Current Role and Future Prospects of Positron Emission Tomography (PET)/Computed Tomography (CT) in the Management of Breast Cancer.

Breast cancer has become the most diagnosed cancer in women globally, with 2.3 million new diagnoses each year. Accurate early staging is essential for improving survival rates with metastatic spread from loco regional to distant metastasis, decreasing mortality rates by 50%. Current guidelines do not advice the routine use of positron emission tomography (PET)-computed tomography (CT) in the staging of early breast cancer in the absence of symptoms. However, there is a growing body of evidence to suggest that the use of PET-CT in this early stage can benefit the patient by improving staging and as a result treatment and outcomes, as well as psychological burden, without increasing costs to the health service. Ongoing research in PET radiomics and artificial intelligence is showing promising future prospects in its use in diagnosis, staging, prognostication, and assessment of responses to the treatment of breast cancer. Furthermore, ongoing research to address current limitations of PET-CT by improving techniques and tracers is encouraging. In this narrative review, we aim to evaluate the current evidence of the usefulness of PET-CT in the management of breast cancer in different settings along with its future prospects, including the use of artificial intelligence (AI), radiomics, and novel tracers.

Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery.

Background: Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery. Methods: This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice. Results: Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit. Conclusions: Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

Assessing variability in breast cancer management across the world: results of a questionnaire survey amongst global international experts in breast cancer management.

Background: Breast cancer is the most common cancer in women worldwide with an estimated 2.3 million breast cancer cases diagnosed annually. The outcome of breast cancer management varies widely across the globe which could be due to a multitude of factors. Hence, a blanket approach in standardisation of care across the world is neither practical nor feasible. Aim: To assess the extent and type of variability in breast cancer management across the globe and to do a gap analysis of patient care pathway. Method: An online questionnaire survey and virtual consensus meeting was carried out amongst 31 experts from 25 countries in the field of breast cancer surgical management. The questionnaire was designed to understand the variability in diagnosis and treatment of breast cancer, and potential factors contributing to this heterogeneity. Result: The questionnaire survey shows a wide variation in breast surgical training, diagnosis and treatment pathways for breast cancer patients. There are several factors such as socioeconomic status, patient culture and preferences, lack of national screening programmes and training, and paucity of resources, which are barriers to the consistent delivery of high-quality care in different parts of the world. Conclusion: On-line survey platforms distributed to global experts in breast cancer care can assess gaps in the diagnosis and treatment of breast cancer patients. This survey confirms the need for an in-depth gap analysis of patient care pathways and treatments to enable the development of personalised plans and policies to standardise high quality care.

A Multicentric Prospective Cohort Study of Modified Lateral Intercostal Artery Perforator Flap in Partial Breast Reconstruction.

BACKGROUND: Oncoplastic breast surgery is well established in many parts of the world and is gaining popularity in the rest of the world. The cornerstone in oncoplastic breast surgery is to respect oncological principles during cancer resection maintaining good aesthetic and cosmetic outcome. With the advancement in local, regional, and systemic treatment for breast cancer, survival has improved, and patients live longer. It is utmost essential to help our patients to maintain a good quality of life. Aesthetic and cosmetic outcomes have a significant impact on patient's psychosocial, emotional, and sexual well-being.Oncoplastic techniques have evolved over the last decade with the increasing use of perforator flaps to enable partial breast reconstruction. We report the findings of a prospective cohort study using modified lateral intercostal artery perforator in partial breast reconstruction. This modified technique offers a less visible scar and good access to the axilla without any need for repositioning the patient during the operative procedure. METHODS: A retrospective review of a prospectively maintained database of patients who underwent partial breast reconstruction with a modified lateral intercostal artery perforator flap was carried out between July 2016 and January 2020 in 2 oncoplastic breast units. The study had local approval from the respective audit departments. Patient demographics, operative data, surgical complications, and outcomes were collected and analyzed. RESULTS: Forty-one patients underwent the procedure between July 2016 and January 2020. The median age of the population data was 58 years (interquartile range, 9 years). There were 10 active smokers (24.4%), and 3 patients had diabetes mellitus (7.3%). Overall, 3 patients (7.1%) developed seroma, 1 had a hematoma (2.4%), and 1 had a locoregional recurrence (2.4%). Two patients (4.9%) underwent margin re-excision for close margins. Most patients (92%) had the procedure carried out as day-case surgery. None of the patients developed wound infection, necrosis, or flap loss. The results were comparable across the 2 participating units. CONCLUSIONS: The data suggest that modified intercostal artery perforator flap is an excellent oncoplastic technique for volume replacement in partial breast reconstruction with a short learning curve and minimal perioperative morbidity.

Evaluation of discrepancies in weights of fresh and fixed specimens in breast surgery: a retrospective cohort study.

