Outcomes of oncoplastic breast surgery compared to breast-conserving surgery in breast cancer patients in a developing country: a retrospective cohort study.

Background and Objective: Breast-conserving surgery (BCS) with adjuvant radiotherapy remains the standard of care for early breast cancers in Pakistan. We sought to compare the outcomes of BCS with oncoplastic surgery (OPS), a relatively infrequent approach to breast cancer treatment in the country. Methods: This retrospective cohort study was conducted at Aga Khan University Hospital and Ziauddin Hospital in Karachi. Patients who had biopsy-proven Stage-I to III breast cancer and underwent either OPS or BCS between August 1, 2016, and December 31, 2021, were identified and followed for 30 days. Data were collected by reviewing patient files and electronic records. Results: A total of 481 patients were included in the study, where 204 (42.4%) underwent BCS and 277 (57.6%) underwent OPS. Mean tumor volume (146.8 vs. 90.4 cm3), and postoperative complications (2.2 % vs. 0%) were higher in OPS while the frequency of positive margins was greater in the BCS group (15.7 % vs. 2.2 %). There were no significant differences in the histologic type of tumor between the two groups. Conclusion: OPS is a valid alternative approach to breast cancer treatment that can be offered to women with early stage, locally advanced, multifocal or tumors at complex locations owing to the reduced occurrence of positive margins and thus lowered re-excision rates.

Impact of Postoperative Antibiotic Prophylaxis on Surgical Site Infections Rates After Mastectomy with Drains but Without Immediate Reconstruction: A Multicenter, Double-Blinded, Randomized Control Superiority Trial.

BACKGROUND: There is no consensus on the use of postoperative antibiotic prophylaxis (PAP) after mastectomy with indwelling drains. We explored the utility of continued PAP in reducing surgical site infection (SSI) rates after mastectomy without immediate reconstruction and with indwelling drains. PATIENTS AND METHODS: A multicenter, two-armed, randomized control superiority trial was conducted in Pakistan. We enrolled all consenting adult patients undergoing mastectomy without immediate reconstruction. All patients received a single preoperative dose of cephalexin within 60 min of incision, and postoperatively were randomized to receive either continued PAP using cephalexin (intervention) or a placebo (control) for the duration of indwelling, closed-suction drains. The primary outcome was the development of SSI within 30 days and 90 days postoperatively. Secondary outcomes included study-drug-associated adverse events. Intention-to-treat analysis was performed using multivariable Cox regression. RESULTS: A total of 369 patients, 180 (48.8%) in the intervention group and 189 (51.2%) in the control group, were included in the final analysis. Overall cumulative SSI rates were 3.5% at 30 days and 4.6% at 90 days postoperatively. PAP was not associated with SSI reduction at 30 (hazard ratio, HR 1.666 [95% confidence interval CI 0.515-5.385]) or 90 (1.575 [0.558-4.448]) days postoperatively, or with study-drug-associated adverse effects (0.529 [0.196-1.428]). CONCLUSIONS: Continuing antibiotic prophylaxis for the duration of indwelling drains after mastectomy without immediate reconstruction offers no additional benefit in terms of SSI reduction. There is a need to update existing guidelines to provide clearer recommendations regarding use of postoperative antibiotic prophylaxis after mastectomy in the setting of indwelling drains.

Quality of life of breast cancer survivors: a comparison of breast conserving surgery versus total mastectomy with and without immediate reconstruction: a prospective cohort study.

