 8 Years Follow-Up and the Lessons Learned.

BACKGROUND: This is a prospective cohort study of partial breast reconstruction (PBR) with a lateral chest wall perforator flap (LCWPF) to facilitate breast conservation surgery (BCS) for women undergoing surgery for breast cancer. The study was undertaken to study the clinical and cancer outcomes. METHODS: Patients diagnosed with ductal carcinoma in situ (DCIS) or breast cancer who consented to undergo BCS with PBR with LCWPF were included in the study. A prospective database has been maintained to collect information on clinico-pathological features, complications, and follow-up. Patients were asked to complete an anonymised PROM questionnaire over the years. The hospital electronic records were interrogated for women who have completed 5 years follow-up to assess for development of recurrence/events. RESULTS: A total of 105 patients underwent PBR with LCWPFs between 2011 and 2018. Of these, 74% underwent cancer resection and PBR as one operation whilst 26% underwent PBR as a two-stage approach. The median tumor size on pre-op imaging was 30 mm for the one-stage approach and 39.5 mm for the two-stage approach (p-value=0.003). The complication rates were low and the re-operation rate for close margins was 10%, with 4% eventually requiring mastectomy. Good-to-excellent esthetic outcomes were reported in more than 80% of cases by patients and clinicians. The local recurrence rate (LR) was 2%, distant recurrence rate 10.5%, disease free survival (DFS) 86%, distant disease-free survival (DDFS) 89% and overall survival (OS) 94.8% at 4.5 years median follow-up. This procedure provides an effective oncological approach, avoiding mastectomy with a good-to-excellent cosmetic outcome. The follow-up data establishes the safety of this approach. DISCUSSION: This is the first published series of recurrence and survival data in patients undergoing PBR. We intend to continue with data collection to assess long-term outcomes beyond 10 years. The authors would recommend consideration of this technique to facilitate BCS and avoid mastectomy. REGISTRATION: Not applicable.

Extreme oncoplasty for centrally located breast cancer in small non-ptotic breasts: extending the indications of chest wall perforator flaps with areolar reconstruction.

BACKGROUND: Breast cancers located centrally require excision of nipple-areola complex. A simple central wide excision is a safe option but results in suboptimal aesthetic outcome. An oncoplastic option involves therapeutic mammoplasty with or without areolar reconstruction, limited to moderate and large ptotic breasts. For small non-ptotic breasts, most surgeons would resort to mastectomy with/without reconstruction. METHODS: Lateral chest wall perforator flap (CWPF) is an option for partial breast reconstruction in small to moderate sized, non-ptotic breasts for laterally located tumours. We have extended the application of CWPF for central tumours to avoid mastectomy in selected patients. RESULTS: We here present a case series of four patients with small to medium-sized non-ptotic breasts, who had centrally located breast cancer or ductal carcinoma in-situ (DCIS). Three patients had single stage CWPF reconstruction, and one had central excision with immediate reconstruction following a failed attempt at therapeutic mammoplasty. All had the areola reconstructed using flap skin; one patient had simultaneous nipple reconstruction. CONCLUSIONS: CWPF is an option for treatment of centrally located breast cancers/DCIS needing nipple-areola complex excision for patients wishing to avoid mastectomy. Patients with small to medium-sized non-ptotic breasts are suitable, and need to be carefully selected.

Tunable NIR-II emitting silver chalcogenide quantum dots using thio/selenourea precursors: preparation of an MRI/NIR-II multimodal imaging agent.

Aqueous-stable, Cd- and Pb-free colloidal quantum dots with fluorescence properties in the second near-infrared region (NIR-II, 1000-1400) are highly desirable for non-invasive deep-tissue optical imaging and biosensing. The low band-gap semiconductor, silver chalcogenide, offers a non-toxic and stable alternative to existing Pd, As, Hg and Cd-based NIR-II colloidal quantum dots (QDs). We report facile access to NIR-II emission windows with Ag2X (X = S, Se) QDs using easy-to-prepare thio/selenourea precursors and their analogues. The aqueous phase transfer of these QDs with a high conservation of fluorescence quantum yield (retention up to ∼90%) and colloidal stability is demonstrated. A bimodal NIR-II/MRI contrast agent with a tunable fluorescence and high T1 relaxivity of 408 mM-1 s-1 per QD (size ∼ 2.2 nm) and 990 mM-1 s-1 per QD (size ∼ 4.2 nm) has been prepared by grafting 50 and 120 monoaqua Gd(iii) complexes respectively to two differently sized Ag2S QDs. The size of the nanocrystals is crucial for tuning the Gd payload and the relaxivity.

