Non-surgical ablation for breast cancer: an emerging therapeutic option.

Non-surgical ablation is emerging as an alternative local therapy option for patients with early-stage breast cancer and encompasses two main types of percutaneous therapeutic procedures: radiofrequency ablation and cryoablation. Both techniques involve obliteration of a spherical lesion and feasibility studies have shown that complete tumour ablation is achievable with good or excellent cosmetic results. Although few clinical studies have directly compared non-surgical ablation with conventional surgical resection, observational studies indicate that clinical outcomes are favourable with acceptable rates of local control and no detriment to long-term survival. There remain outstanding issues with these percutaneous ablative techniques that require resolution before they could be incorporated into routine clinical practice. Hence, a consensus meeting was convened to discuss the challenges of non-surgical ablation and clarify indications for its use alongside clinical management pathways. In this Policy Review we will address some of the broader biological aspects of non-surgical ablation, including immune-modulatory effects and potential novel applications for the future.

Perioperative nursing care speed up recover of a male patient after bilateral endoscopic mastectomy: a case report.

Background: Gynecomastia (GYN) is mainly caused by the benign proliferation of mammary glands and adipose tissue. Currently, up to 38% of adult males have GYN. GYN can be caused by systemic diseases, obesity, endocrine disorders (such as liver cirrhosis, which impairs estrogen inactivation), malignant tumors, and medications. Surgical intervention is required after 12 months pharmacological treatment of GYN was no response who have endocrine disorder, or due to psychological and physiological factors, young patients have a higher demand for surgical intervention. Recent advances in minimally invasive endoscopic surgery, with the advantage of rapid rehabilitation, have markedly improved the surgical management of GYN. Case Description: In November 2021, we admitted a young patient with bilateral GYN whose problem began several years prior and for which he sought surgical intervention. After comprehensive evaluation and psychological consultation, he underwent surgical treatment. The present case report summarizes our experience in nursing this patient. Conclusions: Perioperative nursing care is essential in the management of patients undergoing endoscopic surgical treatment for GYN. The nursing team must be knowledgeable about the procedure, assess and manage the patient's pain, monitor vital signs, prevent infections, and provide emotional support to the patient. With proper nursing care, patients can recover smoothly and quickly after endoscopic surgical treatment of GYN.

The role of irradiation in the management of the axilla in early breast cancer patients.

The need for axillary radiotherapy in patients with invasive breast cancer (IBC) has been a topic of great debate in the last decade. Management of the axilla has evolved significantly over the past four decades with a trend towards de-escalation of surgical interventions and the aim of reducing morbidity and enhancing QOL without compromising long-term oncology outcomes. This review article will address the role of axillary irradiation with a focus on the omission of completion axillary lymph node dissection in selected patients with sentinel lymph node (SLN) positive early breast cancer (EBC) with reference to current guidelines based on evidence to date.

Oncoplastic and reconstructive breast surgery.

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre.

INTRODUCTION: Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. METHODS: A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. RESULTS: A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). CONCLUSION: This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Does pre-operative breast MRI have an impact on surgical outcomes in high-grade DCIS?

OBJECTIVES: High-grade DCIS (HG DCIS) is associated with upgrade to invasive disease but few studies evaluate the role of MRI in this subset of DCIS. This study compared surgical outcomes of females with HG DCIS on biopsy who had pre-operative MRI with those that proceeded directly to surgery. METHODS: This single-centre retrospective, observational study identified patients with pure HG DCIS on pre-operative biopsy from the pathology database. Surgical outcomes, clinicopathological and radiological features were obtained for all patients. RESULTS: From August 2015 to February 2020, 217 patients had HG DCIS on biopsy. Pre-operative MRI was performed in 40 (MRI group) and not in 88 (No MRI group) patients. Initial mastectomy was performed in 25/40 (63%) women in the MRI group and 20/88 (23%) women in the no MRI group (p < 0.0001). No difference was observed in re-operation rate between the two groups, 15% in MRI group vs 22% in No MRI group (p = 0.4749). Mean tumour size on histology was larger in mastectomy cases in the MRI group (73.4 mm, range 6-140 mm), than the total MRI group, (58.3 mm, range 0-140 mm) or no MRI group (30.7 mm, range 0-130 mm) (p < 0.0001). CONCLUSIONS: Pre-operative MRI in HG DCIS is associated with higher mastectomy rates, possibly due to patient selection for MRI, as tumours on final histology were significantly larger. Fewer re-operations were observed in the MRI group although this was not significant. ADVANCES IN KNOWLEDGE: Breast MRI performed pre-operatively in HG DCIS is associated with higher mastectomy rates and fewer re-operation rates.

