Generic professional capabilities hub: developing leadership and management skills in trainees.

High quality leadership is key to delivering high standards of patient care. For many reasons, doctors in training are not currently well represented in leadership positions and struggle to access opportunities to develop these skills. As a key cohort within the medical workforce, using existing present opportunities within clinical training programmes would allow them to engage in leadership development and support them to lead on projects within their trusts and make sustainable changes within their own organisation.Within our anaesthetic department, we designed the Generic Professional Capabilities Hub (GPC hub)-a framework that aims to address some of the barriers to engagement in clinical leadership. Involvement in the GPC hub can be at three different levels, which allows for flexibility around other training needs. Currently, there are seven workstreams within the framework, with trainees being involved through symposia attendance, leading on projects linked to the hub or becoming a trainee workstream lead. We share our learning from setting up this framework, the benefits it brings to trainees and departments, initial evaluation results and our next steps which include regional roll out to four other anaesthetic departments.

Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: A single centre prospective observational study.

BACKGROUND: Nipple-sparing mastectomy (NSM) is becoming a viable oncoplastic option. There is debate regarding the best approach that balances oncological safety with aesthetics. In this study, we describe an approach involving a hemi-periareolar incision and evaluate its safety and outcomes. METHODS: Patients treated at single center between 2012 and 2015 were observed prospectively. After a histologically negative subareolar biopsy, immediate reconstruction with implant and acellular dermal matrix was performed after NSM. Primary end points were wound complications and explantation. Secondary end points included local recurrence, quality of life, patient satisfaction, and esthetic outcome. RESULTS: Sixty-three patients were included with 92 procedures. Twenty-seven percent received chemotherapy and 12.7% received radiotherapy. Mean follow-up was 27.6 months. There were only 2 wound complications, and no recurrences. Mean outcome scores were promising (Breast Q = 88%, subjective esthetic = 9.2, objective esthetic = 9.3, hardening = 2.6). CONCLUSIONS: NSM via a hemi-periareolar incision is oncologically safe with a low-complication rate and high patients' satisfaction.

Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis.

BACKGROUND: Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB). METHODS: Systematic literature review identified 48 studies (9,803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement. RESULTS: The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P = .0201). Meta-regression analysis showed a direct association with tumor size (P = .0333) and grade (P = .00839) but not median age nor tumor upstage rate. CONCLUSIONS: The SLNB should be routinely considered in patients with large (>2 cm) high-grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision.

Improvement of survival with postmastectomy radiotherapy in patients with 1-3 positive axillary lymph nodes: A systematic review and meta-analysis of the current literature.

In breast cancer with >4 positive axillary lymph nodes, it is common practice to deliver radiotherapy to the affected site following mastectomy. However, less is known regarding the benefits this may confer on women with 1-3 positive lymph nodes. In this meta-analysis, we aimed to assess whether post-mastectomy radiotherapy (PMRT) was beneficial for such patients. A literature review was conducted using the PubMed and Ovid databases. Selected studies were analysed and data regarding overall survival (OS) and locoregional recurrence (LRR) rates were extracted. Statistical analysis was then conducted in order to develop a combined risk ratio (RR) for both OS and LRR in the setting of PMRT in women with breast cancer with 1-3 positive lymph nodes. PMRT in women with 1-3 positive lymph nodes significantly reduced the risk of LRR, with a RR of 0.3 [95% confidence interval (CI): 0.23-0.38] and also showed a minor benefit in terms of OS (RR=1.03, 95% CI: 1.00-1.07). Therefore, in breast cancer patients with 1-3 positive lymph nodes, PMRT significantly reduced the risk of LRR and was associated with a minor OS benefit. Until the results of ongoing randomised controlled trials are published, PMRT should be recommended in this group of patients following a careful multidisciplinary discussion.

Oncological Safety of Lipofilling in Patients with Breast Cancer: A Meta-analysis and Update on Clinical Practice.

