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Mammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of nonpalpable breast cancer localization. Methods: A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny. Results: 24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079-0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069-0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050-0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001-0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods. Conclusion: USGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for reoperation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.

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Purpose The Oncotype DX© 21-gene Recurrence Score (RS) estimates the risk of distant disease recurrence in early-stage estrogen receptor-positive, human epidermal growth factor receptor-2-negative (ER+/HER2− ) breast cancer. Using RS to estimate risk of locoregional recurrence (LRR) is less conclusive. We aimed to perform network meta-analysis (NMA) evaluating the RS in estimating LRR in ER+/HER2− breast cancer. Methods A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny. Results 16 studies with 21,037 patients were included (mean age: 55.1 years (range: 22–96)). The mean RS was 17.1 and mean follow-up was 66.4 months. Using traditional RS cut-offs, 49.7% of patients had RS < 18 (3944/7935), 33.8% had RS 18–30 (2680/7935), and 16.5% had RS > 30 (1311/7935). Patients with RS 18–30 (risk ratio (RR): 1.76, 95% confidence interval (CI): 1.32–2.37) and RS > 30 (RR: 3.45, 95% CI: 2.63–4.53) were significantly more likely to experience LRR than those with RS < 18. Using TAILORx cut-offs, 16.2% of patients had RS < 11 (1974/12,208), 65.8% had RS 11–25 (8036/12,208), and 18.0% with RS > 30 (2198/12,208). LRR rates were similar for patients with RS 11–25 (RR: 1.120, 95% CI: 0.520–2.410); however, those with RS > 25 had an increased risk of LRR (RR: 2.490, 95% CI: 0.680–9.390) compared to those with RS < 11. There was a stepwise increase in LRR rates when applying traditional and TAILORx cut-offs (both P < 0.050). Conclusion RS testing accurately estimates LRR risk for patients being treated for early-stage ER+/HER2− breast cancer. Future prospective, randomized studies may validate the predictive value of RS in estimating LRR.

The limited durability of surgical bioprostheses, combined with an ageing population, has led to an increasing demand for replacing degenerated bioprosthetic surgical heart valves, which is projected to increase. Valve-in-valve transcatheter aortic valve implantation involves implanting a transcatheter heart valve within a degenerated bioprosthetic surgical heart valve. A significant minority of patients, however, are left with a suboptimal haemodynamic result with high residual gradients. This is more common with smaller surgical bioprostheses, and may be associated with a worse prognosis. The novel concept of fracturing the previously implanted bioprosthetic surgical heart valve during valve-in-valve transcatheter aortic valve implantation to create a more favourable haemodynamic profile has shown great promise, particularly in smaller valves. Herein, we describe the benefits, limitations and potential complications of this novel approach.