A Prospective Study Evaluating the Accuracy of Indocyanine Green (ICG) Fluorescence Compared with Radioisotope for Sentinel Lymph Node (SLN) Detection in Early Breast Cancer.

BACKGROUND: Dual localization methods with blue dye and radioisotope represents the standard method for SLN identification. Side effects of blue dye and problems with access to radioisotope has prompted assessment of alternative tracers. This study has evaluated a combination of indocyanine green (ICG) fluorescence with radioisotope for SLN biopsy in early breast cancer. METHODS: In a prospective observational study 79 patients scheduled for SLN biopsy underwent dual localization with radioisotope nanocolloid and ICG (0.5%). The primary goal was to assess noninferiority of ICG compared with standard radioisotopic localization. Statistical analysis was performed using Stata (version 15.1). RESULTS: A total of 162 nodes were retrieved from 79 patients with an average nodal count of 2.04 (range 1-4) and an overall identification rate of 98.7% (78/79). Nodal detection rates for ICG alone or combined with radioisotope were 98.1% (151/154) and 73.4% (113/154) respectively. Metastasis were present in 13 nodes, all of which were both fluorescent and radioactive and distributed amongst 13 patients each with a single positive node containing macrometastases (n = 5), micrometastases (n = 6), or isolated tumor cells (n = 2). ICG was noninferior to radioisotope with the lower confidence interval not crossing within the predefined limit. No serious adverse reactions were recorded. CONCLUSIONS: These results confirm comparable performance parameters for ICG to the "gold standard" using radioisotope. ICG can reliably be employed as a sole tracer that avoids potential drawbacks of standard tracer agents, including availability and costs of radioisotope.

Role of early post-operative breast MRI: how helpful is it in deciding the next step for women who may have residual disease?

OBJECTIVES: Positive resection margins following breast conserving surgery are a risk factor for local disease recurrence. Subsequent management of patients is often not straightforward, with post-operative breast MRI increasingly used to aid decision-making. Interpretation of MRI after surgery can prove challenging due to local inflammatory enhancement. We reviewed our experience of post-operative breast MRIs to determine their ability to detect residual disease and to evaluate how they changed initial patient management from re-excision to an alternative. METHODS: A search of breast MRIs performed from August 2014 to December 2019 was undertaken, to identify those performed post-operatively within 4 months of breast conserving surgery. Electronic patient records and imaging were evaluated to determine additional work-up, pathology and surgical outcomes. RESULTS: Of the 2274 breast MRIs during the study period, 44 (2%) were performed post-operatively to evaluate 47 breasts. MRI was normal in 20 cases (43%), suspicious findings at surgical cavity only in 13 (28%), suspicious ipsilateral distant breast findings only in 6 (13%), and both cavity and distant findings in 7 cases (15%). Contralateral abnormalities were identified in 3 cases. Following MRI, mastectomy was performed in 11 cases, re-excision in 25, with 2 subsequent mastectomies, and multidisciplinary team accepted margins in 11 cases, 10 of whom underwent post-operative radiotherapy. MRI altered initial patient management from re-excision to an alternative in 25 cases (45%). CONCLUSION: Post-operative breast MRI, although potentially challenging to interpret, can prove useful in planning the next step in patient management, particularly in its ability to evaluate the whole breast. ADVANCES IN KNOWLEDGE: Post-operative breast MRI is increasingly requested at multidisciplinary team following breast conserving surgery with positive surgical margins on histology, however interpretation is challenging. The value of these studies lie in assessment of the distant breast rather than the surgical resection cavity and can alter patient management guiding the most appropriate next step for definitive treatment.

Extended endocrine therapy in early breast cancer: how long and who for?

Endocrine therapy for early stage breast cancer is currently in a state of flux with much uncertainty about choice of agents and duration of therapy. The standard treatment span of 5 years usually incorporates an aromatase inhibitor in the majority of postmenopausal patients. Hormonal therapy has a cytostatic action that provides a biological rationale for continuing treatment for more prolonged periods to reduce risk of late recurrence in estrogen receptor-positive disease. Several trials of extended endocrine therapy for periods varying from 7.5 to 10 years have shown mixed results for gains in disease-free survival. The challenge is to assimilate available data and apply clinical judgment to tailor therapies taking account of intrinsic risk of disease recurrence, patient preference, tolerability to date, and co-morbidities.