Quality of life after breast cancer surgery is frequently ignored during and after treatment in many cancer survivors. To enhance this aspect of patient's life should be the primary goal of every cancer treatment. Therefore, the present study aimed to highlight the quality of life and patients' satisfaction with their breast cosmesis following breast conserving surgery (BCS), total mastectomy with and without reconstruction. Material and methods: Data were collected prospectively from cancer patients who had undergone breast surgery at our institution from 1 January 2015 to 31 December 2021. The validated Breast-Q questionnaires were utilized for conducting patient interviews and mean scores between three cohorts were compared using one-way ANOVA test / Kruskal-Wallis test. Results: Overall, 210 patients were recruited in which 70 patients (33.3%) had undergone BCS, 71 patients (33.8%) had total mastectomy only and 69 (32.9%) patients had total mastectomy with reconstruction. Physical well-being scores were consistent between the three groups while patients operated with total mastectomy with reconstructive surgery scored higher in sexual and psychosocial health measures as compared to patients of total mastectomy. However, BCS patients were the most satisfied with their cosmetic outcome following patients of total mastectomy with reconstruction and without reconstruction. Conclusion: Reconstruction postmastectomy has a positive impact on sexual and psychosocial well-being of survivors; however, those who had breast conservation were more satisfied with cosmetic outcome post-surgery as compared with mastectomy with or without reconstruction.

Primary angiosarcoma of breast in an octogenarian woman: A case report with literature review.

INTRODUCTION AND IMPORTANCE: Primary breast angiosarcomas are endothelial derived breast sarcomas found in younger to middle age groups. The diagnosis of primary breast angiosarcoma in an octogenarian woman is a rare incidence. CASE PRESENTATION: We report a case of 87-year-old postmenopausal woman presenting with history of lump in her right breast for four months. Ultrasound guided biopsy was performed which confirmed the diagnosis of angiosarcoma hence, subjected to simple mastectomy. She was doing quite well for one year when ultimately, she developed metastatic disease and couldn't survive more. CLINICAL DISCUSSION: Microscopically, these tumours are classified into grades I, II and III. Hematogenous route has been taken for metastasis having lungs being most involved. There are limited case reports and studies that have investigated the use of adjuvant radio/chemotherapy. CONCLUSION: Primary angiosarcoma of breast is a rare disease in old age group with limited treatment options which resulted in poor prognosis and early relapse.

Prophylactic Risk-Reducing Mastectomy (PRRM): A Set Practice or Catch-22 Situation in LMIC. A Single-Centre Prospective Cohort Study.

Background Pakistan's hereditary breast cancer has a higher-than-average prevalence. Our acceptability of prophylactic risk-reducing mastectomy (PRRM) still needs to be determined, and genetic testing still needs to be offered to all eligible. The aim is to determine the number of women presenting to our centre who availed of PRRM after positive genetic tests and the main reasons restraining them from considering PRRM.Materials and methods This study is a single-centre, prospective cohort. We collected data from 2017 to 2022 on BRCA1/2 and other (P/LP) gene-positive patients. Continuous variables are presented as means (±SD) and categorical variables in percentages, with a significant P-value of ≤ 0.05.Results Out of 477 tested individuals, only 95(20.12%) had a positive result. BRCA1/2 was positive in 70 cases, while P/LP variants were in 24 cases. Only 32.6% of eligible families underwent genetic testing, with 54.8% positivity. Altogether, 92.6% of patients had BRCA1/2-related cancers. Only 25/95(26.3%) individuals availed of PRRM, the majority had contralateral risk-reducing mastectomy 68% with a 20% reconstruction rate. The main reasons to decline PRRM were false belief of not having any disease 57.44%, followed by family/spouse pressure 51%, body appearance/societal perception, fear of complications/quality of life and financial constraints.Conclusion Genetic testing and its implications are still a grey area for LMICs, primarily due to the scarcity of centres offering genetic testing to eligible populations, followed by prevalent perceptions about prophylactic surgeries among the masses. Addressing relevant issues in LMICs is the need of time.

Breast cancer in a teenage girl with BRCA mutation: A case report from a low middle-income country.

