Is Autologous Fat Grafting an Oncologically Safe Procedure following Breast Conserving Surgery for Breast Cancer? A Comprehensive Review.

BACKGROUND: Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer. METHODS: We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively. RESULTS: We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls. CONCLUSIONS: Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.

The Evolving Role of Radiofrequency Guided Localisation in Breast Surgery: A Systematic Review.

Wire-guided localisation (WGL) has been the gold-standard for localising non-palpable breast lesions before excision. Due to its drawbacks, various wireless alternatives have been developed, including LOCalizer™, which is based on radio-frequency identification (RFID) technology. In this systematic review, we consulted EMBASE, Medline and PubMed databases using appropriate search terms regarding the use of RFID technology in the localisation of occult breast lesions. Retrospective and prospective studies were included if they quoted the number of patients, rate of successful placement, retrieval rate, margin positivity rate and the re-excision rate. In addition, studies comparing RFID to WGL were also included and analysed separately. Seven studies were included in this systematic review spanning 1151 patients and 1344 tags. The pooled deployment rate was 99.1% and retrieval rate was 100%. Re-excision rate was 13.9%. One complication was identified. Two studies compared RFID with WGL (128 vs. 282 patients respectively). For both techniques the re-excision rate was 15.6% (20/128 vs. 44/282 respectively, p value is 0.995). Based on our review, LOCalizer™ is safe and non-inferior to WGL in terms of successful localisation and re-excision rates. However, further research is required to assess the cost effectiveness of this approach and its impact on the aesthetic outcome compared with WGL and other wire free technologies to better inform decision making in service planning and provision.

The Evolving Role of Marked Lymph Node Biopsy (MLNB) and Targeted Axillary Dissection (TAD) after Neoadjuvant Chemotherapy (NACT) for Node-Positive Breast Cancer: Systematic Review and Pooled Analysis.

Targeted axillary dissection (TAD) is a new axillary staging technique that consists of the surgical removal of biopsy-proven positive axillary nodes, which are marked (marked lymph node biopsy (MLNB)) prior to neoadjuvant chemotherapy (NACT) in addition to the sentinel lymph node biopsy (SLNB). In a meta-analysis of more than 3000 patients, we previously reported a false-negative rate (FNR) of 13% using the SLNB alone in this setting. The aim of this systematic review and pooled analysis is to determine the FNR of MLNB alone and TAD (MLNB plus SLNB) compared with the gold standard of complete axillary lymph node dissection (cALND). The PubMed, Cochrane and Google Scholar databases were searched using MeSH-relevant terms and free words. A total of 9 studies of 366 patients that met the inclusion criteria evaluating the FNR of MLNB alone were included in the pooled analysis, yielding a pooled FNR of 6.28% (95% CI: 3.98-9.43). In 13 studies spanning 521 patients, the addition of SLNB to MLNB (TAD) was associated with a FNR of 5.18% (95% CI: 3.41-7.54), which was not significantly different from that of MLNB alone (p = 0.48). Data regarding the oncological safety of this approach were lacking. In a separate analysis of all published studies reporting successful identification and surgical retrieval of the MLN, we calculated a pooled success rate of 90.0% (95% CI: 85.1-95.1). The present pooled analysis demonstrates that the FNR associated with MLNB alone or combined with SLNB is acceptably low and both approaches are highly accurate in staging the axilla in patients with node-positive breast cancer after NACT. The SLNB adds minimal new information and therefore can be safely omitted from TAD. Further research to confirm the oncological safety of this de-escalation approach of axillary surgery is required. MLNB alone and TAD are associated with acceptably low FNRs and represent valid alternatives to cALND in patients with node-positive breast cancer after excellent response to NACT.

Reflector-guided Localization of Non-palpable Breast Lesions: The First Reported European Evaluation of the SAVI SCOUT® System.