BACKGROUND: Handling of breast specimen is not well monitored and there is limited data on the impact of fixative solutions on specimen weights. Weight of resected breast tissue acts as a guide for future reconstructive and symmetrisation procedures. The aim is to quantitatively evaluate the discrepancies in weight of fresh breast specimen and the weight of specimen after being kept in a fixative solution for a variable length of time. METHODS: Single centre retrospective cohort study including patients undergone breast surgery for both diagnostic and therapeutic purposes between January of 2013 and June 2015. Demographic details were collected from case notes, pathology reports and operation room management information system (ORMIS). RESULTS: A total of 229 patients with a median age of 63 [interquartile range (IQR) 51-73] years were included. The median body mass index (BMI) was 27.9 (IQR 24.3-31.75) kg/m2. Median weight of the fresh specimens was 104 (IQR 44-535) g and that of fixed specimen was 99 (IQR 43-525) g (P value <0.05, Wilcoxon test). The variation was not unidirectional and factors which were important in influencing this variation were: inclusion of overlying skin and larger specimens (P value <0.05, Mann-Whitney U test). Age, BMI, duration of preservation in fixative solution and density of breast did not have significant influence. CONCLUSIONS: Fixative solution does have significant influence on breast specimen weights. This is more pronounced with heavier specimens and those including overlying skin. It is advisable to measure the weight and volume of fresh breast specimen to aid future surgery with best aesthetic outcome.

Accuracy of the Surgeons' Clinical Prediction of Postoperative Major Complications Using a Visual Analog Scale.

BACKGROUND: Although the risk factors that contribute to postoperative complications are well recognized, prediction in the context of a particular patient is more difficult. We were interested in using a visual analog scale (VAS) to capture surgeons' prediction of the risk of a major complication and to examine whether this could be improved. METHODS: The study was performed in 3 stages. In phase I, the surgeon assessed the risk of a major complication on a 100-mm VAS immediately before and after surgery. A quality control questionnaire was designed to check if the VAS was being scored as a linear scale. In phase II, a VAS with 6 subscales for different areas of clinical risk was introduced. In phase III, predictions were completed following the presentation of detailed feedback on the accuracy of prediction of complications. RESULTS: In total, 1295 predictions were made by 58 surgeons in 859 patients. Eight surgeons did not use a linear scale (6 logarithmic, 2 used 4 categories of risk). Surgeons made a meaningful prediction of major complications (preoperative median score 40 mm for complications v. 22 mm for no complication, P < 0.001; postoperative 46 mm v. 21 mm, P < 0.001). In phase I, the discrimination of prediction for preoperative (0.778), postoperative (0.810), and POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) morbidity (0.750) prediction was similar. Although there was no improvement in prediction with a multidimensional VAS, there was a significant improvement in the discrimination of prediction after feedback (preoperative, 0.895; postoperative, 0.918). CONCLUSION: Awareness of different ways a VAS is scored is important when designing and interpreting studies. Clinical assessment of major complications by the surgeon was initially comparable to the prediction of the POSSUM morbidity score and improved significantly following the presentation of clinically relevant feedback.

Tuberculous cold abscess of breast: an unusual presentation in a male patient.

Tuberculosis (TB) of breast is a rare condition especially presentation as a cold abscess. We present a case of male patient with TB of lung and meninges with a cold abscess in the breast. The abscess was incidental finding on the computed tomography (CT) scan. This was further managed by a combination of anti-tuberculous chemotherapy treatment and surgical drainage. We reviewed the current literature related to mammary TB, its presentations and treatment.

Feasibility of autologous fat transfer for replacement of implant volume in complicated implant-assisted latissimus dorsi flap breast reconstruction.

Lipomodeling is gaining popularity and has been widely used in various settings of reconstructive breast surgery. Implant-assisted latissimus dorsi (LD) flap reconstruction of breast is a popular method among the reconstructive surgeons. When this type of reconstruction is met with complications such as infection and capsular contracture, it necessitates removal of implants and patients are left with very limited options of reconstructions. We aim to assess the feasibility of lipomodeling in this setting.Retrospective analysis of prospectively maintained database of 10 patients who underwent lipomodeling to correct the volume deficit after implant removal in patients with implant-assisted LD flaps was carried out. A custom-made questionnaire using a 4-point Likert scale and a visual analog scale was used to assess the patient-reported outcomes. Patients were discharged from care after completion of treatment and were followed up by questionnaire. First questionnaire was sent to assess satisfaction at medium term and the second questionnaire was to assess satisfaction in the longer term.Mean number of sessions were 3 (range, 2-4) and mean duration of treatment was 14 months. Mean duration of initial follow-up was 15 months (range, 3-25 months) and that of longer follow-up was 40 months (range, 19-60 months). Variable amount of fat was harvested and transferred during different sessions. Patients were happy to undergo multiple sessions of fat transfer. No major complications were observed in our series and overall satisfaction was high with a mean score of 9.3 (range, 8-10) in the longer term. Persistence of higher satisfaction during a longer period is reassuring as one of the concerns regarding fat transfer is the unpredictable resorption rate.Lipomodeling is a useful feasible option to replace implant volume in patients with complicated implant-assisted LD reconstruction. Multiple sessions of lipomodeling seem to be acceptable to patients. This technique was associated with negligible complications and high patient satisfaction was maintained during longer periods of follow-up.

