ABSTRACT
The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.
Subject(s)
Breast Neoplasms , Carcinoma, Lobular , Humans , Female , Breast Neoplasms/drug therapy , Combined Modality Therapy , Neoadjuvant Therapy , Adjuvants, Immunologic/therapeutic useABSTRACT
PURPOSE: The aim of the study was to analyze the impact of neoadjuvant systemic treatment (NST) on postoperative complications and the beginning of adjuvant treatment. METHODS: This study includes data from a prospectively maintained database including patients with breast cancer (BC) stage I-IV with or without NST undergoing breast cancer surgery between January 2010 and September 2021. RESULTS: Out of 517 enrolled patients, 77 received NST, 440 had primary breast surgery. After NST patients underwent surgery after a meantime of 34 days (26.5-40 days). No statistical significance could be found comparing the complication grading according to the Clavien Dindo classification. The complications were most frequently rated as grade 3b. There were no complications with grade 4 or higher. When differentiating into short and long-term, the overall rate of short-term complications was 20.3% with no significant difference between the two groups (20.8% vs. 20.2%). Regarding long-term complications, there was more impairment of shoulder mobility (26.0% vs. 9.5%, p ≤ 0.001) and chronic pain (42.9% vs. 28.6%, p ≤ 0.016) for patients with NST. The beginning of the administration of the adjuvant treatment was comparable in both groups (46.3 days vs. 50.5 days). CONCLUSION: In our cohort, complications between both groups were comparable according to Clavien Dindo. This study shows that NST has no negative impact on postoperative short-term complications and most importantly did not lead to a delay of the beginning of adjuvant treatment. Therefore, NST can be safely admitted, even when followed by extensive breast reconstruction surgery.
Subject(s)
Breast Neoplasms , Humans , Female , Breast Neoplasms/drug therapy , Breast Neoplasms/surgery , Neoadjuvant Therapy/adverse effects , Mastectomy/adverse effects , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective StudiesABSTRACT
The 17th St Gallen International Breast Cancer Consensus Conference in 2021 was held virtually, owing to the global COVID-19 pandemic. More than 3300 participants took part in this important bi-annual critical review of the 'state of the art' in the multidisciplinary care of early-stage breast cancer. Seventy-four expert panelists (see Appendix 1) from all continents discussed and commented on the previously elaborated consensus questions, as well as many key questions on early breast cancer diagnosis and treatment asked by the audience. The theme of this year's conference was 'Customizing local and systemic therapies.' A well-organized program of pre-recorded symposia, live panel discussions and real-time panel voting results drew a worldwide audience of thousands, reflecting the far-reaching impact of breast cancer on every continent. The interactive technology platform allowed, for the first time, audience members to ask direct questions to panelists, and to weigh in with their own vote on several key panel questions. A hallmark of this meeting was to focus on customized recommendations for treatment of early-stage breast cancer. There is increasing recognition that the care of a breast cancer patient depends on highly individualized clinical features, including the stage at presentation, the biological subset of breast cancer, the genetic factors that may underlie breast cancer risk, the genomic signatures that inform treatment recommendations, the extent of response before surgery in patients who receive neoadjuvant therapy, and patient preferences. This customized approach to treatment requires integration of clinical care between patients and radiology, pathology, genetics, and surgical, medical and radiation oncology providers. It also requires a dynamic response from clinicians as they encounter accumulating clinical information at the time of diagnosis and then serially with each step in the treatment plan and follow-up, reflecting patient experiences and treatment response.