BACKGROUND: Wire-guided localization (WGL) has been the mainstay for localizing non-palpable breast lesions before excision. Due to its limitations, various wireless alternatives have been developed. In this prospective study, we evaluate the role of radiation-free wireless localization using the SAVI SCOUT® localization at a European centre. PATIENTS AND METHODS: This technique was evaluated in a prospective cohort of 20 patients. The evaluation focused on clinical and pathological parameters in addition to patient and physician acceptance. RESULTS: SAVI SCOUT reflectors (n=23) were deployed to localize 22 occult breast lesions and one axillary lymph node in 20 patients. The mean deployment duration was 5.6 min, with a mean distance from the lesion of 0.6 mm. The migration rate was 0% and the mean identification and retrieval time was 25.1 min. In patients undergoing therapeutic excision for malignancy (n=17), only one (5.9%) required reoperation for positive surgical margins. Radiologists and surgeons rated the technique as better than WGL and patient satisfaction was high. CONCLUSION: Our study demonstrates that wireless localization using SAVI SCOUT® is an effective and time-efficient alternative to WGL with excellent physician and patient acceptance.

Evolving Role of Magseed in Wireless Localization of Breast Lesions: Systematic Review and Pooled Analysis of 1,559 Procedures.

BACKGROUND/AIM: Wire-guided localisation (WGL) remains the most widely used technique for the localisation of non-palpable breast lesions; however, recent technological advances have resulted in non-wire, non-radioactive alternatives, such as magnetic seeds (Magseeds). The aim of this pooled analysis was to determine whether Magseeds are an effective tool for localising non-palpable breast lesions. MATERIALS AND METHODS: Various databases were searched for publications which reported data on the localisation and placement rates of Magseed. Data on re-excision rates under use of Magseed and WGL were also collected. RESULTS: Sixteen studies, spanning the insertion of 1,559 Magseeds, were analysed. The pooled analysis showed a successful placement rate of 94.42% and a successful localisation rate of 99.86%. Four studies were analysed in a separate pooled analysis and showed no statistically significant difference between re-excision rates using Magseeds and WGL. CONCLUSION: The use of Magseeds is an effective, non-inferior alternative to WGL that overcomes many of the limitations of the latter.

Stratification Using hTERT and Stem Cell Markers Confers a Good Prognosis in Invasive Breast Cancer.

BACKGROUND/AIM: In this study, we aimed to investigate the prognostic role of a previously identified panel of 10 stem cell markers stratified against the catalytic subunit of telomerase (hTERT) in human breast cancer. MATERIALS AND METHODS: The mRNA copy numbers of these genes were determined using real time quantitative PCR in 124 breast cancer tissues and adjacent non-cancerous tissues. Relations between mRNA levels and survival were analysed using Kaplan-Meier plots and Cox regression analysis. RESULTS: Five genes (BMI1, NES, POU5F1, ALDH1A2 and CDKN1A) correlated with survival when stratified with hTERT and predicted overall (Wilcoxon: p=0.004; Cox: p=0.006) and disease-free (Wilcoxon: p<0.000; Cox: p=0.000) survival. CONCLUSION: This panel of genes stratified by hTERT could open new avenues for the development of new prognostic tools, as well as for the identification of new research directions regarding breast oncogenesis.

Locoregional therapy of the primary tumour in de novo stage IV breast cancer in 216 066 patients: A meta-analysis.

Patients presenting with de novo stage IV metastatic breast cancer have a complex disease which is normally treated with palliative intent and systemic therapy. However, there is mounting evidence that resection of the primary tumour and/or localised radiotherapy (locoregional therapy; LRT) could be associated with overall survival improvements. We aimed to conduct a meta-analysis to inform decision making. Using the PubMed, Cochrane and Ovid SP databases, a literature review and meta-analysis were conducted to assess the effect of LRT on overall survival. Studies were analysed for the impact of LRT on survival. All forms of LRT resulted in a significant 31.8% reduction in mortality (N = 42; HR = 0.6823 (95% CI 0.6365; 0.7314)). Surgical resection resulted in a significant 36.2% reduction in mortality (N = 37; HR = 0.6379 (95% CI 0.5974; 0.6811)). The prospective trials reported a 19.23% reduction in mortality which was not statistically significant (N = 3, HR = 0.8077 (95% CI 0.5704; 1.1438). 216 066 patients were included. This is the largest meta-analysis regarding this question to date. Our meta-analysis shows that LRT of the primary tumour seems to improve overall survival in de novo stage IV disease. Therefore, this therapeutic option should be considered in selected patients after a careful multidisciplinary discussion.