Feasibility of use of a barbed suture (v-loc 180) for quilting the donor site in latissimus dorsi myocutaneous flap breast reconstruction.

BACKGROUND: Latissimus dorsi (LD) myocutaneous flap is a popular method of breast reconstruction which can be associated with high incidence of seroma formation. Quilting sutures at the harvest site are used to reduce this. Barbed sutures are self anchoring sutures which avoid multiple knotting and can be useful in quilting. METHODS: A retrospective analysis of prospectively maintained database of patients who underwent LD flap breast reconstruction between January 2009 and January 2011 was carried out. Seroma formation at the harvest site, wound related complications, inpatient stay and duration of surgery were analysed and a comparison was made between two groups where quilting was done with barbed (V-Loc) suture and conventional polydioxanone (PDS) II sutures. RESULTS: Fifty-seven patients were included of which 33 had quilting by V-Loc sutures and in 24 patients PDS II suture was used. Median age in the PDS group was 55 years (interquartile range [IQR)], 45 to 61 years) which was comparable to the V-Loc group (53 years [IQR, 48 to 59 years]; P-value 0.948). Sixteen patients (28%) had significant seroma formation and 5 (9%) patients developed superficial wound dehiscence. Incidences of seroma or wound complications were comparable (P-value 0.378 and 1.00, respectively). Secondary outcomes such as total duration of surgery, total inpatient stay, total amount of drain at the donor site were also similar in two groups. CONCLUSIONS: Use of barbed sutures for quilting the donor site in LD flap reconstruction is a feasible option and the associated seroma formation and wound complications are comparable with conventional sutures.

The assessment of a rapid noninvasive immunochromatographic assay test for fecal lactoferrin in patients with suspected inflammation of the ileal pouch.

PURPOSE: Pouchitis is a common complication after ileal pouch-anal anastomosis. Diagnosis is based on the Pouch Disease Activity Index, which comprises clinical symptoms, endoscopic appearance, and histologic confirmation. A Pouch Disease Activity Index > or = 7 confirms pouchitis. Fecal lactoferrin is a marker of intestinal inflammation, which can aid in the diagnosis of pouchitis. The IBD EZ VUE test is a simple, rapid, noninvasive test for fecal lactoferrin. Our goal was to study the sensitivity and specificity of this test in the diagnosis of pouchitis. METHODS: Consecutive patients with pouch dysfunction were recruited from October 2005 to July 2006. A fecal sample was collected before calculation of the Pouch Disease Activity Index. An IBD EZ VUE test was performed on each fecal sample and the results correlated with the diagnosis of pouchitis to calculate sensitivity and specificity of the IBD EZ VUE test. RESULTS: There were 32 patients (21 healthy and 11 inflamed pouches). The IBD EZ VUE test was positive in 14 patients. It had a sensitivity of 100 percent and a specificity of 86 percent in diagnosing pouchitis. The positive predictive value was 76 percent. There were three false-positive results. CONCLUSIONS: The IBD EZ VUE test is a sensitive method that may remove the need for invasive pouch investigations and lead to greater confidence when antibiotic therapy is commenced. Further investigations may be reserved for those patients who have a positive lactoferrin test and fail to respond to antibiotic treatment.

Contribution of posture to anorectal manometric measurements: are the measurements in left-lateral position physiologic?

PURPOSE: Anorectal manometry is commonly used to investigate fecal incontinence. Traditional practice dictates that measurements are performed with the patient in the left-lateral position however, episodes of fecal incontinence usually occur in the erect position. The influence of erect posture on anorectal manometry has not been studied. METHODS: We examined the contribution of posture to commonly measured variables during manometry by performing assessment in the left-lateral position and the erect posture. Maximum mean resting pressure, vector volumes, and resting pressure gradient were compared. RESULTS: Complete data were available for 172 patients. Median age was 55 (interquartile range, 44-65) years. Thirty-seven (22 percent) patients were continent, and 135 (78 percent) were incontinent. Both resting pressure and vector volume increased significantly in the erect position for both continent (P = 0.008 and 0.001, respectively) and incontinent (P = 0.001 for both) patients. A significant negative correlation was seen between severity of incontinence and resting pressure in the erect posture and amount of change in maximum mean resting pressure from left-lateral to erect posture (Spearman coefficients = -0.203, -0.211, and P = 0.013, 0.017, respectively) but not with maximum mean resting pressure in the left-lateral position (Spearman coefficient = -0.119; P = 0.164). CONCLUSIONS: Our study shows significant increase in measurements of manometric variables in the erect position. The increase may be related to anal cushions, which have a significant role in this position. The measurements in erect posture are better correlated with severity of incontinence and may be a more physiologic method of performing anorectal manometry.

The impact of preoperative immunomodulation on pouch-related septic complications after ileal pouch-anal anastomosis.

PURPOSE: We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications. METHODS: A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed. RESULTS: There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27-46) years. Median follow-up period was 52 (interquartile range, 26-86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02-3.45; P=0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09-0.71; P=0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08-0.76; P=0.023) remained predictive of lower rates of sepsis. CONCLUSIONS: Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis.