Assessment of Patient-Reported Outcomes for Closed-Incision Negative Pressure Therapy with Wide-Coverage Dressings in Simple Mastectomy and Immediate Implant-Based Breast Reconstruction.

Objective: A new configuration of closed-incision negative pressure therapy (ciNPT) dressings now covers the incision and a broader area of peri-incisional tissues. We have implemented these ciNPT dressings following simple mastectomy (SM) or skin-sparing mastectomy with implant-based reconstruction (IBR). This study assesses patient-reported outcomes of this new protocol. Approach: Patients underwent SM or IBR for breast cancer. ciNPT with wide-coverage dressings were placed over the entire breast, and -125 mmHg was applied for 14 days. Upon dressing removal, patients rated their experience using the Wound-Q™ Suction Device Scale and recorded their satisfaction on a Likert scale ranging 1-5. Results: Thirteen SM patients and 12 IBR patients were included in the study. The median age was 62 years, and SM patients were significantly older (p < 0.01). Patients rated the ciNPT device highest on items relating to its function and appearance, and lowest on noise and interference with sleep and physical activity. The overall mean score for the combined cohort was 64.8/100. The mean score for SM patients (74.8 ± 19.9) was significantly greater than for IBR patients (53.9 ± 9.6, p < 0.01). The mean overall patient satisfaction rating was 3.92 on a 5-point scale; 4.0 in the SM group and 3.8 in the IBR group. Innovation: This study is the first to report on the patient experience with these newly available wide-coverage ciNPT dressings. Conclusion: Overall, the dressing was well-tolerated by patients, and satisfaction was high. The positive reception of ciNPT with wide-coverage dressings supports continued use at our hospital.

Comparing long-term local recurrence rates of surgical and non-surgical management of close anterior margins in breast conserving surgery.

PURPOSE: While it is known that histologically involved margins lead to a higher local recurrence rate, re-excision of anterior margins is less common than that of radial margins. However, there are minimal long-term data on the oncological safety of non-surgical management of anterior margins. PATIENTS AND METHODS: A retrospective study was performed of all patients who underwent breast conserving surgery for breast cancer between 2000 and 2008 at two tertiary referral centres. A close margin was defined as disease within two mm of the resection margin (including disease at the margin). RESULTS: 6922 patients underwent surgery for invasive or in situ breast cancer of whom 277 patients had a close anterior margin alone after breast conserving surgery. Two hundred and twenty patients had non-surgical management of their margins, while 57 had re-excision surgery. Overall, there were 4/57 local recurrences in the surgical management group and 12/220 in the non-surgical management group. The local recurrence-free survival rate at 5 years was 98.2% (1 recurrence, 95% CI 87.8-99.7) in the surgical management group and 97.2% (6 recurrences, 95% CI 93.8-98.7) in the non-surgical management group. At 10 years, the rates were 92.2% (4 recurrences, 95% CI 80.3-97.0) in the surgical management group and 93.9% (12 recurrences, 95% CI 89.4-96.5) in the non-surgical management group. There was no significant difference found in the local recurrence rate between management groups (HR 1.24, 95% CI 0.40, 3.85; p = 0.71). CONCLUSIONS: Local recurrence rates are acceptable and similar in both the surgically and non-surgically managed groups. Non-surgical management of close anterior margins appears oncologically safe when combined with appropriate adjuvant therapy.

Radioactive seed localization compared with wire-guided localization of non-palpable breast carcinoma in breast conservation surgery- the first experience in the United Kingdom.

OBJECTIVE: In the UK, guidewires have traditionally been used for localization of non-palpable breast lesions in patients undergoing breast conservation surgery (BCS). Radioactive seed localization (RSL) using Iodine-125 seeds is an alternative localization method and involves inserting a titanium capsule, containing radioactive Iodine-125, into the breast lesion. We aim to demonstrate feasibility of RSL compared with guidewire-localization (GWL) for BCS in the UK. METHODS: Data were collected on 100 patients with non-palpable unifocal invasive carcinoma of the breast undergoing GWL WLE prior to the introduction of RSL and the first 100 patients treated with RSL WLE. Statistical comparisons were made using Χ2-squared analysis or unpaired two-sample t-test. Significance was determined to be at p ≤ 0.05. RESULTS: Mean total tumour size was 19.44 mm (range: 5-55) in the GWL group and 18.61 mm (range: 3.8-59) in the RSL group (p = 0.548), while mean total specimen excision weight was significantly lower in the RSL group; 31.55 g (range: 4.5-112) vs 37.42 g (range: 7.8-157.1) (p = 0.018). Although 15 patients had inadequate surgical resection margins in the GWL group compared the 13 in the RSL group (15 vs 13%, respectively, p = 0.684), 10 of the patients in the GWL group had invasive carcinoma present resulting in at least one positive margin compared with only 3 patients in the RSL group (10 vs 3%, respectively, p = 0.045). CONCLUSION: In this study, RSL is shown to be non-inferior to the use of GWL for non-palpable carcinoma in patients undergoing BCS and we suggest that it could be introduced successfully in other breast units. Advances in knowledge: Here we have demonstrated the use of RSL localization results in significant lower weight resection specimens of breast carcinoma when compared with a matched group using GWL, without any significant differences in oncological outcome between the groups.

