Loco-regional recurrence after skin and nipple-sparing mastectomy and immediate breast reconstruction using free flap autologous tissue in a single institution.

BACKGROUND: Immediate autologous tissue breast reconstruction after skin- and nipple-sparing mastectomy, is becoming increasingly popular, while the benefits are evident, the concern is in leaving breast tissue under the skin envelope, which could potentially lead to a higher chance of recurrence. We aim to determine the incidence and study the management of loco-regional recurrence (LR) of breast cancer following immediate autologous free flap reconstruction (AFFR) from a 10-year database at a single tertiary breast unit. METHODS: This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent AFFR between July 2008 and December 2018. All patients undergoing delayed reconstruction and risk-reducing surgery were excluded, leaving a total of 216 patients. Statistical analysis was performed to determine significance in the prediction of LR. Management and outcome of the LR was also studied. RESULTS: LR was found in 7/216 cases (3.25%). The median age at surgery for patients with LR, was 45 (range 31-54). Median time to recurrence was 54 months (7-79 months). Three patients presented with self-detected lesions. In all, 6/7 patients were ER/PR positive, 2/7 were HER2 + at recurrence, and 1/7 was triple negative. All patients underwent surgical excision for the LR followed by radiotherapy, either chemotherapy (n-5) and/or hormone therapy (n-2). No patients have developed further LR. Because of low numbers of recurrences, no statistical significance was observed for factors causing recurrence. CONCLUSION: The low LR we report demonstrates that immediate AFFR is oncologically safe. Timely recognition through post-reconstruction patient education and appropriate management results in good outcomes.

Gynaecomastia: a cosmetic concern or a concerning clinical sign?

Gynaecomastia is common and often physiological, leading to frequent dismissal as a cosmetic condition. It can however be a symptom of underlying hormone imbalance, which requires further assessment to exclude underlying sinister pathology. We discuss a rare cause of gynaecomastia that demonstrates the importance of a holistic approach to patient assessment.

SNOLL. Sentinel node and occult (impalpable) lesion localization in breast cancer.

AIM: To evaluate the efficacy and safety for use of dual radioisotopes for localization of occult (impalpable) breast lesions and sentinel node biopsy as a combined technique (SNOLL) using a lower dose than previous studies. MATERIALS AND METHODS: One hundred and twenty-seven SNOLL procedures were performed. The impalpable breast lesions were localized with an intra-lesion injection of 0.2 ml of (99m)Tc MAA (1 MBq) with a particle size of 10-90 µm (radio-guided occult lesion localization, or ROLL) 1 to 4 h before surgery. Sentinel node localization was performed using 0.2 mls of (99)Tc nanocolloid (20 MBq) particle size no greater than 80 nm injected subdermally in the periareolar region within the index quadrant, the night before or the morning of surgery. RESULTS: Lesion localization was consistently achieved with a lower dose than that described in other studies without the need to use scintigraphy or additional imaging with radioopaque contrast medium. One hundred percent lesion localization with a negative clearance margin of 94.8% and 100% sentinel node localization was achieved. The use of dual radioisotopes with the lower dose used for ROLL did not compromise the localization of the impalpable lesion or the sentinel nodes. CONCLUSION: The combined use of radioisotopes for lesion and sentinel node removal is feasible and reliable with the lower radioisotope dose suggested compared with previously published studies. This method should be recommended as a standard procedure for SNOLL.

Long-term outcomes after ROLL lumpectomy.