BACKGROUND: Lipofilling is an increasingly popular technique for breast reconstruction following both mastectomy and breast-conserving surgery (BCS). However, concerns remain over its oncological safety and its effect on cancer recurrence. MATERIALS AND METHODS: A systematic literature review and meta-analysis was carried out. Patients who had undergone mastectomy or BCS were investigated separately in order to find out whether the addition of lipofilling had a significant effect on locoregional recurrence rate. RESULTS: Eleven studies were used in the analysis, yielding a total of 2,382 patients. For patients undergoing mastectomy (mean follow-up=36.2 months, range=12-90 months) or BCS (mean follow-up=30.2 months, range=12-60 months), the addition of lipofilling was not found to significantly affect the locoregional recurrence rate. CONCLUSION: This meta-analysis demonstrates that lipofilling is an oncologically safe procedure to be incorporated into breast reconstruction following either mastectomy or BCS for breast cancer. However, a careful oncological follow-up is recommended. In the future, more adequately powered controlled clinical trials are needed in order to fully understand long-term outcomes after lipofilling.

Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis? An updated meta-analysis involving 3,398 patients.

BACKGROUND: The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial. METHODS: A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR). RESULTS: Nineteen articles were used in the analysis yielding 3,398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased pCR rate when compared to N2 or N3 disease (P = .06). CONCLUSIONS: SLNB after NAC in biopsy-proven node-positive patients results in reasonably acceptable FNR and IR, making it a valid alternative management strategy to axillary dissection. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.

The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures.

Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4-156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.

Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMend™) in implant based immediate reconstruction following skin sparing mastectomy: A prospective observational study in a single centre.

INTRODUCTION: The advent of acellular dermal matrix devices (ADMs) has enhanced both the scope of implant-based immediate breast reconstruction (IBR) following skin sparing mastectomy (SSM) for the treatment or risk reduction of breast cancer. Currently, there are a wide range of options available for the use of ADMs. METHODS: This is a prospective observational single institution study of 118 consecutive patients undergoing a total of 164 SSM and IBR procedures either for treatment for breast cancer or for risk reduction, between 2012 and 2014. IBR was performed using an implant and bovine-derived ADM (SurgiMend™). Nipple sparing mastectomy (NSM) accounted for 103 procedures. IBR was performed as a single stage procedure in 23% of patients. The primary endpoint of this prospective study was the explantation rate and secondary endpoints included quality of life, patient satisfaction, aesthetic outcome assessed objectively, surgical complications, overall and disease free survival. RESULTS: Forty-six patients (39%) had a bilateral and 72 underwent a unilateral SSM. Of those who underwent a unilateral SSM, 25 had a contralateral adjustment procedure. Out of 164 procedures, 117 (71%) were for the treatment of breast cancer. Sixty-one patients received chemotherapy (52%) and 32 (27%) had radiotherapy. In this study 27 patients underwent post-mastectomy radiotherapy. At a mean follow of 21 months, the explantation rate was 1.2%, 4% (6 patients) developed wound complications. The patient satisfaction with the procedure was found to be very high. The mean Breast Q Score was 85 and the mean overall patient satisfaction rating was 9 out of a possible 10. The mean objective assessment score was 8.9 out of a possible 10 and the mean subjective capsular contracture severity score was 2.9 out of 10. There were two cases of local recurrence (1.7%), one distant recurrence (0.8%) and one patient died of metastatic breast cancer (0.8%). Overall survival was 99.2% and locoregional disease free survival (LRFS) was 98.3%. One patient (0.8%) developed a mild inflammatory reaction secondary to the underlying mesh. CONCLUSIONS: SurgiMend™ is an effective adjunct to implant based IBR following SSM. It is associated with a very low rate of implant loss and a high level of patient satisfaction and is associated with a very low incidence of inflammatory reaction. Neither prior radiotherapy nor post-mastectomy radiotherapy (PMRT) represents a contraindication to its use.

Refining the Performance of Sentinel Lymph Node Biopsy Post-neoadjuvant Chemotherapy in Patients with Pathologically Proven Pre-treatment Node-positive Breast Cancer: An Update for Clinical Practice.