Vacuum-assisted biopsy is a viable alternative to surgical biopsy in the investigation of breast lesions of uncertain malignant potential.

AIMS: In patients presenting with a breast lesion, when initial core biopsy histology falls into the category of "uncertain malignant potential" (i.e. a B3 lesion), the next line of investigation has traditionally been a surgical biopsy (SBx). Vacuum-assisted biopsy (VAB) may be a viable minimally invasive alternative to SBx for B3 lesions. The primary aims of this study were to establish whether VAB reduces the need for surgical biopsy and determine VAB sensitivity for carcinoma following initial B3 histology. MATERIALS AND METHODS: B3 lesion data was collected from 2004 to 2013 retrospectively, from a single institution that utilises both VAB and SBx. RESULTS: A total of 413 lesions were categorised B3 on initial biopsy. Mean age was 61 years (range: 24-91 years). Mean follow up was 52 months (range: 19-60 months). 156 patients (38%) underwent VAB. Only 20% of patients underwent VAB in 2004, with an increase to 95% by 2013. VAB histology revealed twelve carcinomas, all of which progressed to surgical excision. In six cases, a SBx was required following VAB in order to provide further diagnostic information. In one case, carcinoma was missed on VAB. CONCLUSION: The increase in VAB use over time suggests that the procedure is well tolerated. The results demonstrate a VAB sensitivity of 92% for carcinoma diagnosis. In 96% of cases (150 of 156), VAB results were conclusive enough to avoid a subsequent SBx. This data suggests that VAB may be a preferable alternative to surgical biopsy for many B3 lesions.

Porcine acellular dermis-based breast reconstruction: complications and outcomes following adjuvant radiotherapy.

BACKGROUND: Acellular dermal matrices (ADM) such as StratticeTM are increasingly used in UK during implant-based reconstruction. However, there are mixed opinions regarding the compatibility of radiotherapy treatment in pre- and post-reconstructed breasts. The aims of this study are to audit the rates of radiation induced complications in patients who underwent breast reconstruction using StratticeTM and establish whether there is an association between timing of radiotherapy and complication rates. METHODS: Retrospective data collection was performed for all patients who underwent skin-sparing mastectomy and immediate or delayed StratticeTM-based reconstruction, and received pre- or post-reconstruction radiotherapy from July 2010 to November 2014. RESULTS: The age ranged from 33 to 78 years (mean age 51 ± 10.6) with a mean follow-up time of 21 months. There were 25 StratticeTM-based reconstructions performed. Sixteen had delayed reconstruction, and 9 had skin-sparing mastectomy and immediate reconstruction. There were 4 (16 %) abandoned procedures due to inability to stretch the mastectomy flap secondary to poor skin compliance. Two women (8 %) presented 4 and 9 months later with wound breakdown. One case (4 %) developed severe capsular contracture following radiotherapy post-reconstruction and 1 case (4 %) of implant rupture. There were no episodes of extrusion or implant infection. Overall complication rates were 32 %. The majority (75 %) of complications occurred in breasts reconstructed post-radiotherapy; however, this is not significant when analysed using chi-square (p = 0.43). CONCLUSIONS: Our evidence suggests that there is no difference in complication rates in pre- and post-radiation individuals; this would suggest that implant-based reconstruction using StratticeTM should not be an absolute contraindication in pre- or post-radiotherapy patients. However, when planning these procedures, it is paramount that the increased risks are emphasised to patients in order to better manage patient expectation in cases where complications arise. Level of Evidence: Level III, risk / prognostic study.

Rectal metastasis from Breast cancer: A rare entity.

INTRODUCTION: Breast cancer metastases occurs in around 50% of all presentation. It is the second most common type of cancer to metastasise to the GI tract but this only occurs in less than 1% of cases. PRESENTATION OF CASE: We report a case that underwent treatment for invasive lobular cancer (ILC) of the breast and 5 years later was found to have rectal and peritoneal metastasis. She is currently receiving palliative management including chemotherapy in the form of weekly Paclitaxel (Taxol(®)) and stenting to relieve obstruction. CONCLUSION: There should be high clinical suspicion of bowel metastasis in patients presenting with positive faecal occult blood with or without bowel symptoms even if the incidence is less <1% of metastases, particularly in cases where the initial breast tumour was large, with positive axillary nodes.

Pleomorphic lobular carcinoma in situ of the breast: Can the evidence guide practice?

