Introduction Axillary nodal involvement is a poor prognostic indicator in breast cancer1. Sentinel lymph node biopsy (SLNB) is known to have a >95% rate for identification of nodal metastatic spread, its use has significantly reduced common complications of total axillary lymph node clearance (TALNC)1. However, a recent large American study (ZOO11 RCT)2 demonstrated that in cases of 1- 2 positive sentinel lymph nodes (SLN) in patients with T1/T2 tumours, conservative management is non- inferior to TALNC and does not impact on the 10 year survival rate2. In this retrospective study we have analysed a cohort of patients from our centre to clinically evaluate the need for TALNC in patients who have 1-2 positive SLN. Methods Retrospective analysis of histopathology data within our centre identified 1100 patients who had a breast surgery procedure recorded between 2012- 2017. Patients were excluded from this original data set due to duplication of results, lack of electronic patient records as well as coding for non breast surgery related procedures. This left a total of 774 patients. A data collection tool was used to identify and record those patients who had SLNB performed. We recorded the number of nodes yielded as well as the number found to be positive for both SLNB and TALNC. Results From 774 patients 47.5% (368) patients had SLNB performed. The remaining 52.6% (407) patients had a core biopsy, no biopsy or radiological identification of lymphatic spread. A total of 82% (635) patients had TALNC. There were 30.4% patients who had a TALNC based on positive SLNB. The percentage of patients who had TALNC that yielded positive lymph nodes was 13.2%. There were 9.56% (74) patients with only 1-2 positive SLN excised that went on to have TALNC. There were 6.71% patients who had only 1 positive SLN (mean no. of nodes removed = 2.3) and 2.84% patients with 2 positive SLN (mean no. of nodes removed = 3.2). Interestingly there were 2 patients who had 0 positive SLN but had TALNC. Conclusion Our study demonstrates that the number of patients who had SLNB performed with only 1-2 positive nodes identified and then went on the have a TALNC, was very low (9.56%). It brings in to question whether performing a TALNC on this cohort of patients is a necessary routine procedure. Especially given that the ZOO11 RCT demonstrated no difference in 10 year survival (in a similar group of patients) between TALNC vs no TALNC, with both groups receiving radiotherapy post operatively. We could possibly suggest that a change in routine management for patients with only 1-2 positive SLN is that they do not undergo further operative TALNC but proceed straight to radiotherapy treatment. Bibliography 1. Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update. Journal of Breast Cancer. 2017;20(3):217-227. 2. Giuliano AE, Ballman KV, McCall L, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318(10):918-926. Citation Format: Saeed S, Javadzadeh S, Clark S, Kirupakaran A, Ullah MZ, Aggarwal S, Frecker PB. A clinical evaluation of performing total axillary lymph node clearance in breast cancer patients after positive sentinel lymph node biopsy in light of the ZOO11 randomised control trial, based at one centre in the UK [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-37.
A 72-year-old man was referred to the authors' hospital in December 1999 with a 2–3-month history of dyspepsia, abdominal bloating and loss of appetite. Upper gastrointestinal endoscopy with biopsy revealed a moderate active atrophic gastritis with widespread intestinal metaplasia. Gastric biopsies also showed the presence of Helicobacter pylori which was subsequently treated with standard triple therapy. His symptoms improved with H. pylori eradication treatment and a subsequent 6-month follow-up endoscopy with biopsy showed no evidence of residual gastritis or H. pylori infection. He re-presented with similar symptoms 18 months later and a repeat upper gastrointestinal endoscopy showed a diffuse lesion in the gastric fundus. Histological biopsy showed features consistent with a highgrade diffuse non-Hodgkin's lymphoma of the stomach (Figure 1). There was no evidence of further H. pylori infection. A subsequent staging whole body computed tomography scan and laparoscopy revealed no other lymphoid tissue involvement. Omental biopsies undertaken at laparoscopy showed focal infiltration by malignant non-Hodgkin's lymphoma. Immunohistochemistry showed the cells to be CD20 (a B-cell lymphoid marker) positive and CD3 (a T-cell lymphoid marker) negative, confirming the tumour to be a non-Hodgkin's lymphoma of B-cell type. Immunohistochemistry of bone marrow aspirates showed no evidence of infiltration. He was treated with 6 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) chemotherapy in November 2001. A carbon-13-urea breath test in December 2001 was negative. Repeat gastroscopy 4 months after starting chemotherapy showed only erosive gastritis at the gastro-oesophageal junction with no histological evidence of residual lymphoma. Subsequently, the patient's body weight started to increase and his initial symptoms resolved. A surveillance gastroscopy in October 2002 showed a new ulcerative lesion at the incisura of the stomach. Initially, this was thought to be a recurrence of the non-Hodgkin's lymphoma. However, subsequent histology of this lesion showed features of a gastric mucinous adenocarcinoma with signet ring features (Figure 2). He then underwent a subtotal gastrectomy and histological examination of the resected stomach confirmed the presence of a gastric adenocarcinoma with no residual non-Hodgkin's lymphoma. He made a good postoperative recovery and was further treated with chemoradiotherapy. Unfortunately the patient developed a recurrence of the adenocarcinoma in the gastric remnant 3 years later. He is currently alive and has declined any further treatment.