Subject(s)
Breast Neoplasms , COVID-19 , Breast Neoplasms/diagnosis , Breast Neoplasms/epidemiology , Breast Neoplasms/therapy , Female , Humans , Neoadjuvant Therapy , Pandemics , SARS-CoV-2ABSTRACT
BACKGROUND: Antimicrobial prophylaxis (AMP) adjustment according to bodyweight to prevent surgical-site infections (SSI) is controversial. The impact of weight-adjusted AMP dosing on SSI rates was investigated here. METHODS: Results from a first study of patients undergoing visceral, vascular or trauma operations, and receiving standard AMP, enabled retrospective evaluation of the impact of bodyweight and BMI on SSI rates, and identification of patients eligible for weight-adjusted AMP. In a subsequent observational prospective study, patients weighing at least 80 kg were assigned to receive double-dose AMP. Risk factors for SSI, including ASA classification, duration and type of surgery, wound class, diabetes, weight in kilograms, BMI, age, and AMP dose, were evaluated in multivariable analysis. RESULTS: In the first study (3508 patients), bodyweight and BMI significantly correlated with higher rates of all SSI subclasses (both P < 0.001). An 80-kg cut-off identified patients receiving single-dose AMP who were at higher risk of SSI. In the prospective study (2161 patients), 546 patients weighing 80 kg or more who received only single-dose AMP had higher rates of all SSI types than a group of 1615 who received double-dose AMP (odds ratio (OR) 4.40, 95 per cent c.i. 3.18 to 6.23; P < 0.001). In multivariable analysis including 5021 patients from both cohorts, bodyweight (OR 1.01, 1.00 to 1.02; P = 0.008), BMI (OR 1.01, 1.00 to 1.02; P = 0.007) and double-dose AMP (OR 0.33, 0.23 to 0.46; P < 0.001) among other variables were independently associated with SSI rates. CONCLUSION: Double-dose AMP decreases SSI rates in patients weighing 80 kg or more.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Antibiotic Prophylaxis/methods , Body Weight , Surgical Wound Infection/prevention & control , Adult , Aged , Body Mass Index , Female , Humans , Male , Middle Aged , Prospective Studies , Retrospective Studies , Risk FactorsABSTRACT
PURPOSE: Some studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups. METHODS: Patients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011-3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years. RESULTS: One hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery. CONCLUSION: Our findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.
Subject(s)
Breast Neoplasms , Mammaplasty , Aged , Breast Neoplasms/surgery , Female , Humans , Mastectomy , Mastectomy, Segmental , Middle Aged , Patient Reported Outcome Measures , Quality of Life , Retrospective StudiesABSTRACT
The emphasis on esthetic outcomes and quality of life after breast cancer surgery has motivated surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of the techniques. The present article attempts to standardize OPS nomenclature, indications, and reconstruction choice selection embedded in a thorough review of the literature. We propose four breast conserving surgery (BCS) categories: Conventional tumorectomy, oncoplastic mastopexy, oncoplastic tumorectomy and oncoplastic reduction mammoplasty. The main volume displacement techniques are glandular re-approximation, use of tailored glandular or dermoglandular flaps and nipple-areola complex pedicles. We developed an indication algorithm based on the size and shape of the breast as well as the size and location of the tumor. A reconstruction algorithm suggests a selection of suitable tailored flaps and pedicles based on tumor location and vascular supply of the breast. The application of these algorithms results in known and novel OPS techniques, which are presented here with long-term results. We designed the algorithms to help tailor every operation to the individual patient in a standardized manner, since OPS is now on the rise, more than two decades after the publication of the first techniques. A rapidly increasing body of observational evidence suggests comparable rates of local recurrence between OPS and conventional BCS. Importantly, the rates of clear resection margins are in favor of OPS despite extended indications to larger tumors. Finally, OPS optimizes patient satisfaction by improving esthetic outcomes after BCS.