The clinical significance of pleomorphic lobular carcinoma in situ (PLCIS) is a subject of controversy. As a consequence, there is a risk of providing inconsistent management to patients presenting with PLCIS. This review aims to establish whether the current guidelines for the management of PLCIS are consistent with current evidence. A systematic electronic search was performed to identify all English language articles regarding PLCIS management. The data was analysed, specifically looking at: incidence of concurrent disease, recurrence rates, long-term prognosis and PLCIS management. A search was also performed for PLCIS management guidelines for the United Kingdom, United States, Canada, Australia, Germany and pan-European. The results of the evidence analyses were compared to the guidelines in order to establish whether the recommended management is consistent with the published evidence. Nine studies (level 3-4 evidence), involving a total of 176 patients and five management guidelines (from United Kingdom, United States, Australia and pan-European) were included in the review. From the evidence, 46 of 93 (49%) patients were found to have PLCIS with concurrent invasive disease on excision specimen analysis. Regarding recurrence rates, 11 of 117 (9.4%) patients developed a recurrence of PLCIS. There were no instances of invasive disease or ductal carcinoma in situ (DCIS) on recurrence histology. There were no studies assessing long-term outcomes in PLCIS cases. With regards to the management guidelines, the Association of Breast Surgery (United Kingdom) and the National Breast and Ovarian Cancer Care (Australia) do not mention PLCIS. The National Comprehensive Cancer Network (United States) suggest considering excision of PLCIS with negative margins. The NHS Breast Screening Programme (United Kingdom) and the European Society of Medical Oncology (pan-European) recommend PLCIS should be treated as with DCIS. We conclude that high quality evidence to inform guidance is lacking, thus recommendations are relatively vague. However, based on the available evidence, it would seem prudent to treat PLCIS in a similar manner to DCIS.

Temporal artery biopsy: are we doing it right?

PURPOSE: Temporal artery biopsy (TAB) is the gold standard for diagnosing temporal arteritis; however, sensitivity is relatively poor (30-40 per cent). The British Society of Rheumatology (BSR) guidelines state two major factors that can improve sensitivity: TAB specimen size > 10mm; and pre-biopsy steroid treatment < 7 days. Owing to the low sensitivity, TA treatment is often commenced/continued despite negative histology. The purpose of this paper is to establish the extent to which TAB results influence clinical management and determine specimen adequacy regarding BSR guidelines. DESIGN/METHODOLOGY/APPROACH: In total, 55 patients underwent TAB between 2009-2011. Patients' medical notes were analysed, specifically looking at biopsy specimen size, histology results and steroid therapy duration, pre- and post-biopsy. FINDINGS: From 55 TABs, three (6 per cent) were positive, 47 (85 per cent) were negative and five (9 per cent) were "inadequate". Of those patients with negative results, 18 (46 per cent) received > six months steroid treatment. From 50 "adequate" specimens, 31 (62 per cent) were < 10mm and 11 (28 per cent) received > seven days steroid treatment pre-biopsy. PRACTICAL IMPLICATIONS: Despite negative results, many patients went on to receive long-term steroids. Action must be taken to reduce false and true negative biopsies. False negatives may-be reduced by improving adherence to BSR guidance (increased specimen size and early biopsy after commencing steroids). To reduce total true-negative biopsies, the authors suggest implementing the American College of Rheumatology scoring system, designed to objectify the decision to perform TAB. ORIGINALITY/VALUE: This article addresses a common problem seen in most UK hospitals. There is little literature discussing a plausible solution to reducing negative biopsies.

Visual analogue self-assessment of acute mountain sickness in adolescents: experience from two Himalayan expeditions.

OBJECTIVE: Recent studies have investigated visual analogue scales (VAS) as an alternative to the Lake Louise AMS Self-Report Score (LLS) for the self-assessment of acute mountain sickness (AMS). We investigated their use in adolescents. METHODS: The study was conducted during the 2009 and 2010 British Schools Exploring Society 35-day expeditions to Ladakh. Comparable ascent profiles were followed, reaching a maximum altitude of 6000 m. LLS and VAS AMS scores were recorded each morning. VAS comprised 100 mm lines for each LLS symptom; VAS scores were summed to give a composite daily total (VAS(c), expressed as a percentage). In 2010, an additional line was used to score overall "altitude sickness' (VAS(o)). RESULTS: 42 individuals participated in 2009 (83% compliance; mean age 17.4 years); 28 in 2010 (82% compliance; 17.5 years). 759 data points were recorded in 2009; 529 in 2010. There was a significant correlation between LLS and VAS(c) on both expeditions (rho=0.80, p<0.001 in 2009; rho=0.65, p<0.001 in 2010). These significant correlations remained when cases of AMS were analyzed separately. However, in all cases, the relationship between LLS and VAS was distorted, with a tendency for VAS to underscore symptoms of AMS when LLS<5. A VAS(c) value of 5.5% had an 82% specificity and sensitivity for all cases of AMS; VAS(c) of 9.5% had a 90% specificity and sensitivity for moderate and severe AMS. CONCLUSIONS: Whilst adolescents are capable of self-monitoring for AMS using VAS, the relationship with LLS is distorted. The LLS, despite its limitations, therefore remains the preferred method for the self-assessment of AMS in adolescents.