BACKGROUND: Occult breast lesions are being successfully targeted by means of Radioactive-guided Occult Lesion Localization (ROLL). Several reports demonstrate suitability of ROLL technique to excise non-palpable breast lesions with immediate advantages. AIM: Evaluation of long-term outcomes after ROLL guided lumpectomy for early breast cancer. MATERIALS AND METHODS A CONSECUTIVE SERIES OF NON PALPABLE EARLY INVASIVE BREAST CANCERS EXCISED WITH ROLL (151 PTS; DECEMBER 2002#ENTITYSTARTX02013;JUNE 2006) WERE FOLLOWED UP FOR LONG-TERM OUTCOMES, I.E. LOCAL AND/OR SYSTEMIC RECURRENCE. OUR FOLLOW-UP PROTOCOL INCLUDED 6 MONTHLY PHYSICIAN ADMINISTERED CLINICAL EXAMINATIONS AND 18 MONTHLY IMAGING, I.E. MAMMOGRAM. BONE SCAN, LIVER AND BRAIN IMAGING WERE REQUESTED ON CLINICAL NEED. CLINICAL AND/OR RADIOLOGICAL SUSPICIOUS LESIONS FOR LOCAL RECURRENCE WERE CONFIRMED PATHOLOGICALLY: RESULTS: The median follow-up was 46 months with all patients having a minimum 22 months follow-up. 3/151 local recurrences occurred (1.98%). CONCLUSIONS: Long-term outcomes, i.e. local recurrence of invasive breast cancer excised with ROLL guidance compares well with existing localization techniques.

Recurrence after ROLL lumpectomy for invasive breast cancer.

BACKGROUND: Impalpable breast lesions are being successfully targeted by means of radio-guided occult lesion localisation (ROLL). Although ROLL allows adequate removal of sub-clinical breast lesions within a smaller volume of glandular tissue no long-term outcomes have been reported. AIM: To evaluate the recurrence of invasive cancer after ROLL lumpectomy. METHODS: A consecutive series of impalpable invasive breast cancers excised with ROLL (151 pts; Dec 2002-June 2006) has been followed up for local and/or systemic recurrence with six monthly clinical examinations and 18 monthly mammograms. Bone scan, liver and brain imaging were requested when clinically appropriate. Clinical and/or radiological suspicious lesions for local recurrence were confirmed pathologically. RESULTS: The median follow-up was 33 months with all patients having a minimum 22 months follow-up. Three (out of 151 impalpable invasive cancers) local recurrences occurred (1.98%). CONCLUSIONS: Local recurrence of sub-clinical invasive breast cancer excised with radioisotope guidance compares well with the existing localisation techniques. Its implementation is highly recommended.

Tumour localisation with a metal coil before the administration of neo-adjuvant chemotherapy.

Complete clinical response (CR) with tumour disappearance is not uncommon after neo-adjuvant chemotherapy (NAC) for locally advanced breast cancer, avoiding 25% mastectomies by facilitating breast-conserving procedures. We reviewed our series to understand the feasibility and utility of marking the cancer site before administering NAC. In total, 23 women (median age 47 years) with T2-4, N0-1, M0 tumours were considered unsuitable for breast conserving surgery between January 2002 and November 2003, thus received NAC following a coil placement at the core of tumour. All patients had the coil successfully inserted and no migration or infection was recorded. Eight patients (35%) had a radiological CR (rCR) including 3 (13%) with pathological CR (pCR). In total, 87% patients were managed conservatively. The insertion of a metal coil is a simple mean to provide a landmark for localisation and excision when the breast lump becomes impalpable and radiologically undetectable after the administration of NAC.

Radio-guided localization of clinically occult breast lesions (ROLL): a DGH experience.

AIM: Wire-guided localization (WGL) of clinically occult breast lesions is a well established technique. The aim of this study was to evaluate radio-guided localization (ROLL) within the breast screening service of a district general hospital. METHOD: The study group comprised 70 women who underwent ROLL under US and stereotaxis. This required an injection of Technetium-labelled colloidal albumen into the impalpable breast lesion. The women then proceeded to theatre, where localization was achieved with the use of a gamma probe. The lesion was identified by the presence of a high signal, caused by the injected isotope. The results of 70 consecutive cases in which a breast lesion was localized using ROLL were compared with the results of the latest 70 WGLs. RESULTS: All 140 lesions were successfully localized. However, the change in technique from WGL to ROLL offered significant benefits to patients. CONCLUSION: Our study demonstrated that ROLL is a practical and reliable localization technique. It can be implemented in hospital units without using valuable gamma camera time. The cost compares well with WGL. There is an improved cosmetic outcome for patients, and the very small quantity of radioactivity used is safe for both patients and staff.

