Post-mastectomy radiotherapy for women with early breast cancer and one to three positive lymph nodes.

BACKGROUND: Continual improvement in adjuvant therapies has resulted in a better prognosis for women diagnosed with breast cancer. A surrogate marker used to detect the spread of disease after treatment of breast cancer is local and regional recurrence. The risk of local and regional recurrence after mastectomy increases with the number of axillary lymph nodes affected by cancer. There is a consensus to use radiotherapy as an adjuvant treatment after mastectomy (postmastectomy radiotherapy (PMRT)) in women diagnosed with breast cancer and found to have disease in four or more positive axillary lymph nodes. Despite data showing almost double the risk of local and regional recurrence in women treated with mastectomy and found to have one to three positive lymph nodes, there is a lack of international consensus on the use of PMRT in this group. OBJECTIVES: To assess the effects of PMRT in women diagnosed with early breast cancer and found to have one to three positive axillary lymph nodes. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov up to 24 September 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs). The inclusion criteria included women diagnosed with breast cancer treated with simple or modified radical mastectomy and axillary surgery (sentinel lymph node biopsy (SLNB) alone or those undergoing axillary lymph node clearance with or without prior SLNB). We included only women receiving PMRT using X-rays (electron and photon radiation), and we defined the radiotherapy dose to reflect what is currently being recommended (i.e. 40 Gray (Gy) to 50 Gy in 15 to 25/28 fractions in 3 to 5 weeks. The included studies did not administer any boost to the tumour bed. In this review, we excluded studies using neoadjuvant chemotherapy as a supportive treatment before surgery. DATA COLLECTION AND ANALYSIS: We used Covidence to screen records. We collected data on tumour characteristics, adjuvant treatments and the outcomes of local and regional recurrence, overall survival, disease-free survival, time to progression, short- and long-term adverse events and quality of life. We reported on time-to-event outcome measures using the hazard ratio (HR) and subdistribution HR. We used Cochrane's risk of bias tool (RoB 1), and we presented overall certainty of the evidence using the GRADE approach. MAIN RESULTS: The RCTs included in this review were subgroup analyses of original RCTs conducted in the 1980s to assess the effectiveness of PMRT. Hence, the type and duration of adjuvant systemic treatments used in the studies included in this review were suboptimal compared to the current standard of care. The review involved three RCTs with a total of 829 women diagnosed with breast cancer and low-volume axillary disease. Amongst the included studies, only a single study pertained to the modern-day radiotherapy practice. The results from this one study showed a reduction of local and regional recurrence (HR 0.20, 95% confidence interval (CI) 0.13 to 0.33, 1 study, 522 women; low-certainty evidence) and improvement in overall survival with PMRT (HR 0.76, 95% CI 0.60 to 0.97, 1 study, 522 women; moderate-certainty evidence). One of the other studies using radiotherapy techniques that do not reflect modern-day practice reported on disease-free survival in women with low-volume axillary disease (subdistribution HR 0.63, 95% CI 0.41 to 0.96, 1 study, 173 women). None of the included studies reported on PMRT side effects or quality-of-life outcome measures. AUTHORS' CONCLUSIONS: Based on one study, the use of PMRT in women diagnosed with breast cancer and low-volume axillary disease indicated a reduction in locoregional recurrence and an improvement in survival. There is a need for more research to be conducted using modern-day radiotherapy equipment and methods to support and supplement the review findings.

Wire- and magnetic-seed-guided localization of impalpable breast lesions: iBRA-NET localisation study.