Is oncoplastic breast conserving surgery oncologically safe? A meta-analysis of 18,103 patients.

BACKGROUND: Oncoplastic Breast Conserving Surgery (OBCS) allows adequate resection margins of tumours unsuitable for standard breast conserving surgery (SBCS) whilst allowing for better cosmesis and reduced morbidity when compared to mastectomy. However, there is limited evidence on its oncological safety. METHODS: This study aims to compare oncological safety of OBCS with SBCS and mastectomy by examining the relative risk of cancer recurrence and re-operation rates through meta-analysis. RESULTS: 18 studies met the search criteria including 18,103 patients. The primary outcome measure (recurrence) was not significantly different between OBCS and SBCS or mastectomy (RR 0.861; 95% CI 0.640-1.160; p = 0.296). The secondary outcome measure (re-operation) initially achieved significance in favour of OBCS (RR 0.64; 95% CI 0.46-0.89; p = 0.01). However, after adjustment for publication bias this was attenuated to insignificance between the two study groups (RR 0.86; 95% CI 0.56-1.31; p = 0.44). CONCLUSIONS: For both cancer recurrence and re-operation rate, there was no significant difference between OBCS and traditional techniques. OBCS is of comparable oncological safety to more established surgical procedures and a useful option in suitable patients.

The Use of Magnetic Seeds and Radiofrequency Identifier Tags in Breast Surgery for Non-palpable Lesions.

BACKGROUND: Wire-guided localisation (WGL) remains the most widely used technique to guide surgical excision of non-palpable breast lesions worldwide. However, recent technological advances have led to the advent of less invasive radiation-free localisation methods to overcome the limitations of WGL. PATIENTS AND METHODS: This study prospectively evaluated the role of two radiation-free non-wire localisation methods. Magnetic seeds (n=16) and radiofrequency tags (n=6) were deployed under imaging guidance to guide the surgical excision in 19 consecutive patients. RESULTS: The identification/retrieval and migration rates were 100% and 4.5%, respectively. Twenty-one out of 22 (95.5%) cases had clear surgical margins and no complications were observed. All radiologists and the surgeon rated these methods as being much better than wire localisation. Patient satisfaction data were recorded using a linear visual analogue scale (n=10/19). The mean score was 9.7/10 (range=8-10). CONCLUSION: Our study provides further evidence that radiation-free wireless breast localisation is an effective alternative to WGL.

Wireless Breast Localization Using Radio-frequency Identification Tags: The First Reported European Experience in Breast Cancer.

BACKGROUND/AIM: Wire-guided localisation (WGL) has been the mainstay for localisation of clinically occult breast lesions before excision. However, it has restrictive scheduling requirements, and causes patient discomfort. This has prompted the development of various wireless alternatives. In this prospective study we shall evaluate the role of radiation-free wireless localisation using a radiofrequency identification (RFID) tag and a hand-held reader (LOCalizer™) in the management of occult breast lesions. PATIENTS AND METHODS: This technique was evaluated in a prospective cohort of 10 patients. The evaluation focused on: i) successful deployment, ii) identification and retrieval, iii) the status of surgical margins and need for re-operation, iv) resected specimen weight, v) marker migration rates (>5mm), and vi) acceptance by patients, radiologists and surgeons. RESULTS: RFID tags (n=11) were deployed under ultrasound guidance pre-operatively to localise occult breast lesions in 10 patients. The mean time for deployment of the RFID tag was 5.4 min (range=2-20). The mean distance from the lesion was 0.45 mm (range=0-3). The mean duration for retrieval was 10.2 min (range=6-20). Mean specimen weight was 19.6 g for malignant lesions (range=4.5-42). All tags were identified, and none had migrated. There were no positive margins, re-operations, nor complications. Patient feedback was highly positive. Both radiologists and surgeons rated the LOCalizer™ technique as better than WGL. CONCLUSION: Our study demonstrates that wireless localisation using RFID is an effective and time-efficient alternative to WGL, with low margin positivity and re-operation rates, and high patient, radiologist and surgeon acceptance.

Does Transdermal Testosterone Increase the Risk of Developing Breast Cancer? A Systematic Review.

