Background Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England. Methods Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery. Results Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla. Conclusion Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.
The lymphatic drainage for the majority of primary breast tumors is to the axillary lymph nodes (ALNs). Some, however, drain to the so-called extra-axillary basins, namely the internal mammary, supra- and infraclavicular regions. Another potential drainage route includes the intramammary lymph nodes (IMLNs). Current guidance suggests IMLNs should be considered as part of the axillary group, potentially affecting axillary management. However, due to evolution in imaging and advancement in technology, IMLNs may now be distinguished more accurately pre-operatively. There are currently no published guidelines for the management of IMLNs in the United Kingdom. The authors suggest that it is time to reclassify IMLNs as a separate focus of cancer and treat it as a separate entity. Clin. Anat. 31:684-687, 2018. © 2018 Wiley Periodicals, Inc.
Introduction Guidelines advise use of CT or MRI to detect bone metastasis in breast cancer. Bone-scintigraphy (BS) is not routinely indicated. However, our patients with new node positive breast cancer, or symptoms suggestive of bone metastases, undergo both CT and BS. We aimed to evaluate discrepancies between CT and BS results, and assess whether CT is more accurate in diagnosing bone metastases in breast cancer patients. Method Over a 2-year period, breast cancer patients who underwent CT and BS within 28 days of each other, were included. Scan reports were reviewed, and where unclear, MDT outcome was consulted. Results Of 149 patients, 15 (10.1%) had discordant scan results. Where CT was negative, and BS suspicious (n = 6) or positive (n = 3), patients were either found to have visceral metastases on CT, BS was found to be a false positive, or MDT concluded there were no bone metastases. Where CT was positive and BS negative (n = 4), MDT confirmed metastases. Conclusions CT is as good as BS in demonstrating bone metastases, and also detects visceral metastases. Using CT only would reduce radiation exposure, costs, and burden on service provision. We advise a change in local policy, with CT scan as the primary investigation for breast cancer staging.
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