BACKGROUND: Wire localization is historically the most common method for guiding excision of non-palpable breast lesions, but there are limitations to the technique. Newer technologies such as magnetic seeds may allow some of these challenges to be overcome. The aim was to compare safety and effectiveness of wire and magnetic seed localization techniques. METHODS: Women undergoing standard wire or magnetic seed localization for non-palpable lesions between August 2018 and August 2020 were recruited prospectively to this IDEAL stage 2a/2b platform cohort study. The primary outcome was effectiveness defined as accurate localization and removal of the index lesion. Secondary endpoints included safety, specimen weight and reoperation rate for positive margins. RESULTS: Data were accrued from 2300 patients in 35 units; 2116 having unifocal, unilateral breast lesion localization. Identification of the index lesion in magnetic-seed-guided (946 patients) and wire-guided excisions (1170 patients) was 99.8 versus 99.1 per cent (P = 0.048). There was no difference in overall complication rate. For a subset of patients having a single lumpectomy only for lesions less than 50 mm (1746 patients), there was no difference in median closest margin (2 mm versus 2 mm, P = 0.342), re-excision rate (12 versus 13 per cent, P = 0.574) and specimen weight in relation to lesion size (0.15 g/mm2versus 0.138 g/mm2, P = 0.453). CONCLUSION: Magnetic seed localization demonstrated similar safety and effectiveness to those of wire localization. This study has established a robust platform for the comparative evaluation of new localization devices.

Impact of Preoperative MRI in Invasive Ductal Carcinoma With Lobular Features on Core Biopsy.

BACKGROUND: Invasive breast cancer is comprised of a wide spectrum of histological types with different clinical presentations, imaging characteristics, and behaviors. Almost 10% of breast cancers with predominantly invasive ductal features have lobular components on core biopsy at primary diagnosis. Although the role of magnetic resonance imaging (MRI) in patients with purely lobular cancers is well-established, it is not clear if preoperative MRI is indicated in ductal cancer with lobular features. The aim of this study was to assess the role of preoperative MRI in patients with invasive ductal cancers with lobular features on core biopsy. MATERIALS AND METHODS: Data regarding patients with lobular features on core biopsy who underwent a preoperative MRI from January 2015 to December 2017 were retrospectively identified and analyzed. Imaging findings, additional investigations, and changes in treatment plans following the MRI scan were reviewed. RESULTS: The study included 120 patients, of whom 42 (35%) patients required a second-look ultrasound. Following a repeat ultrasound scan, 25 breasts and 4 axillae were biopsied. Thirty-eight percent of the breast biopsies and 50% of the axillary biopsies were malignant. Based on MRI findings, treatment plans changed in 22.5% of patients. MRI size was concordant with the histological size in 58.3% of cases, and MRI was accurate in 90% of patients in detecting multifocal disease requiring mastectomy. The majority of patients with changes in the management plans had mixed ductal and lobular cancer on final histology. CONCLUSION: This study has demonstrated that MRI picks up additional malignancies and changes management plans in patients with lobular features on core biopsy and should be considered in the preoperative workup.

Patient-reported Upper Limb Function After Sentinel Lymph Node Biopsy for Breast Cancer: A Prospective Observational Study.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is the standard procedure for axillary staging in breast cancer. There is a lack of consistency in studies reporting on upper limb morbidity after SLNB. We present a prospective study evaluating upper limb function after SLNB using the validated quickDASH questionnaire. MATERIALS AND METHODS: Consecutive patients who underwent wide local excision and SLNB were included in the study. Arm function was assessed using the quickDASH questionnaire at 3 time points - prior to surgery and 2 weeks and 3 months after SLNB. The scores obtained were labeled as A, B, and C respectively. The mean and median scores were compared using the paired t test and Wilcoxon signed rank test. RESULTS: Ninety-nine patients met all inclusion criteria and were included in the final analysis. The mean A, B, and C scores were 8.46, 16.05, and 13.36. The median A, B, and C scores were 2.27, 7.5, and 4.54. There was a statistically significant difference between mean and median A and B scores, B and C scores, and A and C scores. A similar trend was observed in patients with better preoperative upper limb function. Patients with a higher body mass index had significantly worse B and C scores. CONCLUSION: There is a significant deterioration in upper limb function following SLNB. This improves at 3 months but does not reach baseline levels. Larger studies with long-term follow-up are required to establish the extent of upper limb functional morbidity and natural course of functional recovery after SLNB.

Chest wall perforator flaps for partial breast reconstruction: Surgical outcomes from a multicenter study.

BACKGROUND: Perforator artery flaps based on the branches of intercostal arteries and lateral thoracic artery can be used for reconstruction after breast-conserving surgery (BCS). Although described more than a decade ago, these have not been adopted widely in clinical practice. We report on short-term and long-term surgical outcomes of partial breast reconstruction using chest wall perforator flaps from a prospective multicenter audit. METHODS: All patients operated for BCS and partial breast reconstruction using intercostal artery perforator or lateral thoracic artery perforator flaps from January 2015 to October 2018 were included in the analysis. Oncoplastic breast surgeons with appropriate level of training performed all tumor excisions and reconstructions as a single-stage procedure. Patient characteristics, treatment details and surgical outcomes were noted. Specific outcomes recorded were margin re-excision and complication rates. RESULTS: One hundred and twelve patients underwent the procedure in the given study period. The median age was 54 years. Median specimen weight was 62.5 g and median volume of excision was 121.4 mL. Fifteen patients (13.39%) underwent a margin re-excision for close or positive margins without additional morbidity. One patient required a completion mastectomy. Eight patients (7.14%) had an early complication. None of the patients required a contralateral symmetrization procedure. The results were comparable across the participating centers. CONCLUSIONS: Chest wall artery perforator-based flaps are an excellent option for lateral and inferior quadrant partial breast reconstructions. The short and long-term surgical outcomes are comparable across sites and can be performed with minimal morbidity. Patient-reported outcome measures need to be studied.

Demography and treatment pattern of patients with head and neck carcinoma presenting to a tertiary care center in India: Need for urgent decentralization of cancer care.

AIMS: This study aims to report on the demographic profile and treatment pattern of head and neck cancer patients and impact of an early treatment decision on treatment. This study also aims to suggest recommendations to improve treatment compliance. METHODS: All new patients registered under the head and neck disease management group (DMG) over a period of 3 months at a single center were included. Their demographic details, time to treatment decision, and treatment compliance were determined. The findings were presented to head and neck DMG, and changes were implemented to patient workup with an aim to improve compliance. A reaudit was performed over a period of 3 months and results were compared. RESULTS: Two thousand two hundred and forty patients were included in the analysis. Patients with a treatment decision at 1-4 weeks stood at 28.32%, 63.88%, 80.8%, and 89.87%, respectively. Dropout rate was 26%. About 50% of patients planned for surgical intervention could be treated within the institution. After implementation of changes as recommended by DMG, 2418 patients were analyzed and findings were compared to the previous audit. The dropout rate reduced to 17.57%. The number of patients with a treatment decision at 1-4 weeks were 51.26%, 77.42%, 89.46%, and 94.31%, respectively. CONCLUSION: Early treatment decision and referral could significantly improve patient dropout and possibly compliance to treatment. Decentralization of cancer care is urgently needed to manage the high numbers of patients presenting to tertiary care centers. Setting up of new regional cancer centers and increasing infrastructure in the existing centers should be the long-term goals.

Can CRM Status on MRI Predict Survival in Rectal Cancers: Experience from the Indian Subcontinent.

To determine the role of MRI as a predictor of circumferential resection margin (CRM) involvement. To study the impact of CRM status on MRI on recurrence and survival, in correlation with pathology. Analysis of a prospective database was performed over a period of 1 year. All patients with adenocarcinoma of rectum were included in the study. The MRI at presentation for all patients irrespective of stage (MRIT), pre-NACTRT MRI (MRI1) for patients with locally advanced tumours, and post-NACTRT MRI (MRI2) of these patients were analysed separately. The status of CRM on MRI was compared to that on histopathology and as a predictor of recurrence and survival. Two hundred twenty-one patients were included with a median follow-up 30 months. Sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy were 50%, 65.46%, 5.63%, 96.95% and 64.85% for MRIT; 50%, 55.32%, 5.97%, 95.12% and 55.03% for MRI1; and 77.78%, 63.29%, 10.77%, 98.04% and 64.07% for MRI2, respectively. On multivariate analysis, pathological positive margin alone predicted a poor overall survival (OS) whereas involved CRM on pathology and MRIT predicted poorer disease-free survival (DFS) and local recurrence. Pre-treatment and post-treatment MRI scans have a moderate sensitivity, specificity and accuracy and a high negative predictive value to predict CRM status on pathology. Pathological CRM status is the only factor to impact OS, DFS and LR on multivariate analysis. CRM status on MRI at presentation (MRIT) does impact DFS and local recurrence but not OS.