INTRODUCTION: A staggering majority of pediatric breast masses are benign (mostly fibroadenoma) and so a biopsy is not readily performed as it can potentially lead to a future breast disfigurement. However, this should not be standard practice as this can lead to a delayed diagnosis, and hence, the treatment of pediatric breast cancer (BC); this was also seen in our patient's scenario. CASE HISTORY: Here, we report the case of the youngest known breast cancer patient in Pakistan, a 15-year-old girl. The right-sided breast lump which was diagnosed clinically as a fibroadenoma later turned out to be stage IIb pT3N0M0 metaplastic breast carcinoma with BRCA1 positivity and mutations in SMARCA4. Being young and unmarried, the patient and her family decided to opt for breast-conserving surgery with high-risk surveillance for breast and ovaries. DISCUSSION: We believe that prophylactic surgeries can be delayed with strict surveillance and thorough counseling. As pediatric BC is linked to a less favorable prognosis, every young patient diagnosed with breast cancer and their family should undergo genetic testing. BC management should be handled by specialists in the field and doctors should be trained for initial diagnostics and timely referral of patients. CONCLUSION: It is important to improve our understanding of genetic predisposition and testing in lower-middle-income countries. Considering the changing global trends, we suggest that the utilization of genetic services is direly needed to improve preventative care for at-risk individuals with breast and other cancers.

Analysing the trends in breast surgery practice during COVID-19 pandemic: A comparative study with the Pre-COVID era.

BACKGROUND: The emergence of coronavirus disease 2019 (COVID-19) pandemic has crippled the healthcare systems all over the world. Cancer treatment is indispensable and disruption in its provision can lead to unanticipated consequences. No local data exists that has quantified the impact of COVID-19 pandemic on breast cancer surgery in a lower middle-income country (LMIC), therefore, the present retrospective comparative cohort study is directed to determine the trends in breast surgery operative volumes and its outcomes at our institution in Pakistan. MATERIALS AND METHODS: Data was collected retrospectively from Pre-COVID-19 and COVID-19 era to determine impact of the current pandemic on breast cancer management practices and outcomes. RESULTS: Cohort results showed a decline in the number of surgeries during COVID-19 era. A total 149 cases were operated during study period vs. 231 during same Pre-COVID-19 i.e. a 35.5% drop in cancer surgeries. In early COVID-19 time frame, only 4 patients had breast reconstruction, 12 out of 149 (8.05%) surgical candidates were identified having positive COVID-19 status preoperatively and one ASA class 3 patient caught COVID-19 post-surgery and succumbed to virus. CONCLUSION: Pandemic has a negative effect on cancer management in a LMIC with compromised access and care of cancer patients.

Utility of post mastectomy radiotherapy among patients with T1/ T2 N1 disease: A retrospective cohort study.

BACKGROUND: Pakistan has the highest incidence of breast cancer among Asian Countries but there is insufficient representation of local data addressing breast cancer treatment and outcome. We sought to determine the role of post-mastectomy radiotherapy (PMRT) in T1- T2 breast cancer with 1-3 positive axillary lymph nodes. METHODS: Data was reviewed retrospectively of total 755 patients out of which 291 received PMRT and 464 did not from two large breast cancer centres. RESULTS: With a median follow up of 78 months, 4 (4.5%) patients developed loco regional recurrence (LRR) in the PMRT group while a substantial number 74 (24.4%) recurred in the non PMRT group (p = 0.000). Loco regional free survival rate (LRFS) and overall survival rate (OS) was significantly better for PMRT patients than non-PMRT patients (P = <0.000). Multivariate analysis identified young age, lymphovascular invasion, extra capsular extension, triple negative and ER/PR negative were independent prognostic factors affecting loco regional free survival (LRFS). CONCLUSION: Disease recurrence is a substantial issue in 1-3 node group despite early stage, PMRT has an instrumental effect in improving LRFS and OS.

Concordance Between Clinical and Pathological Response Assessment After Neo-Adjuvant Chemotherapy in Patients With Invasive Lobular Carcinoma.