Subject(s)
Algorithms , Breast Neoplasms/surgery , Mammaplasty/standards , Mastectomy, Segmental/standards , Patient Selection , Esthetics , Female , Humans , Mammaplasty/methods , Mastectomy, Segmental/methods , Quality of Life , Terminology as TopicABSTRACT
Recent studies in multiple epithelial cancers have shown that the inhibitory receptor programmed cell death 1 (PD-1) is expressed on tumor-infiltrating lymphocytes and/or programmed death ligand 1 (PD-L1) is expressed on tumor cells, suggesting that antitumor immunity may be modulated by the PD-1/PD-L1 signaling pathway. In addition, phase 1 clinical trials with monoclonal antibodies targeting PD-1 or PD-L1 have shown promising results in several human cancers. The purpose of this study was to investigate the impact of PD-L1 expression in human breast cancer specimens. We conducted an immunohistochemistry study using a tissue microarray encompassing 650 evaluable formalin-fixed breast cancer cases with detailed clinical annotation and outcomes data. PD-L1 was expressed in 152 (23.4 %) of the 650 breast cancer specimens. Expression was significantly associated with age, tumor size, AJCC primary tumor classification, tumor grade, lymph node status, absence of ER expression, and high Ki-67 expression. In univariate analysis, PD-L1 expression was associated with a significantly worse OS. In multivariate analysis, PD-L1 expression remained an independent negative prognostic factor for OS. In subset analyses, expression of PD-L1 was associated with significantly worse OS in the luminal B HER2(-) subtype, the luminal B HER2(+) subtype, the HER2 subtype, and the basal-like subtype. This is the first study to demonstrate that PD-L1 expression is an independent negative prognostic factor in human breast cancer. This finding has important implications for the application of antibody therapies targeting the PD-1/PD-L1 signaling pathway in this disease.
Subject(s)
B7-H1 Antigen/metabolism , Breast Neoplasms/metabolism , Breast Neoplasms/mortality , Adult , Aged , Aged, 80 and over , B7-H1 Antigen/genetics , Breast Neoplasms/genetics , Breast Neoplasms/pathology , Female , Gene Expression , Humans , Immunohistochemistry , Immunophenotyping , Middle Aged , Neoplasm Grading , Neoplasm Metastasis , Neoplasm Staging , Prognosis , Tissue Array Analysis , Tumor BurdenABSTRACT
BACKGROUND: Snail is a key regulator of epithelial-mesenchymal transition of tumor cells. Several studies have shown nuclear Snail expression to be a negative prognostic factor in human cancer, where it is generally associated with more aggressive tumor behavior and worse survival. OBJECTIVES AND METHODS: To further explore the role of Snail expression in breast cancer, we conducted a study on a tissue microarray, encompassing 1043 breast cancer cases. RESULTS: A total of 265 (25.4%) breast cancers were positive for Snail. Snail expression was significantly associated with greater tumor size, higher tumor stage and grade, positive lymph node status, and hormone receptor negative status and was differently expressed in the intrinsic subtypes of breast cancer, being the highest in the basal-like subtype and the lowest in the luminal A subtype. In multivariate analysis, Snail proved to be an independent negative prognostic factor for OS. In the intrinsic subtypes, Snail expression was a negative prognostic factor for OS in the luminal B HER2(-), the luminal B HER2(+), and the basal-like subtype. CONCLUSIONS: This is the first study demonstrating that nuclear Snail expression is an independent negative predictor of prognosis in breast cancer, thus suggesting that it may represent a potential therapeutic target.
Subject(s)
Biomarkers, Tumor/metabolism , Breast Neoplasms/diagnosis , Cell Nucleus/metabolism , Transcription Factors/metabolism , Adult , Aged , Aged, 80 and over , Biomarkers, Tumor/genetics , Breast Neoplasms/metabolism , Breast Neoplasms/pathology , Female , Humans , Middle Aged , Prognosis , Snail Family Transcription Factors , Transcription Factors/genetics , Tumor BurdenABSTRACT
INTRODUCTION: This study evaluates the frequency of and indications for disease-related surgical procedures in the palliative breast cancer (BC) situation. PATIENTS & METHODS: Based on a cohort of women who were treated for newly diagnosed BC during a 20-year period (1990-2009), we analyzed 340 patients who developed distant metastatic disease (DMD) until 2011 and died (i.e. still ongoing palliative disease courses were not included). RESULTS: One hundred and twenty-seven surgical procedures were performed in 100 patients (29.4% of all patients with metastatic disease). The most common site for surgery was breast (n = 60, 47.2%). The primary tumor was removed at first diagnosis of DMD in 43 patients (33.9%); sixteen operations (12.6%) were performed for local recurrence. In 37 patients, 50 surgical procedures (39.4%) were necessary to stabilize osseous structures due to metastases. Procedures were rarely performed on other common metastatic sites: lung: n = 1 (0.8%); liver: n = 1 (0.8%), brain: n = 4 (3.1%). When excluding surgery for primary breast tumors at initial diagnosis of DMD from analysis, 34 of 84 surgeries (40.4%) were performed in the first third of survival follow-up (i.e. period of metastatic disease survival); operations in the last two-thirds each totaled 29.8% (n = 25). The median survival after surgery was 16 months (range: 0.5-89 months). CONCLUSIONS: In a cohort of BC patients who had primary or developed secondary DMD, nearly one third of the patients received disease-related surgical procedures during their palliative disease course. This high rate of operations shows that surgery has a clearly established role in the palliative therapy concept.