Transcriptomic analysis of human primary breast cancer identifies fatty acid oxidation as a target for metformin.

BACKGROUND: Epidemiological studies suggest that metformin may reduce the incidence of cancer in patients with diabetes and multiple late phase clinical trials assessing the potential of repurposing this drug are underway. Transcriptomic profiling of tumour samples is an excellent tool to understand drug bioactivity, identify candidate biomarkers and assess for mechanisms of resistance to therapy. METHODS: Thirty-six patients with untreated primary breast cancer were recruited to a window study and transcriptomic profiling of tumour samples carried out before and after metformin treatment. RESULTS: Multiple genes that regulate fatty acid oxidation were upregulated at the transcriptomic level and there was a differential change in expression between two previously identified cohorts of patients with distinct metabolic responses. Increase in expression of a mitochondrial fatty oxidation gene composite signature correlated with change in a proliferation gene signature. In vitro assays showed that, in contrast to previous studies in models of normal cells, metformin reduces fatty acid oxidation with a subsequent accumulation of intracellular triglyceride, independent of AMPK activation. CONCLUSIONS: We propose that metformin at clinical doses targets fatty acid oxidation in cancer cells with implications for patient selection and drug combinations. CLINICAL TRIAL REGISTRATION: NCT01266486.

Increasing the incidence of drain-free day-case mastectomies with the use of a fibrin tissue sealant; data from a single surgical center in the United Kingdom.

Day-case mastectomy surgery provides benefits to both patients and hospitals. Key barriers are the use of a drain and the risk of postoperative seroma formation. We introduced the use of a tissue sealant (Artiss) into the surgical site (post-mastectomy without immediate reconstruction and postaxillary clearance) and evaluated its effect on our practice, particularly day-case rates. A prospective audit of 177 patients who underwent a simple mastectomy with or without axillary surgery, or axillary node clearance with or without breast-conserving surgery was conducted at a single surgical center in the UK between November 2015 and November 2016. Artiss was used in all operations and, where appropriate, the drain was omitted to facilitate day-case surgery. The clinical outcomes were compared between patients undergoing different operations and duration of hospital stay. There was no statistically significant difference between day-case patients and inpatients in seroma aspiration rates (24.5% and 21.7%, respectively; P = 0.381) or other complications (22.4% and 16.1%, respectively; P = 0.106). The day-case mastectomy rate increased from 3.9% in the first quarter to 45.5% in the final quarter, which was a significant increase reaching well beyond the national target. The use of Artiss enabled us to increase the drain-free day-case surgery rates over a 1-year period, exceeding the 30% target recommended by the British Association of Day Surgery. We did not observe any increase in patient morbidity, and the change was cost-effective. We have now implemented the routine use of Artiss in women undergoing simple mastectomy with or without axillary surgery and stand-alone axillary node clearances as part of enhanced recovery clinical pathways.

The Results of Surveillance Imaging After Breast Conservation Surgery and Partial Breast Reconstruction With Chest Wall Perforator Flaps; A Qualitative Analysis Compared With Standard Breast-Conserving Surgery for Breast Cancer.

INTRODUCTION: Partial breast reconstruction (PBR) using chest wall perforator flaps (CWPF) allows for excision of tumors in the outer quadrant of the breast in women with small to moderate non-ptotic breasts resulting in a good aesthetic outcome. There are limited data available in the literature regarding long-term follow-up and the effect of CWPF on subsequent surveillance mammographic interpretation and recall rates. A retrospective audit with qualitative analysis of initial mammograms was performed to assess this. PATIENTS AND METHODS: This retrospective analysis of a prospectively maintained database included all consecutive patients who underwent either PBR with CWPF or wide local excision (WLE) between January 2013 and December 2014 by a single surgeon in a tertiary referral center. Qualitative analysis of the postoperative mammograms was performed after review by 2 blinded radiologists. RESULTS: Thirty-six patients were included in the study, 18 in each arm. The CWPF group was younger and had larger tumor size anticipated on preoperative imaging, which correlated with larger specimens excised. Both groups were comparable with respect to tumor pathological characteristics. Comparing the first postoperative mammograms, both groups were similar in features reported such as calcifications, fat necrosis, volume loss, and radiotherapy changes. During the follow-up period (median 4 years), 138 surveillance mammograms were performed. One patient was recalled for further imaging in the CWPF group. There was no significant difference in the need for diagnostic imaging and biopsy between the groups. CONCLUSION: Patients who underwent PBR using CWPF had similar features on postoperative surveillance mammograms compared with that post WLE.