[Show abstract][Hide abstract] ABSTRACT: The role of surgery in the management of breast cancer has continuously evolved over the last 100 years. William Halsted pioneered in breast cancer management by establishing that the primary goal of surgery was to treat the disease and prolong survival by containing the loco-regional spread with radical resections; his radical mastectomy was widely used for almost 100 years. Thanks to the results of well-designed randomized control trials that began in the 1970s, the treatment goal for the management of breast cancer shifted in a different direction, and the role of surgery altered dramatically. As a result, the extreme “one size fits all” radical mastectomies were gradually replaced by a more “tailor-made” less invasive modified technique, but without compromising the prognosis and survival. Eventually, the correct and timely resection of the tumour in a way that minimized morbidity, without causing unnecessary harm and burden to the patient, became the basic goal of breast surgery. Conservation of the breast and acceptable cosmesis became the main purpose of breast surgery and the gold standard for early stage breast cancer. Notwithstanding, approximately 20-30% of women with breast cancer undergo mastectomy. Nevertheless, the face of mastectomy has altered during the last three decades and what used to be a simple, and unfortunately often mutilating removal of the cancerous breast lesion, has become a sophisticated, often technically demanding, and definitely quality-of-lifeoriented part of the multidisciplinary process. In this review, we present the historical evolution of mastectomy while analyzing the indications, technical points and safety of each approach. In the “Halsted” radical mastectomy, the breast was removed along with the overlying skin and both pectoralis muscles, together with complete en bloc resection of the regional lymph nodes. In the 1940s, a less radical procedure was proposed by Patey: a modification of the radical mastectomy where the pectoralis major was preserved, followed a few years later by a less radical approach that preserved both pectoral muscles. This modified technique subsequently became the gold standard procedure in the USA in the 1970s and remains, to date, the current conventional form of mastectomy. In the 1950s, silicone implants were introduced to breast surgery. Given the prolonged survival for many patients, breast reconstruction became a reality. In 1991, Toth and Lambert described a new form of mastectomy (the skin sparing mastectomy) where the breast was removed from well-planned incisions in a way that most of the skin, particularly the inframammary fold, was preserved in order to allow immediate reconstruction and better cosmetic results. Eventually, a new form of SSM where the nipple areola complex (NAC) was also preserved emerged as a surgical option in order to further improve the cosmetic outcome of mastectomy in selected patients. In conclusion, mastectomy still remains necessary for a high percentage of breast cancer patients, though radical mastectomy is rarely used nowadays. The main indications for mastectomy are extensive or multicentric disease, contraindication, failure or recurrence after breast conserving surgery (BCS), locally advanced and inflammatory cancer, risk reduction, and if the patient so chooses. Skin-sparing mastectomy is a safe option offering better cosmetic results for patients with an indication for mastectomy and immediate reconstruction, provided that the skin is not involved and there is no inflammatory cancer. Nipple-sparing mastectomy can be applied safely in carefully selected patients, providing them with even better cosmetic results. Riskreducing mastectomy should be performed when indicated in a way that provides the patient optimal quality of life.
[Show abstract][Hide abstract] ABSTRACT: Unnecessary referrals of patients with breast lumps represent a significant issue, since only a few patients actually have lumps when examined by a breast specialist. Tactile imaging (TI) is a novel modality in breast diagnostics armamentarium. The aim of this study was to assess TI's diagnostic performance and compare it to clinical breast examination (CBE). This is a prospective, blinded, comparative study of 276 consecutive patients. All patients underwent conventional imaging and tissue sampling if either a radiological or a palpable abnormality was present. Sensitivity, specificity and positive and negative predictive values for CBE and TI were calculated. Radiological findings and final diagnosis based on histology and/or cytology were used as reference standards. Receiver operator characteristic (ROC) curve analysis was also performed for each method. Sensitivity and specificity of TI in detecting radiologically proven abnormalities were 85.5 % and 35 %, respectively. CBE's sensitivity was 80.3 % and specificity 76 %. In detecting a histopathological entity according to histology/cytology, sensitivity was 88.2 % for TI and 81.6 % for CBE. Specificity was 38.5 % and 85.7 % for TI and CBE, respectively. These results suggest a trend towards higher sensitivity of TI compared to CBE but significantly lower specificity. Subgroup analysis revealed superior sensitivity of TI in detecting a histological entity in pre-menopausal women. However, CBE's overall performance was superior compared to TI's according to ROC curve analysis. Although further research is necessary, the use of TI by the primary care physician as a selection tool for referring patients to a breast specialist should be considered especially in pre-menopausal women.
Breast Cancer Research and Treatment 09/2014; 147(3). DOI:10.1007/s10549-014-3123-3 · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Primary hyperparathyroidism is a disease commonly seen in patients above 60 years of age. It is the most common cause of asymptomatic or symptomatic hypercalcemia, usually found incidentally on routine check-ups. Surgical treatment is the only definitive treatment of choice in the symptomatic patient; however, it can also be employed in asymptomatic patients. First described in 1925, bilateral neck exploration is the gold standard of treatment for primary hyperparathyroidism. The recent interest in minimally invasive surgeries has led to better and improved techniques of neck exploration with improved cosmetic results and lesser chances of transient or permanent hypoparathyroidism due to inadvertent removal of normally functioning parathyroid tissue. These include unilateral neck explorations, minimally invasive parathyroidectomies and minimally invasive radio-guided parathyroidectomy. The intact parathyroid hormone assays have greatly added to the detection of normal and abnormal functioning glands, hence better surgical outcomes.
Indian Journal of Surgery 08/2014; 76(4). DOI:10.1007/s12262-013-0898-0 · 0.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Current techniques for assessing the adequacy of tumour excision during breast conserving surgery do not provide real-time direct cytopathological assessment of the internal cavity walls within the breast. This study investigates the ability of probe-based confocal laser endomicroscopy (pCLE), an emerging imaging tool, to image the morphology of neoplastic and non-neoplastic breast tissues, and determines the ability of histopathologists and surgeons to differentiate these images. Freshly excised tumour samples and adjacent non-diseased sections from 50 consenting patients were stained with 0.01 % acriflavine hydrochloride and imaged using pCLE. All discernible pCLE features were cross-examined with conventional histopathology. Following pattern recognition training, 17 histopathologists and surgeons with no pCLE experience interpreted 50 pCLE images independently whilst blinded to histopathology results. Three-hundred and fifty pCLE image mosaics were analysed. Consistent with histopathology findings, the glandular structures, adipocytes and collagen fibres of normal breast were readily visible on pCLE images. These were distinguishable from the morphological architecture exhibited by invasive and non-invasive carcinoma. The mean accuracy of pCLE image interpretation for histopathologists and surgeons was 94 and 92 %, respectively. Overall, inter-observer agreement for histopathologists was 'almost perfect', κ = 0.82; and 'substantial' for surgeons, κ = 0.74. pCLE morphological features of neoplastic and non-neoplastic breast tissues are readily visualized and distinguishable with high accuracy by both histopathologists and surgeons. Further research is required to investigate a potential role for the use of pCLE intraoperatively for in situ detection of residual cancerous foci, thereby guiding operating decision-making based on real-time breast cavity scanning.
European Journal of Surgical Oncology 11/2013; 39(11):S80. DOI:10.1016/j.ejso.2013.07.106 · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Acquisition of additional breast tissue has become integral to breast oncology research. This questionnaire study examines patient willingness to undergo research-dedicated breast biopsies either at time of diagnostic biopsy (T1) or after carcinoma diagnosis has been confirmed and eligibility for a specific study established (T2), and influencing factors thereof.
Prior to consultation, patients attending breast clinics were recruited to complete a questionnaire examining willingness to undergo an extra fine needle aspirate (FNA) and/or core needle biopsy (CNB) for research either at T1 or T2. Descriptions of FNA and CNB procedures were supplied to those with no prior experience. Patient perspectives towards donating surplus tissue remaining from a diagnostic procedure and/or surgery for future research were also explored.
A total of 100 patients were recruited, 42% with prior history of breast carcinoma (BC), 22% with family history of BC (FHBC) and 65%/42% with previous experience of CNB/FNA respectively. Overall, 57% were willing to undergo additional biopsy at one or both time points. Willingness to undergo additional biopsy was greater for T1 than T2, but equivalent for CNB and FNA (willingness CNB T1, 50% vs T2, 26%, willingness FNA T1 50% vs T2 29%). A statistically significant increase in willingness to undergo CNB and/or FNA at T1 and/or T2 was seen in association with prior diagnosis of BC, FHBC, previous visit to breast clinic and prior experience of breast biopsy. 83% of patients expressed a willingness to allow surplus tissue to be stored in a biobank for future research.
Where possible patients should be approached to undergo baseline research biopsies at time of diagnostic process rather than subsequently. Patients do not find FNA more acceptable than core biopsy. Prior exposure to the biopsy procedure increases willingness to undergo research-dedicated biopsies.