Subject(s)
Breast Neoplasms/pathology , Breast Neoplasms/surgery , Palliative Care , Surgical Procedures, Operative/statistics & numerical data , Adult , Aged , Aged, 80 and over , Breast Neoplasms/mortality , Databases, Factual , Female , Humans , Mastectomy, Segmental , Middle Aged , Palliative Care/methods , Prospective Studies , Reoperation , Surgical Procedures, Operative/mortality , Surgical Procedures, Operative/standards , Survival Analysis , Switzerland/epidemiology , Treatment OutcomeABSTRACT
BACKGROUND: The ACOSOG Z0011 trial (Z0011) expanded our thinking about breast cancer (BC) and showed that limited metastatic disease left behind in the axilla did not compromise oncological safety in a selected group of patients. The aim of the current study was to assess the potential impact of Z0011 on clinical practice by testing the applicability of its criteria to a European patient population. METHODS: We reviewed a consecutive series of 389 sentinel lymph node biopsies (SLNB) performed for invasive BC at the University Hospital Basel between 2003 and 2009 (65.6% of all surgically treated patients, n = 593). RESULTS: When compared to the axillary lymph node dissection (ALND) arm of Z0011, our patients had significantly less advanced LN involvement (≥ 3 LN: 8.5% vs. 21.0%, p = 0.048). Thirty-five patients (9.0%) met the Z0011 inclusion criteria and had 1-2 SLNs with macrometastases (5.9% of all surgically treated BC patients). If the inclusion criteria of Z0011 had been applied, a considerable number of LNs would have been missed in two cases (0.5% of all SLNBs). CONCLUSIONS: The application of the Z0011 led to the omission of completion ALND in less than 10% of all SLNB procedures (<6% of all surgically treated BC patients); therefore, we do not think that the perception of Z0011 as "practice changing" is justified. On the other side, skeptics of the routine implementation of the Z0011 protocol may overestimate its potential hazards. When performing a thorough preoperative clinical axillary staging, the number of patients who would have been undertreated is minimal.
Subject(s)
Breast Neoplasms/surgery , Mastectomy , Sentinel Lymph Node Biopsy/methods , Adult , Aged , Aged, 80 and over , Breast Neoplasms/diagnosis , Breast Neoplasms/epidemiology , Female , Follow-Up Studies , Humans , Middle Aged , Morbidity/trends , Neoplasm Recurrence, Local/epidemiology , Prognosis , Retrospective Studies , Risk Factors , Survival Rate , Switzerland/epidemiology , Time FactorsABSTRACT
BACKGROUND: Numerous recent studies conducted in the USA reported a considerable rise in the rates of contralateral prophylactic mastectomy (CPM) in early-stage breast cancer (BC). However, this aggressive surgical approach only showed an evidence-based improvement in prognosis for a small subgroup of high-risk BC patients. We present the first European study reporting CPM rates in an unselected cohort of patients with BC. PATIENTS & METHODS: The data of 881 patients (≤ 80 years) who underwent surgery for stage I-III BC from 1995 to 2009 at the University of Basel Breast Center was analyzed. RESULTS: CPM was performed in 23 of 881 patients (2.6%). Of the entire patient population, 37.5% underwent ipsilateral mastectomy and of those, only 7.0% chose to undergo CPM. Importantly, there was no trend over time in the rate of CPM. Women who chose CPM were significantly younger (54 vs. 60 years, p < 0.001), had more often a positive family history (39.1% vs. 24.4%, p = 0.032) and tumors of lobular histology (30.5% vs. 13.9%, p = 0.035). CONCLUSIONS: Our analysis of CPM rates in BC patients, conducted at a European University breast center, does not show the considerably rising CPM rates observed in the USA. We hypothesize that different medico-social and cultural factors, which are highlighted by a different public perception of BC and a different attitude toward plastic surgery, determine the varying CPM rates between the USA and Europe.