BACKGROUND: Neoadjuvant chemotherapy (NAC) has become the standard treatment regimen for locally advanced breast cancer and has recently been incorporated into the treatment of early breast cancer. It allows down-staging of tumors favoring breast-conservative surgery over mastectomy. Furthermore, NAC results in nodal conversion in about 40% of patients. This favorable outcome has complicated the decision-making regarding the best approach in managing the axilla post-treatment; especially in pathologically proven nodal disease prior to NAC. Axillary lymph node clearance is still the standard-of-care for this group of patients; however, it is clearly an over-treatment in a substantial number of patients. Given the high accuracy of sentinel lymph node biopsy (SLNB) post-NAC in clinically node-negative cases prior to treatment, substantial research has been carried out in order to validate the feasibility of post-NAC SLNB in pathologically proven node-positive cases. The results so far are still inconclusive, yet promising. MATERIALS AND METHODS: We performed a computer-aided review of the literature for relevant articles on the performance of SLNB post-NAC in pathologically proven node-positive patients prior to chemotherapy. We also targeted studies on important factors that can refine the accuracy of SLNB in this group of patients, as well as elements favoring pathological complete response. All studies focusing on post-NAC SLNB in pre-treatment node-positive cases including randomized controlled trials, retrospective and prospective series, review articles, and two meta-analyses were included. RESULTS: The review established a false-negative rate of 14-15.1% and an IR of 89-92.3%. Several technical enhancements, as well as imaging modalities, may be incorporated to improve the performance of SLNB. Furthermore, selected patients with more likelihood of pathological complete response represent the best candidates for this technique. CONCLUSION: SLNB is a valid option after NAC in patients with pathologically proven node-positive breast cancer, given the high node-conversion rate. The literature demonstrated a false-negative rate that is slightly higher than that of patients initially node-negative which although might increase the locoregional recurrence in theory, has no effect on chemotherapy-decision making, and will most probably have no impact on overall survival. We identified several measures to refine its accuracy.

Surgical treatment of the primary tumour improves the overall survival in patients with metastatic breast cancer: A systematic review and meta-analysis.

Traditionally, stage IV metastatic breast cancer has been treated with systemic therapy and/or radiotherapy in order to decrease cancer-associated symptoms, maintain quality of life and control disease burden. Previous research suggests that surgical treatment of the primary tumour may prolong survival, as well achieve local control of disease. Using the PubMed and Ovid SP databases, a literature review and meta-analysis was performed in order to assess whether surgical resection of the primary tumour in metastatic breast cancer prolongs survival. In this meta-analysis, a pooled hazard ratio of 0.63 (95% confidence interval, 0.58-0.7; P<0.0001) was revealed, equating to a 37% reduction in risk of mortality in patients that underwent surgical resection of the primary tumour. Therefore, it was concluded that surgery of the primary tumour in stage IV breast cancer appears to offer a survival benefit in metastatic patients.

Capsular Contracture after Breast Augmentation: An Update for Clinical Practice.

Capsular contracture is the most common complication following implant based breast surgery and is one of the most common reasons for reoperation. Therefore, it is important to try and understand why this happens, and what can be done to reduce its incidence. A literature search using the MEDLINE database was conducted including search terms 'capsular contracture breast augmentation', 'capsular contracture pathogenesis', 'capsular contracture incidence', and 'capsular contracture management', which yielded 82 results which met inclusion criteria. Capsular contracture is caused by an excessive fibrotic reaction to a foreign body (the implant) and has an overall incidence of 10.6%. Risk factors that were identified included the use of smooth (vs. textured) implants, a subglandular (vs. submuscular) placement, use of a silicone (vs. saline) filled implant and previous radiotherapy to the breast. The standard management of capsular contracture is surgical via a capsulectomy or capsulotomy. Medical treatment using the off-label leukotriene receptor antagonist Zafirlukast has been reported to reduce severity and help prevent capsular contracture from forming, as has the use of acellular dermal matrices, botox and neopocket formation. However, nearly all therapeutic approaches are associated with a significant rate of recurrence. Capsular contracture is a multifactorial fibrotic process the precise cause of which is still unknown. The incidence of contracture developing is lower with the use of textured implants, submuscular placement and the use of polyurethane coated implants. Symptomatic capsular contracture is usually managed surgically, however recent research has focussed on preventing capsular contracture from occurring, or treating it with autologous fat transfer.

Breast lipofilling: a review of current practice.

Lipofilling is a reconstructive and aesthetic technique that has recently grown in popularity and is increasingly being used in breast surgery. Previous concerns had been raised regarding its safety when used for remodelling and reconstruction of the breast; however, these concerns have since been dismissed. Over the subsequent two decades, little evidence has been found to support these early theoretical concerns, and growing numbers of proponents of the procedure are confident in its safety. Many developments and refinements in the technique have taken place in recent years, and several studies have been published regarding the safety of lipofilling in the breast. We reviewed the current literature regarding the use of different lipofilling techniques as well as the current evidence regarding the oncological safety of the procedure in patients seeking aesthetic breast enhancement and in patients requiring reconstruction after treatment for breast cancer.