Aims: The National Mastectomy and Breast Reconstruction Audit report (NMBRA, 2011)1 revealed that immediate implant-based breast reconstruction (IIBR) was the most common type of primary reconstruction performed in the UK (37%). The main reason given by clinicians for not offering immediate breast reconstruction was the need for adjuvant radiotherapy. Post-mastectomy radiotherapy (PMRT) decreases the rate of local recurrence as well as increase the long-term survival in patients who demonstrate intermediate to high-risk features2,3 but has been shown to increase the risk of implant complications in IIBR by up to 24% (Berry et al, 2010)4. Cordeiro et al (2004)5 showed the incidence of capsular contracture was 28% higher in the PMRT group compared with non-irradiated patients. Most patients in the UK receive hypofractionated PMRT of 40.05Gy in 15 fractions over 3 weeks based on the UK Standardisation of Breast Radiotherapy (START) trial6, which demonstrated that hypofractionated PMRT is as safe and effective as the conventional PMRT of 50Gy in 25 fractions over 5 weeks. The aim of this study was to determine whether the conventional PMRT of 50Gy in 25 fractions over 5 weeks (2Gy per fraction) was associated with a reduced risk of implant complications in patients undergoing mastectomy with IIBR compared with hypofractionated PMRT regiment of 40.05Gy in 15 fractions over 3 weeks (2.67Gy per fraction). Methods: A single centre retrospective review of data on patients who underwent IIBR followed by PMRT between September 2012 and May 2017 was conducted. Radiotherapy-related complications (surgical site infection, contracture, implant rupture or leakage, wound breakdown) were compared between the two groups of patients receiving conventional and hypofractionated PMRT. Results: Fifty-nine patients underwent IIBR followed by PMRT. Twenty-six patients received hypofractionated PMRT and thirty-three patients received conventional PMRT. Radiotherapy-related complications occurred in 62% of patients in the hypofractionated PMRT group compared with 45% in the conventional PMRT group (p = 0.30). The incidence of capsular contracture (31% in vs. 21%, p = 0.55) and wound breakdown (23% vs. 15%, p = 0.51) was higher in the hypofractionated PMRT group, but surgical site infection (SSI) was more common in the conventional group (4% vs. 6%, p = 1.00). Discussion: Possible confounding factors (BMI, smoking status, and adjuvant chemotherapy) were not analysed due to the small sample size and limitations of the retrospective nature of this study. However, our overall rate of SSI is low in comparison with national data from the NMBRA (2011), which states the SSI rate of 25% in patients who underwent breast reconstruction surgery. Conclusions: This study suggests that the rate of radiotherapy-related complications is lower in patients treated with conventional PMRT compared with hypofractionated PMRT, however the sample size is too small to demonstrate statistical significance. Further research is required to evaluate the effectiveness of conventional PMRT as an option to facilitate immediate implant-based reconstruction following mastectomy. Citation Format: Chaichanavichkij P, Arun KS, Conibear J, Ullah MZ. Post-mastectomy radiotherapy following immediate implant based reconstruction: A possible solution to a reconstructive challenge [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-10.
BackgroundLoco-regional recurrence of breast cancer in patients with large chest wall defects following mastectomy poses significant oncoplastic challenges. Reverse abdominoplasty is most commonly used to treat patients with excess upper abdominal soft tissue and laxity following massive weight loss. Widely employed as a technique for aesthetic contouring of the upper anterior trunk, as well as in augmentation mammoplasty, its use to date for reconstructive purposes is mainly limited to burns and large site surgical tumour ablation. MethodHere we review our experience of using reverse abdominoplasty as a novel approach to filling major anterior chest wall defects in patients with cutaneous manifestations of loco-regional or distant recurrence of breast cancer. ResultsSeven patients with metastatic breast cancer underwent reverse abdominoplasty for disease recurrence following mastectomy, with good patient-reported outcomes, and minimal surgical complications. Moreover, follow-up data in the patients surveyed also showed minimal to no limitations on their activities of daily living following the procedure. ConclusionHere we demonstrate the successful employment of reverse abdominoplasty -a technique not usually reserved in breast oncoplastic surgery -to treat fungating breast lesions and/or other manifestations of loco-regional recurrence in metastatic breast cancer. This may herald a paradigm shift in the way surgeons approach breast cancer recurrence in patients with pre-existing major chest wall defects.
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