Subject(s)
Breast Neoplasms/prevention & control , Breast Neoplasms/surgery , Health Services Needs and Demand , Mastectomy/statistics & numerical data , Adult , Aged , Aged, 80 and over , Breast Neoplasms/pathology , Cohort Studies , Female , Humans , Middle Aged , Neoplasm Metastasis , Neoplasm Staging , Socioeconomic Factors , Switzerland , United StatesABSTRACT
The standard of practice in breast cancer surgery is that all patients with a positive sentinel node mandate an axillary lymph node dissection (ALND). Recently, this dogma has been challenged by a trial from ACOSOG (American College Of Surgeons Oncology Group) (Trial Z0011) which demonstrated that patients (without clinically/radiologically apparent axillary metastases) undergoing breast conserving surgery (i.e lumpectomy followed by whole breast radiotherapy) with positive sentinel nodes failed to derive any significant benefit by having an axillary lymph node dissection (ALND) [2]. The logical progression from this study is to question the validity of performing routine axillary lymph node dissections on all patients with positive sentinel lymph nodes (SLN). In addition to the Z0011 trial, there is emerging data that additional patients exist who fail to derive any benefit from axillary surgery. The aim of this article is to discuss the potential subpopulations of patients that may avoid unnecessary ALND in the modern era of breast cancer management.
Subject(s)
Breast Neoplasms/surgery , Lymph Node Excision/methods , Axilla , Female , Humans , Lymphatic Metastasis , Neoplasm Recurrence, Local , Sentinel Lymph Node Biopsy , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers. METHODS: Consecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates. RESULTS: From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education. CONCLUSION: ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.
Subject(s)
Ambulatory Surgical Procedures , Breast Neoplasms/surgery , Critical Pathways , Lymph Node Excision/methods , Ambulatory Surgical Procedures/standards , Axilla , Continuity of Patient Care , Critical Pathways/organization & administration , Critical Pathways/standards , Female , Humans , Lymph Node Excision/standards , Patient Care Team , Patient Education as Topic , Patient Readmission/statistics & numerical data , Postoperative Complications/epidemiology , Quality Assurance, Health CareABSTRACT
BACKGROUND: We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety. MATERIALS AND METHODS: As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days. RESULTS: Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented. CONCLUSIONS: This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.
