Background: Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node-negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node-positive patients.Methods: Current evidence for intraoperative sentinel node analysis following SLNB in breast cancer was reviewed and evaluated, based on articles obtained from a MEDLINE search using the terms 'sentinel node', 'intra-operative' and 'breast cancer'.Results and conclusion: Current methods for evaluating the sentinel node during surgery include cytological and histological techniques. Newer quantitative molecular assays have been the subject of much recent clinical research. Pathological techniques of intraoperative SLNB analysis such as touch imprint cytology and frozen section have a high specificity, but a lower and more variably reported sensitivity. Molecular techniques are potentially able to sample a greater proportion of the sentinel node, and could have higher sensitivity.
Background Biological and synthetic meshes may improve the outcomes of immediate implant-based breast reconstruction (IBBR) by facilitating single-stage procedures and improving cosmesis. Supporting evidence is, however, limited. The aim of this study was to explore the impact of biological and synthetic mesh on patient-reported outcomes (PROs) of IBBR 18 months after surgery. Methods Consecutive women undergoing immediate IBBR between February 2014 and June 2016 were recruited to the study. Demographic, operative, oncological and 3-month complication data were collected, and patients received validated BREAST-Q questionnaires at 18 months. The impact of different IBBR techniques on PROs were explored using mixed-effects regression models adjusted for clinically relevant confounders, and including a random effect to account for clustering by centre. Results A total of 1470 participants consented to receive the questionnaire and 891 completed it. Of these, 67 women underwent two-stage submuscular reconstructions. Some 764 patients had a submuscular reconstruction with biological mesh (495 women), synthetic mesh (95) or dermal sling (174). Fourteen patients had a prepectoral reconstruction. Compared with two-stage submuscular reconstructions, no significant differences in PROs were seen in biological or synthetic mesh-assisted or dermal sling procedures. However, patients undergoing prepectoral IBBR reported better satisfaction with breasts (adjusted mean difference +6.63, 95 per cent c.i. 1.65 to11.61; P = 0.009). PROs were similar to those in the National Mastectomy and Breast Reconstruction Audit 2008–2009 cohort, which included two-stage submuscular procedures only. Conclusion This study found no difference in PROs of subpectoral IBBR with or without biological or synthetic mesh, but provides early data to suggest improved satisfaction with breasts following prepectoral reconstruction. Robust evaluation is required before this approach can be adopted as standard practice.
Intraoperative assessment of SLNs in breast cancer using a molecular assay is a safe, acceptable and accurate technique that allows a reduction in the frequency of delayed axillary clearance surgery. Take-up of this method may be hampered by perverse incentives operating within healthcare funding.
Introduction of IOSR significantly reduced specimen weights without increasing re-excision rates. As volume of breast tissue removed is the most significant determinant of cosmetic outcome following breast-conserving surgery, the use of IOSR should be advocated in the surgical management of palpable breast cancer.
161Breast reconstruction and oncoplastic techniques have been widely adopted in the surgical management of patients with breast cancer. The National Mastectomy and Breast Reconstruction Audit (NMBRA) 1 is the largest prospective audit of breast reconstruction ever carried out. It was designed and implemented by the Clinical Effectiveness Unit at The Royal College of Surgeons of England with input from the Association of Breast Surgery (ABS), the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the Royal College of Nursing. The NMBRA examined a broad range of clinical and patient reported outcomes in more than 18,000 women. Factors examined included patient information and access to reconstructive services as well as the level of pain, complications, quality of life and wellbeing after surgery.The patient reported outcomes in the NMBRA highlight the positive effects of breast reconstruction on quality of life and the very high levels of satisfaction with the clinical care provided. The audit did, however, find complication rates, levels of postoperative pain and readmission rates that were much higher than expected. There were also variations in preoperative provision of information, access to services and some clinical outcomes.The original ABS guidelines 2 predated the NMBRA. One of the key recommendations of the audit was that new guid-ance should be written that describes 'best practice' and sets current standards of care. Following this, a multidisciplinary writing group of specialists with expertise in the management of patients undergoing oncoplastic procedures was set up by the ABS and BAPRAS to develop comprehensive new guidelines: Oncoplastic Breast Reconstruction: Guidelines for Best Practice. 3 A patient representative was involved throughout as a core member of the group. Feedback from a wide range of stakeholders has been incorporated into the document, which enjoys the support of Professor Sir Mike Richards, the National Cancer Director. The guidelines are available on the ABS and BAPRAS websites.The NMBRA identified more than 80 unique metrics, reflecting previously undisclosed standards of care. These provided a benchmark for the selection and development of 25 new quality criteria, which form the backbone of the new guidelines (Table 1). The quality criteria were selected to be outcome based, measurable and clinically relevant. They set standards that can be used for future audits, within individual units or nationally.Since oncoplastic breast surgery is a developing area of clinical practice with a limited evidence base, the guidance reflects a combination of peer opinion and the best available evidence informed by peer reviewed publications. External advice was commissioned on pain management from
HighlightsLarge multicentre prospective study involving breast cancer units across the UK.Valuable data collection regarding utilisation of NST in breast cancer treatment.Data on real-world short-term surgical and pathological outcomes.Potentially strengthen the multidisciplinary collaborative network in breast cancer.