BACKGROUND/AIM: Hypoactive sexual desire disorder (HSDD) is hypothesised to manifest in postmenopausal women at onset of menopause due to decreased oestrogen levels. Transdermal testosterone is a potential treatment option. This systematic review explores the relationship between the incidence of breast cancer and transdermal testosterone use. MATERIALS AND METHODS: Searches were conducted on the PubMed and Ovid databases. In Ovid, the advanced search function was used: 'transdermal testosterone not male'. In PubMed, the following search terms were used: 'transdermal, testosterone, menopausal, women, breast cancer, women'. Abstracts that fitted our initial criteria were further investigated. RESULTS: A total of 25 publications from PubMed and 192 publications from Ovid were initially assessed. Three randomised control trials were judged to have sufficiently met our inclusion criteria. However, these trials were too heterogeneous for a meta-analysis. A systematic review was deemed the most appropriate analysis of the data available. CONCLUSION: The publications examined in this systematic review suggest that the use of transdermal testosterone to treat HSDD in postmenopausal women does not increase breast cancer incidence. However, further research in the form of adequately powered randomised controlled trials with breast cancer incidence being the primary end point is required in order to confirm this.

Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland.

INTRODUCTION: There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS: A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS: A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION: There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.

Systematic review of laparoscopic adjustable gastric banding in patients with body mass index ≤35 kg/m².

BACKGROUND: Recently, the Food and Drug Administration (FDA) panel approved laparoscopic adjustable gastric banding (LAGB) in patients with a body mass index (BMI) ≥30 kg/m(2) and related co-morbidities. To our knowledge there is no systematic review assessing LAGB in this group. The objective of this study was to analyze the use of LAGB in patients with BMI ≤35 kg/m(2). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to systematically search MEDLINE and Embase using the medical subject headings (MeSH) terms "bariatric surgery" and "obese" with equivalent free text searches and cross-references. Studies that described LAGB in patients with BMI ≤35 kg/m(2) were reviewed with particular focus on weight loss after LAGB as well as morbidity/mortality, co-morbidity resolution. RESULTS: Six studies evaluating 515 patients were included. Mean percentage excess weight loss (%EWL) ranged from 52.5 (±13.2) to 78.6 (±9.4) at 1 year and 57.6 (±29.3) to 87.2 (±9.5) at 2 years postoperatively. Two studies reported weight loss at 3 years with mean %EWL of 53.8 (±32.8) to 64.7 (±12.2). The only study with follow-up data after 3 years reported a mean %EWL of 68.8 (±15.3) and 71.9 (±10.7) at 4 and 5 years, respectively. Thirty-four patients (6.6%) developed complications. There was 1 reported mortality (.19%), which occurred at 20 months postoperatively. CONCLUSION: This systematic review shows that LAGB is well tolerated and effective in patients with a BMI ≤35 kg/m(2). There are encouraging suggestions that co-morbidities show partial or total resolution; however, a paucity of data remains in this BMI group, particularly with regard to long-term outcomes.

Consenting practice for laparoscopic cholecystectomy - are we doing enough to warn patients about their operation?

INTRODUCTION: Provision of informed consent prior to surgery is fundamental in allowing patients to make balanced choices about their care. This study compares consenting practice amongst different grade of surgeons for Laparoscopic Cholecystectomy (LC) with specific reference to the documentation of the complications of surgery. Timing and delivery of source of information is also evaluated. METHODS: Retrospective review of medical notes of all patients undergoing LC at London district general hospital between September 2006 to April 2009. RESULTS: Records were successfully retrieved for 163 patients. The five most commonly mentioned complications were bleeding (99%), infection (95%), conversion to open (93%), bile duct injury (82%) and visceral injury (65%). There were 27 documented complications in 23 patients and in 9 of these patients (39%) the specific complication was not discussed during the written consent process. Consultant surgeons tended to focus on important operation-specific risks such as bile duct injury whereas junior surgeons tend to focus on a broad range of general complications. CONCLUSION: Consenting practice for LC remains variable and is resulting in failure to warn patients of significant complications. This can lead to potential medico-legal implications. Having a structured consent form detailing all significant and common risk is one way of improving the consent process.