Six-year experience of oncoplastic volume replacement using local perforator flaps.

Local perforator flaps may be utilised to correct volume defects after breast-conserving surgery (BCS), improving the cosmetic outcome and avoiding the need for contralateral symmetrising surgery. The aims of this study were to assess longer term oncological outcomes following local perforator flap reconstruction, and to demonstrate the learning curve associated with incorporating such techniques within routine clinical practice. We report a consecutive case series of 116 local perforator flaps performed between January 2014 and May 2020. Data collected included patient demographics, tumour characteristics, surgical procedure data, complications and follow-up outcomes. All breast cancer patients are followed with annual mammographic surveillance for a minimum of five years. Of 116 procedures, 101 were performed as immediate partial breast reconstruction and 15 as delayed reconstructive procedures for patients who had prior breast surgery. The overall complication rate was 15%; the majority were minor surgical site infections, 1.7% required haematoma evacuation. At a median follow-up of 37 months, there were no local cancer recurrences. Three patients who underwent delayed reconstruction required revision procedures, and one required a contralateral symmetrisation procedure. One patient in the immediate reconstruction group required additional lipofilling. Over time, the mean lesion size selected for immediate local flap reconstruction increased, operative times decreased and the proportion of day case procedures increased. Our data confirm that local perforator flaps are associated with low morbidity, excellent oncological outcomes and long-term durability. The use of local flaps can increase the range of indications for BCS, reducing mastectomy rates and the associated revision and symmetrising procedures associated with them.

Breast conservation surgery by round block mammoplasty.

BACKGROUND: Round block mammoplasty (RBM) is a type of Oncoplastic procedure to facilitate breast conservation surgery for breast cancer. METHODS: Retrospective study of 270 patients who underwent this surgery. The surgical and oncological outcomes of RBM were studied. RESULTS: The median age was 61 years and median follow-up 39 months. Most cancers (59%) were screen-detected. The location of the cancer was commonly in the upper outer quadrant followed by upper inner quadrant (20%). The average tumor size was 18 mm and in 48% of patients the whole tumor size increased to 23.5 mm due to associated DCIS. The median specimen weight was 41 gm. Forty patients (14.8%) had positive margins. Postoperative complications were seen in 18 patients (6.6%). There were 4 local and 1 axillary recurrences, and 8 distant metastasis. Contralateral symmetrising surgery was required in 13 patients (4.8%). CONCLUSION: RBM is a robust and easily adaptable technique which provides good exposure for a safe oncological excision. The surgical and oncological outcomes are good and contralateral symmetrising surgery is rarely required.

Evaluation of Radiation Exposure During Sentinel Lymph Node Biopsy in Breast Cancer: A Retrospective Study.

INTRODUCTION: Sentinel node biopsy (SNB) is the standard of care for nodal staging in breast cancer. Currently, radioisotope-guided SNB is the standard technique. We have undertaken this study to analyse radiation exposure during SNB for breast cancer over a significant period of time. METHODS: The study was conducted over a period of 41 months and included 183 patients. The radioisotope was usually administered the day preceding the surgery at a dose of 40 MBq (±10%), and a lower dose of 20 MBq (±10%) was given if injected on the day of surgery. The radiation exposure was measured by dosimeters worn by the surgeon and surgical assistant. RESULTS: The surgical procedures performed were mastectomy and SNB (56 patients), wide local excision and SNB (109 patients), and SNB alone (18 patients). The median time interval between the injection and surgery was 19.3 h, and median duration of surgery 93 min. The annual exposure for the surgeon was 0.125 mSv (range 0.01-0.03 mSv) and for the assistant was 0.265 (range 0.01-0.13 mSv). CONCLUSION: Contrary to other studies, we found the radiation exposure in the assistant was higher than that in the surgeon and we think this is because the assistant is positioned closer to the injection site during the procedure. However, the cumulative levels of radiation with SNB were very low and significantly below the permissible limits. The timing of injection, type of breast surgery and duration of procedure did not affect the levels of radiation exposure.

Feasibility of Axillary Reverse Mapping and Clinicopathological Features Predicting ARM Node Metastasis in Breast Cancer-a Pilot Study.

The axillary reverse mapping (ARM) technique has been described as an attempt to map and preserve the upper extremity lymphatic drainage during axillary lymph node dissection (ALND) and/or SLNB. This technique is based on the hypothesis that the lymphatic pathway from the upper extremity is not involved by metastasis from primary breast cancer. The ARM node/s however, has been found, in various studies, to be involved with metastatic foci in patients with extensive axillary lymph node metastases. Therefore, the oncological safety of this procedure has not yet been determined. In this pilot study, we assessed the ARM node intraoperatively for various parameters and compared it to final HPR, to try and determine the oncologic safety of preserving the ARM node. Seventy-two breast cancer patients were screened for this prospective pilot study which was planned to recruit 20 patients. The study was initiated on May 2014, 20 patients were recruited till July 2015. Eligibility criterion was as follows: patients requiring primary axillary lymph node dissection based on a clinically positive axilla. Forty-five patients were ineligible because they had either received neoadjuvant chemotherapy or underwent previous axillary surgery or axillary radiation (exclusion criteria). Seven patients refused to give consent. ARM node identification rate was 75%. The most common location of the ARM node was lateral to the latissimus dorsi pedicle (42.10%), none of them being malignant. None of the oval or firm nodes were malignant. Tumor deposits were identified in 13%. Fine-needle aspiration cytology (FNAC) had 100% specificity, 94.4% negative predictive value, 100% positive predictive value, and 50% sensitivity. ARM is feasible using blue dye alone, with an acceptable identification rate. Location, consistency, and intraoperative FNAC of the ARM node, put together, may be reliable parameters to predict involvement of the ARM node with metastasis.