Breast (Edinburgh, Scotland) 05/2013; 22(5). DOI:10.1016/j.breast.2013.03.011 · 2.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
This phase II, open-label, multicentre study aimed to evaluate changes in cell proliferation and biomarkers, as well as efficacy of lapatinib in treatment-naïve patients with HER-2-negative primary breast cancer.Patients and methodsPatients received 1500 mg lapatinib for 28-42 days before surgery with repeat biopsies and measurements. The primary end point was inhibition of cell proliferation measured by Ki67; the secondary end points included clinical response, adverse events and changes in FOXO3a, FOXM1, p-AKT and HER-3.ResultsOverall, there was no significant reduction in Ki67 with treatment (assessment carried out in 28 of 31 subjects enrolled). However, four patients (14%) showed a reduction in Ki67 ≥50%. Four of 25 patients (16%) had a partial response to treatment judged by sequential ultrasound measurements. Response, in terms of either Ki67 or ultrasound, did not relate to changes in any biomarker assessed at baseline, including the estrogen receptor (ER) and epidermal growth factor receptor (EGFR). However, all four clinical responders were HER-3 positive, as were three of four Ki67 responders.Conclusions
Overall, a pre-surgical course of lapatinib monotherapy had little effect on this group of patients; however, in subsets of patients, especially those with HER-3-positive tumors, we observed either reduction in proliferation (Ki67) or tumor size; EGFR/ER status had no impact.
Annals of Oncology 12/2012; 24(4). DOI:10.1093/annonc/mds594 · 7.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The introduction of the National Health Service (NHS) Breast Screening Programme has led to a considerable increase in the detection of impalpable breast cancer. Patients with impalpable breast cancer typically undergo oncological resection facilitated either by the insertion of guide wires placed stereo-tactically or through ultra-sound guided skin markings to delineate the extent of a lesion. The need for radiological interventions on the day of surgery adds complexity and introduces the risk that a patient may accidentally transferred to the operating room directly without the image guidance procedure.
A case is described of a patient who required a pre-operative ultrasound scan in order to localise an impalpable breast cancer but who was accidentally taken directly to the operating theatre (OR) and anaesthetised without pre-operative intervention. The radiologist was called to the OR and an on-table ultrasound was performed without further consequence.
It is evident that breast cancer patients undergoing image-guided resection are exposed to an additional layer of clinical risks. These risks are not offset by the World Health Organisation surgical safety checklist in its present guise. Here, we review a number of simple and inexpensive changes to the system that may improve the safety of the breast cancer patient undergoing surgery.
Patient Safety in Surgery 07/2012; 6(1):15. DOI:10.1186/1754-9493-6-15
[Show abstract][Hide abstract] ABSTRACT: The finding of micrometastases (M(i)) and isolated tumour cells (ITC) within the axillary lymph nodes of patients with breast cancer has raised the question whether either/both have some prognostic significance. Several studies have shown that compared to node-negative patients, prognosis is significantly poorer in patients with M(i) and ITC. The fact that patients with M(i)/ITC in their sentinel lymph nodes have a systemic relapse risk that is higher than that of node-negative patients may be considered as an indication for systemic treatment. Most studies in the literature suggest that in patients with M(i) or ITC in their sentinel nodes who receive systemic therapy and whole breast radiotherapy, the risk of axillary relapse without axillary lymphadenectomy is under 2%. Given the fact that axillary lymphadenectomy is associated with a 5-25% risk of lymphoedema, we propose that a policy of close follow up should be adopted in these patients rather than axillary lymphadenectomy.
Breast (Edinburgh, Scotland) 06/2012; 22(1). DOI:10.1016/j.breast.2012.05.006 · 2.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The role of surgery has been continuously evolving for the last 100 years, as have the various techniques for the management of breast cancer. Thanks to the results of well-designed randomized control trials, the mutilating radical mastectomies of the past came to be gradually replaced by modified techniques and, eventually, by local excisions combined with radiotherapy without compromising prognosis and survival. The purpose of this approach was to minimize morbidity and avoid unnecessary harm and burden to the patients.
Conserving the breast was a start, but up to a decade ago the techniques used were limited to just cancer excision and closure of the wound, leaving behind a mutilated breast in many women. The introduction and evolution of oncoplastic surgery completely changed the modern surgical approach to breast cancer, taking the development to the next level.
The concept of oncoplastic breast surgery combines oncologic tumour resection, in the form of either breast conservation or mastectomy, with traditional or modified plastic surgical techniques aiming to achieve an optimal cosmetic result with long-term local tumour control
Eventually, what used to be a simple yet frequently mutilating removal of the cancerous breast lesion became a sophisticated, though often technically demanding, quality-of-life-oriented part of the multidisciplinary process in the treatment of cancer that nowadays affects almost 1 out of 9 women.
In this review article, we present the basic principles, elements and techniques of oncoplastic breast surgery. We further discuss the indications, contraindications, advantages and disadvantages of these techniques.