Background There is wide variation in the approach to staging for distant metastatic disease in breast cancer. This study sought to identify factors predictive of distant metastatic disease at presentation to enable appropriate selection of patients for pretreatment CT. Methods Data were collected retrospectively for all patients with newly diagnosed breast cancer (screening and symptomatic) over 3 years (2014–2017). Detailed demographic, pathological, biological, and management data were recorded at presentation, and outcome data were recorded after follow-up. Binomial logistic regression was used to identify variables independently associated with distant metastatic disease at presentation. Results A total of 1377 patients with newly diagnosed breast cancer were identified, of whom 1025 had complete data; 323 staging CT examinations were performed. Distant metastases were identified at presentation in 47 (4.6 per cent). Some 30 of 47 patients with metastatic disease met established criteria for staging (T4, recurrence, symptoms of possible distant metastases), leaving 17 patients with metastatic disease potentially missed by use of these criteria alone. Multivariable analysis showed that tumour size at least 3 cm combined with sonographically abnormal axillary lymph nodes predicted a high probability of distant metastatic disease at presentation (positive predictive value 18.8 per cent, odds ratio 4.83, P < 0.001). Addition of this criterion increased the positive CT rate to 17.1 per cent. Conclusion Selective pretreatment CT staging can be further optimized with the addition of tumour size at least 3 cm with abnormal axillary nodes to established staging criteria.
Since the introduction of mammographic breast screening there has been a significant increase in the rate of detection of ductal carcinoma in situ (DCIS) without an invasive component (pure DCIS). This now comprises approximately 20% of all screen-detected breast malignancies in the uK. 1 DCIS may progress to invasive breast cancer. Apparently, pure DCIS frequently coexists with concurrent invasive breast cancer, which in cases of widespread high-grade DCIS is found unexpectedly on final histology following surgery in up to 10-25% of cases and necessitates additional staging of the axilla if axillary surgery is not performed. 2Screening mammography is very sensitive at detecting calcified high-grade DCIS. Approximately 80-90% of DCIS lesions are calcified, 3,4 which enables accurate prediction of disease extent. This is a major determinant of the suitability to treatment by wide local excision (WLE) and therefore breast conservation. It is recognised, however, that the distribution of calcification seen mammographically as well as on specimen radiographs is not always representative of the full extent of disease, leading to an underestimation of extent, both preoperatively and in intraoperative specimen radiographs.5 For example, DCIS is often found at or within a few millimetres of the initial excision margins. Re-excision procedures are often required as DCIS present at the surgical margin leads to a greater incidence of local recurrence. [6][7][8] Annual returns to the NHS Breast Screening Programme (NHSBSP) indicate that our re-excision rates for all pure screen-detected DCIS were 23% between 2008 and 2009. This figure is within normal limits for a large breast screening unit and is given as an example. As an NHSBSP centre, our unit is audited on a yearly basis against national standards. These audits confirmed that the overall rates of reexcision for DCIS historically over the period of this study were also within acceptable levels. However, we suspected from anecdotal evidence that the re-excision rates for pure The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures. METHODS A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS
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