Dedifferentiated chondrosarcoma: an aggressive variant of chondrosarcoma.

Dedifferentiated chondrosarcomas are a rare and aggressive subtype of chondrosarcoma with a bimorphic pattern on histopathology. Rib is a rare site of dedifferentiated chondrosarcoma. Diagnosis of this subtype preoperatively can be challenging. Treatment options for dedifferentiated chondrosarcoma are limited because they are chemoresistant, and therefore adequate surgery forms the main stay of treatment. We present our experience with a dedifferentiated chondrosarcoma of the rib, and discuss the management of this rare entity.

An unusual presentation of thyroid cancer.

Well-differentiated thyroid cancers can present with nodal metastasis that have undergone cystic degeneration. Rarely, mediastinal nodes may undergo cystic changes and pose a diagnostic dilemma, especially if the primary lesion is occult. We describe the case of a patient who presented with a large mediastinal cystic lesion which turned out to be metastasis from thyroid cancer.

Esophagectomy for cancer of the esophagus. A regional cancer centre experience.

Surgery is an important component of treatment for patients with resectable cancer of the mid and lower third of the esophagus. There are many controversies associated with esophagectomy. We share our experience with esophagectomy for cancer of the mid and lower third of the esophagus. Between January 2007 and December 2011, 210 patients with cancer of the esophagus underwent surgery. The patients' pre and intra- operative factors, morbidities and mortality were noted and studied. Transhiatal esophagectomy was done in 175 patients and right transthoracic esophagectomy was done in 35 patients. The most common location of the tumor was lower third and most common histopathology was squamous cell carcinoma. There were 5 in-hospital deaths (2.4 %) and the common morbidities encountered were respiratory (30 %), anastomotic leak (5 %) and anastomotic stricture (15 %). The morbidity was higher in the transthoracic group. Our R0 resection rate was 89 %. Esophagectomy can be accomplished with acceptable morbidity in the management of patients with oesophageal cancer. We attribute the favourable results to the high volume at our centre, surgical expertise, good patient selection and performance of the anastomosis in the neck.

Giant solitary fibrous tumour of the pleura.

Solitary fibrous tumour of the pleura is a rare primary pleural neoplasm. These tumours are usually asymptomatic and are incidentally detected. Majority of these neoplasms are benign and surgical excision provides excellent results. With the widespread use of imaging and better diagnostic criteria, this tumour is likely to be detected more frequently. We encountered a patient with a giant solitary fibrous tumour of the pleura. In this report, we describe the case of a patient with a giant solitary fibrous tumour of the pleura, review the literature and present the details of management of this patient.

Castleman's disease of the pleura.

Castleman's disease is a rare benign disease of the lymph nodes. Its origin from the pleura is rare. Surgical excision, when feasible, appears to provide good results. We encountered a patient who had the disease arising from the parietal pleura. We present the clinical scenario, investigations, and our management of the patient.

To operate or not to operate n0 neck in early cancer of the tongue? A prospective study.

Squamous cell carcinoma (SCC) of the tongue is a common cancer across the globe. These cancers have a high predilection for nodal metastasis and a high incidence of occult metastasis. The management of clinically negative neck nodes (N0) remains controversial. We have undertaken a prospective study to evaluate the rate of occult nodal metastasis, the characteristic of metastasis, and assess the usefulness of tumor depth as a predictor of metastasis and as a guide to treat the neck. Prospective study between January 2000 to December 2005. Patients with SCC of the anterior 2/3rd of tongue with N0 neck were included. Wide excision of the primary and subsequent modified radical neck dissection (in patients with tumor depth > 4 mm) was performed. Postoperative radiotherapy was given in patients with lymph node metastasis. Patients who had no node metastasis (p N -ve) were observed. The total number of eligible patients was 180. Occult lymph node metastasis (p N +ve) was seen in 122 (62.2%) patients (p < 0.001), multiple levels of node involvement in 79 (70.5%) patients and extracapsular spread (ECS) in 38 (33.6%) patients. Patients in the p N +ve group who were disease free was 63.1% as compared to 68.2% in the p N -ve group (p = 0.36). Recurrence was seen in 28 (36.8%) patients of p N +ve group and 14 (31.8%) patients of p N -ve group. Early cancer of tongue with tumor depth >4 mm was associated with predominantly high grade tumors, high incidence of occult nodal metastasis, multiple levels of nodal involvement and ECS. The disease free status of patients with occult metastasis who were treated was similar to that of patients with no nodal metastasis. Elective neck dissection appears essential for early oral tongue cancer with tumor depth >4 mm as there is no investigational modality which can reliably identify patients without occult metastasis.

The ileosigmoid knot.

Ileosigmoid knot is rare yet life-threatening condition caused by acute double loop intestinal obstruction. Preoperative diagnosis is difficult and it is associated with high morbidity and mortality. We present one such patient we encountered and outline our management, and discuss the surgical options available.

Pulmonary oncocytoma: a rare case.

Oncocytomas are rare tumors with characteristic histological features of large eosinophilic cells with prominent nucleoli and small round nuclei. They commonly occur in the kidney and salivary glands. Their occurrence in the lungs is very rare; fewer than 6 cases being reported so far in the available world literature. We encountered one such case and present the details of the management and its outcome.