Subject(s)
Breast Neoplasms/surgery , Length of Stay/statistics & numerical data , Mastectomy , Postoperative Care/methods , Female , Follow-Up Studies , Humans , Middle Aged , Prognosis , Prospective Studies , Time FactorsABSTRACT
Surgical site infections (SSIs) significantly increase post-operative morbidity and mortality. SSI surveillance is an established monitoring tool and reduces SSI rates. The purpose of this study was to compare prospective in-hospital SSI surveillance (I) by the surgical staff and (II) additionally by an infection control team (ICT). The reference method (III) was defined by data generated by the surgical team, supplemented by the ICT and completed by post-discharge surveillance with a post-operative follow-up of one year representing the sum of all available resources. During 24 months, all consecutive inpatient procedures (N=6283) were prospectively recorded by the surgical staff until patients' discharge (I). SSI rates were compared with the surveillance performed by the ICT (II) and with the reference method (III). The overall SSI rate (reference method) was 4.7% (N=293), of which 187 (63.8%) were detected in-hospital and 106 (36.2%) after discharge. (I) The surgical staff detected 91/187 (48.7%) of in-hospital SSIs [91/293 (31.0%) of the reference], (II) the ICT an additional 96/187 (51.3%) during hospitalisation [96/293 (32.8%) of the reference]. Further cross-checking as performed in the visceral surgery department increased the surgeons' detection rate (I) to 59/105 (56.2%) of in-hospital SSIs [59/147 (40.1%) of the reference]. SSI surveillance by the surgical staff detects almost half of all in-hospital SSIs and has the potential to increase the detection rate by simple interventions such as cross-checking. Such a relatively inexpensive surveillance system is an option for hospitals without an ICT or for low risk surgical procedures. Moreover, trends in SSI rates can easily be detected, allowing early intervention.
Subject(s)
Cross Infection/diagnosis , Cross Infection/epidemiology , Data Collection/methods , Infection Control/methods , Physicians , Surgical Wound Infection/diagnosis , Surgical Wound Infection/epidemiology , Adult , Aged , Aged, 80 and over , Female , Humans , Infection Control/standards , Male , Middle AgedABSTRACT
Cancer cells' growth in three-dimensional (3D) architectures promotes resistance to drugs, cytokines, or irradiation. We investigated effects of 3D culture as compared to monolayers (2D) on melanoma cells' recognition by tumour-associated antigen (TAA)-specific HLA-A(*)0201-restricted cytotoxic T-lymphocytes (CTL). Culture of HBL, D10 (both HLA-A(*)0201+, TAA+) and NA8 (HLA-A(*)0201+, TAA-) melanoma cells on polyHEMA-coated plates, resulted in generation of 3D multicellular tumour spheroids (MCTS). Interferon-gamma (IFN-gamma) production by HLA-A(*)0201-restricted Melan-A/MART-1(27-35) or gp 100(280-288)-specific CTL clones served as immunorecognition marker. Co-culture with melanoma MCTS, resulted in defective TAA recognition by CTL as compared to 2D as witnessed by decreased IFN-gamma production and decreased Fas Ligand, perforin and granzyme B gene expression. A multiplicity of mechanisms were potentially involved. First, MCTS per se limit CTL capacity of recognising HLA class I restricted antigens by reducing exposed cell surfaces. Second, expression of melanoma differentiation antigens is downregulated in MCTS. Third, expression of HLA class I molecules can be downregulated in melanoma MCTS, possibly due to decreased interferon-regulating factor-1 gene expression. Fourth, lactic acid production is increased in MCTS, as compared to 2D. These data suggest that melanoma cells growing in 3D, even in the absence of immune selection, feature characteristics capable of dramatically inhibiting TAA recognition by specific CTL.
Subject(s)
Antigens, Neoplasm/immunology , Melanoma/immunology , Spheroids, Cellular/immunology , T-Lymphocytes, Cytotoxic/immunology , Cell Culture Techniques , Fas Ligand Protein/genetics , Fas Ligand Protein/metabolism , Granzymes/genetics , Granzymes/metabolism , HLA-A1 Antigen/immunology , HLA-A2 Antigen/immunology , Histocompatibility Antigens Class I/genetics , Histocompatibility Antigens Class I/metabolism , Humans , MART-1 Antigen , Melanoma/secondary , Membrane Glycoproteins/genetics , Membrane Glycoproteins/metabolism , Neoplasm Proteins/immunology , Perforin , Pore Forming Cytotoxic Proteins/genetics , Pore Forming Cytotoxic Proteins/metabolism , Spheroids, Cellular/metabolism , Spheroids, Cellular/pathology , T-Lymphocytes, Cytotoxic/metabolism , Tumor Cells, CulturedABSTRACT
BACKGROUND: Evidence-based surgery has been established as a cornerstone of good clinical practice, promising to improve the treatment of patients and the quality of surgical education. However, evidence-based surgery requires dedicated clinicians trained to perform methodologically sound clinical investigations. Statistical knowledge is therefore invaluable. Surgical studies often cannot be randomized. Propensity scores offer a powerful alternative to multivariable analysis in the assessment of observational, non-randomized surgical studies. Unfortunately, many surgeons are unaware of this important analytical approach that has gained increasing stature in medical research. Thus, propensity score analyses are not used often in surgical studies. OBJECTIVE: The purpose of this paper is to provide a comprehensive overview of propensity score analysis, allowing the surgeon to understand the role, advantages and limitations of propensity scores, boosting their development in surgical investigations.