Acellular dermal matrix in implant-based immediate breast reconstructions: a comparison of prepectoral and subpectoral approach.

BACKGROUND: Implant-based immediate breast reconstruction (IBR) is the most common technique for post-mastectomy reconstructions in the United Kingdom (UK). Subpectoral implant placement is the conventional method of reconstruction. Placement of implant in the subcutaneous pocket covered by an acellular dermal matrix (ADM) is a relatively recent approach. We report a comparative analysis of prepectoral versus subpectoral approach for implant-based IBR from a single institution in the UK. METHODS: Retrospective analysis from a prospectively maintained data was conducted from January 2015 to May 2017 including all patients who underwent a mastectomy with immediate implant-based IBR in a single breast unit. The demographic details, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. Factors affecting complication rates and implant loss were analyzed. RESULTS: One hundred and fifty-four reconstructions were included in the analysis with a median follow-up of 11.8 months. Mean age of the cohort was 50 years with a mean BMI of 26.09 kg/m2. Major implant-related complication rate was 12.3% with an implant loss rate of 7.8%. Age more than 50 years (P=0.037) and bilateral reconstructions (P=0.0001) had significant impact on complication rate, on multivariate analysis. Patients with bilateral implants had a significantly higher implant loss rate (P=0.0001). Implant loss rates in the prepectoral group (4.2%) and subpectoral group (10.8%) were not statistically significant (P=0.29). CONCLUSIONS: Prepectoral and subpectoral techniques of IBR have comparable outcomes. Studies reporting on long-term outcomes are planned.

Early multicentre experience of pre-pectoral implant based immediate breast reconstruction using Braxon®.

BACKGROUND: The last two decades have seen significant changes in surgical management of breast cancer. The offer of immediate breast reconstruction (IBR) following mastectomy is currently standard practice. Skin sparing and nipple sparing mastectomy with implant-based IBR have emerged as oncologically safe treatment options. Prepectoral implant placement and complete coverage of implant with acellular dermal matrix (ADM) eliminates the need to detach the muscle from underlying chest wall in contrast to the subpectoral technique. We report short-term outcomes of a multicentre study from the United Kingdom (UK) using Braxon® in women having an IBR. METHODS: A prospective study was conducted from December 2015 to October 2016 and included all patients from three breast units in the UK who underwent a mastectomy and an implant-based IBR using Braxon®. The demographic details, co-morbidities, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. A comparison was made with complications reported in the National Mastectomy and Reconstruction Audit. RESULTS: Seventy-eight IBRs were included in the analysis with a median follow-up of 9.98 months. Mean age of the cohort was 50 years with a mean body mass index of 25.7 kg/m2. Mean implant volume was 365 cc. The inpatient hospital stay was 1.48 days. About 23% of patients had a seroma, 30% had erythema requiring antibiotics and the explant rate was 10.2 percent. Bilateral reconstructions were significantly associated with implant loss and peri-operative complications on univariate analysis. CONCLUSIONS: Our early experience with this novel prepectoral technique using Braxon® has shown it to be an effective technique with complication rates comparable to subpectoral IBR. The advantages of prepectoral implant-based IBR are quicker postoperative recovery and short post-operative hospital stay. Long-term studies are required to assess rippling, post-operative animation, capsular contracture and impact of radiotherapy.

Embryonal rhabdomyosarcoma of the broad ligament.

Broad ligament tumors are uncommon. Sarcomas rarely arise from the broad ligament, leiomyosarcomas being the most common. Rhabdomyosarcomas of the broad ligament are very rare. To the best of our knowledge, no case of an embryonal rhabdomyosarcoma of the broad ligament has been reported in literature.

Metachronous solitary metastasis of papillary thyroid cancer in the cavernous sinus: case report and review of literature.

Papillary carcinoma is a well-differentiated type of thyroid carcinoma with very good overall prognosis. The commonest site of metastases is the lymph node, distant metastases being rare. We present a case of a 52-year-old male who presented with a solitary metastasis in the left para-sellar region and cavernous sinus more than three years after treatment of primary. Given the atypical radiological features and longstanding symptoms, a surgical excision was performed and focal radiotherapy was given after confirmation of the diagnosis. We discuss this case and review the relevant literature.