Occult breast lesions: A comparison between radioguided occult lesion localisation (ROLL) vs. wire-guided lumpectomy (WGL).

Mammographic screening increases the number of impalpable breast cancers requiring surgical excision. It is important to optimise the localisation technique to remove the smallest amount of tissue, still adequately excising the lesion. The last 65 wire-guided lumpectomies (WGLs) were compared vs. the first 65 radioguided occult lesion localisations (ROLLs) performed for impalpable breast cancers. Data collection included patient's age, radiological abnormality, pre-operative core biopsy, type of primary surgery, length of localisation and excision, hospital stay, cancer size, weight and volume of the excised specimen, clearance margins. All patients were successfully localised with ROLL and WGL. Localisation time was reduced with ROLL (P<0.001). Clear margins were achieved in 83% ROLLs and 57% WGLs (P=0.001). Pathological cancer size and specimen weight were similar in both groups, although the specimen volume was slightly smaller for ROLL. A total of 74% ROLLs had excellent cosmetic outcomes and 26% good, vs. 55% excellent and 45% good in WGLs. A larger amount of normal breast tissue was excised with WGL, without achieving any better cancer clearance. ROLL provides a feasible alternative to WGL. This quick and simple technique achieves an improved rate of clear margins.

Management of gallstone disease in the elderly.

AIM: To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more. PATIENTS AND METHODS: A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared. RESULTS: Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 CONCLUSIONS: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.

Surgical practice is evidence based.

BACKGROUND: The quality of surgical research, and particularly the reluctance of surgeons to perform randomized controlled trials, has been criticized. The proportion of surgical treatments supported by satisfactory scientific evidence has not been evaluated previously. METHODS: A 1-month prospective audit was performed of 100 surgical inpatients admitted under two consultants in a general surgical/vascular unit at an urban teaching hospital; the main illness and interventions were agreed through group discussions in each case. The literature concerning the efficacy of each treatment was reviewed, and the evidence was categorized as: (1) supported by randomized controlled trial evidence; (2) sufficient other evidence of efficacy to make a placebo-controlled trial unethical; or (3) neither of the above. RESULTS: Of the 100 patients studied, 95 (95 per cent confidence interval (c.i.) 89-98) received treatment based on satisfactory evidence (categories 1 and 2) and, of these, 24 patients (95 per cent c.i. 17-35) received treatments based on randomized controlled trial evidence and 71 had treatments based on other convincing evidence (95 per cent c.i. 62-80). CONCLUSION: Inpatient general surgery is 'evidence based', but the proportion of surgical treatments supported by randomized controlled trial evidence is much smaller than that found in general medicine. Some reasons for this are clear, but the extent to which surgical practice needs to be reevaluated is not. Current methods for classifying and describing evidence in therapeutic studies need improvement.

D2 gastrectomy: lessons from a prospective audit of the learning curve.

A 3-year prospective study of the learning curve for D2 gastrectomy was carried out by one surgeon beginning to perform the operation independently after intensive specialist training. Some 38 patients were treated; there were four postoperative deaths and 22 patients had complications. Postoperative morbidity decreased significantly with time (rS = -0.38, P = 0.02, 95 per cent confidence interval -0.62 to -0.07). The physiological component of POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) was significantly lower in the third year (median value 15, 16 and 14 for years 1, 2 and 3, n = 31, chi 2 = 7.5, 2 d.f., P = 0.02, Kruskal-Wallis test), but the operative POSSUM scores and the number of lymph nodes found were not decreased (median operative POSSUM score 19, 18 and 21, n = 31, chi 2 = 0.2, 2 d.f., P = 0.91, Kruskal-Wallis test). The results suggest a learning curve lasting about 18-24 months or 15 to 25 procedures before a plateau is reached. Improved results were associated with changes in case selection and operative tactics but not with reduced extent of lymphadenectomy. D2 gastrectomy should be restricted to specialist centres where adequate training and supervision can be provided during the learning curve.