Background Neo-adjuvant chemotherapy (NAC) is frequently administered in breast carcinoma patients. The clinical response to NAC guides further treatment. The pathological response is not only an independent prognostic factor, but it also guides further treatment and prognosis. Objectives The aim of our study was to find the degree of concordance between clinical and pathological response assessments after NAC in Invasive lobular Carcinoma (ILC) cases by using World Health Organization (WHO) criteria and different pathological systems, respectively. We also tried to identify any useful parameter of clinical assessment that could better correlate with pathologic assessment and provide a better estimation of residual tumor. Methods This retrospective study was conducted on 26 ILC tumors diagnosed in 24 patients who were treated with NAC followed by surgical resection between January 2009 and December 2020. Medical records and microscopy glass slides were reviewed for clinical and pathological response assessments, respectively. Results The pre-treatment tumor area ranged from 1.8-255 cm2 and the mean±SD was 52.2±66.8 cm2. After NAC, complete clinical response was observed in four (15.3%) cases. The clinically assessed mean tumor area significantly reduced from 52.2±66.8 cm2 to 17.2±22.6 cm2 (p-value<0.001). The pathologically assessed mean tumor area (27.4±24.1 cm2) didn't differ significantly from the clinically assessed mean tumor area (17.2±22.6 cm2) (p-value=0.114). Pathologically, the majority of the cases showed partial response, and a complete pathological response was achieved in only two (7.7%) cases. The concordance rates between clinical assessment by the WHO method and pathological assessment of the breast using the Sataloff method, Miller-Payne (MP) system, Residual Cancer Burden system, and Chevallier method were 26.7%, 15.8%, 9%, and 3.5%, respectively, with insignificant p-values. Percentage reduction in clinical size and percentage reduction in tumor cellularity differed significantly (p-value=0.038). Conclusion Clinical response assessment provides a less accurate estimation of residual disease, as it shows poor concordance with pathological assessment using different assessment systems/methods.

COVID-19 pandemic and breast cancer management: A retrospective observational clinical study from Pakistan.

BACKGROUND: COVID-19 outbreak has adversely affected care of breast cancer patients world-wide. There is paucity of available data on cancer management in lower-middle income countries during this pandemic, we sought to determine the institutional approach towards management of breast cancer patients and the outcomes during COVID-19 pandemic at our institution. MATERIALS AND METHODS: Clinicopathological and treatment record of cancer patients who presented to the Breast Clinic from 15th March to 31st December 2020 was retrieved from the institutional database for this retrospective clinical observational study. RESULTS: A total of 292 patients were qualified for the analysis in which 206 patients (70.5%) underwent breast cancer surgeries. Only 10 of them (4.9%) were identified to be COVID-19 virus positive on routine pre-operative RT-PCR test before elective surgeries. All were asymptomatic, received home-based care via telecommunication and were operated at a later date when test turned out negative. None of them developed any complications post-operatively. Another group of 86 patients (29.5%) were referred for Neoadjuvant/Systemic chemotherapy in which COVID-19 infection was detected in only 4 patients (4.6%) while receiving cycles. Two patients shown symptoms of cough and fever hence hospitalised but were not candidates for Intensive Care Unit admission while other two patient were asymptomatic and isolated at home. All patients recovered well and chemotherapy was commenced again after negative RT-PCR test. No mortality was observed. CONCLUSION: Despite of being a global crisis particularly for cancer patients we observed infectivity, complications and fatality much lower among breast cancer cases. Further research is needed in this regard including public and private sector hospitals for better understanding behavior of COVID-19 disease and achieve common goal to combat COVID-19 and cancer together.

Recurrent Phyllodes Tumour of the Breast Transforming to a Fibrosarcoma.

Phyllodes tumours of the breast are characterized by having both an epithelial as well as stromal component and these usually comprise almost 3% of all fibroepithelial tumours. They are exceptional in this aspect to convert into a stromal sarcoma of the breast after multiple recurrences. To the best of our knowledge, there are only three case reports regarding this in the available literature as it is an exceptional change. In this case report, we present a case of recurrent phyllodes transforming into a breast fibrosarcoma in a middle age postmenopausal woman. Histopathological examination and immunohistochemistry of the lesion were performed to confirm the diagnosis of breast fibrosarcoma.