Subject(s)
Evidence-Based Medicine , General Surgery/standards , Confounding Factors, Epidemiologic , Humans , Outcome Assessment, Health Care , Predictive Value of Tests , Prognosis , Regression AnalysisABSTRACT
Fractionation of polydispersed polysiloxanes (1-2 g) into narrow molecular weight fractions has been achieved by a rapid (30-60 min) convenient process, using the Cyclograph Centrifugal Chromatography System. These narrow molecular weight poly(dimethylsiloxane) fractions can be used as secondary standards for GPC.
Subject(s)
Chromatography, Gel , Coated Materials, Biocompatible/analysis , Dimethylpolysiloxanes/analysis , Silicones/analysis , Centrifugation/methods , Chromatography, Thin Layer/methodsABSTRACT
OBJECTIVE: To assess the potential of advanced breast biopsy instrumentation (ABBI) to clarify the diagnosis of impalpable mammographic lesions and to remove the entire malignant lesions with clear margins. DESIGN: Prospective assessment in a consecutive series of patients. SETTING: University hospital, Basel, Switzerland. SUBJECTS: 139 patients presenting with 144 impalpable microcalcifications or solid nodular densities evident on screening and follow-up mammograms that were suspicious of malignancy. MAIN OUTCOME MEASURES: Feasibility, sensitivity, efficiency in obtaining definitive diagnoses in an outpatient clinic under local anaesthesia, feasibility of complete removal of a primary malignancy, and intervention-related morbidity. RESULTS: The ABBI procedure was successful in 135/144 (94%); an accurate diagnosis was made in 129/130 patients followed up (99%), sensitivity for malignant lesions was 31/32 (97%) and there were 2 complications (2%). Margins of the biopsy cylinder contained a malignant lesion in 26/31 (84%). CONCLUSIONS: Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low morbidity. As in other published series margins were often not clear of tumour and therefore the therapeutic use of the ABBI procedure is limited.
Subject(s)
Biopsy/instrumentation , Breast Neoplasms/pathology , Adult , Aged , Biopsy/methods , Feasibility Studies , Female , Humans , Mammography/methods , Middle Aged , Neoplasm Staging , Predictive Value of Tests , Reproducibility of Results , Sensitivity and Specificity , Stereotaxic TechniquesABSTRACT
BACKGROUND: Stereotactic biopsy techniques supersede conventional hook-wire localization followed by open excision to clarify the dignity of nonpalpable mammographic lesions. The advanced breast biopsy instrumentation (ABBI) allows stereotactically guided excision of a specimen up to 20 mm in diameter on an outpatient basis under local anaesthesia. METHODS: Demographic information, mammographic and pathological findings, complications, subsequent interventions and sensitivity as well as efficiency of a series of 144 planned ABBI procedures were documented (largest published single institution series). RESULTS: The ABBI procedure was successfully performed in 93.8% (135/144); accurate diagnosis was made in 99.3% (134/135), sensitivity for malignant lesions was 96.9% (31/32) and morbidity was 1.5%. Consistent with other published series margins of the biopsy cylinder containing a malignant lesion were involved in 83.9% (26/31). CONCLUSIONS: Excisional biopsy using the ABBI system is a reliable diagnostic tool with a low incidence of morbidity. The therapeutic use is of limited potential.