Tumor-infiltrating lymphocytes as a predictor of axillary and primary tumor pathological response after neoadjuvant chemotherapy in patients with breast cancer: a retrospective cohort study.

PURPOSE: Tumor-infiltrating lymphocytes (TILs) can predict complete pathological response (pCR) of tumor in the breast but not so well-defined in the axilla after neoadjuvant chemotherapy. Since axillary surgery is being increasingly de-escalated after NACT, we aimed to investigate the relationship between TILs and pCR in the axilla and breast, as well as survival amongst NACT patients. METHODS: Clinicopathological data on patients who underwent NACT between 2013 and 2020 were retrospectively examined. Specifically, pre-TILs (before NACT), post-TILs (after NACT) and ΔTIL (changes in TILs) were assessed. Primary endpoint was pCR and secondary endpoints were breast cancer-free interval (BCFI) and overall survival (OS). RESULTS: Two hundred and twenty patients with nodal metastases were included. Overall axillary and breast pCR rates were 42.7% (94/220) and 39.1% (86/220), respectively, whereas the combined pCR rate was 32.7% (72/220). High pre-TILs (OR 2.03, 95% CI 1.02-4.05; p = 0.04) predicted axillary pCR whereas, high post-TILs (OR 0.33, 95% CI 0.14-0.76; p = 0.009) and increased ΔTILs (OR 0.25, 95% CI 0.08-0.79; p = 0.02) predicted non-axillary pCR. TILs were not a significant predictor for BCFI and OS. CONCLUSIONS: This study supports the potential use of pre-TILs to select initially node-positive patients for axillary surgical de-escalation after NACT.

Evaluation of tumor-infiltrating lymphocytes and mammographic density as predictors of response to neoadjuvant systemic therapy in breast cancer.

BACKGROUND: Response rates vary among breast cancer patients treated with neoadjuvant systemic therapy (NAST). Thus, there is a need for reliable treatment predictors. Evidence suggests tumor-infiltrating lymphocytes (TILs) predict NAST response. Still, TILs are seldom used clinically as a treatment determinant. Mammographic density (MD) is another potential marker for NAST benefit and its relationship with TILs is unknown. Our aims were to investigate TILs and MD as predictors of NAST response and to study the unexplored relationship between TILs and MD. MATERIAL AND METHODS: We studied 315 invasive breast carcinomas treated with NAST between 2013 and 2020. Clinicopathological data were retrieved from medical records. The endpoint was defined as pathological complete response (pCR) in the breast. TILs were evaluated in pre-treatment core biopsies and categorized as high (≥10%) or low (<10%). MD was scored (a-d) according to the breast imaging reporting and data system (BI-RADS) fifth edition. Binary logistic regression and Spearman's test of correlation were performed using SPSS. RESULTS: Out of 315 carcinomas, 136 achieved pCR. 94 carcinomas had high TILs and 215 had low TILs. Six carcinomas had no available TIL data. The number of carcinomas in each BI-RADS category were 37, 122, 112, and 44 for a, b, c, and d, respectively. High TILs were independently associated with pCR (OR: 2.95; 95% CI: 1.59-5.46) compared to low TILs. In the univariable analysis, MD (BI-RADS d vs. a) showed a tendency of higher likelihood for pCR (OR: 2.43; 95% CI: 0.99-5.98). However, the association was non-significant, which is consistent with the result of the multivariable analysis (OR: 2.51; 95% CI: 0.78-8.04). We found no correlation between TILs and MD (0.02; p = .80). CONCLUSION: TILs significantly predicted NAST response. We could not define MD as a significant predictor of NAST response. These findings should be further replicated.

The Magnetic Technique-A Novel and Promising Method to Improve Axillary Staging Localisation from a Swedish Perspective.

The magnetic technique using superparamagnetic nanoparticles of iron oxide has been well established for sentinel lymph node detection. Its main advantage is in the context of logistics, with the possibility to inject several weeks before surgery and the possibility to give access to sentinel lymph node biopsy for women worldwide in places without nuclear medicine facilities. We have not yet seen the full potential of this technique, and new implications have been developed for breast tumour localisation with paramagnetic clips and axillary staging after neoadjuvant chemotherapy using paramagnetic clips inserted in lymph node metastases before chemotherapy. In this report, we have presented our experience of the magnetic technique starting in 2014, and we have highlighted our current and future research directions.

Impact of Surgical Care Bundle on Surgical Site Infection after Non-Reconstructive Breast Cancer Surgery: A Single-Centre Retrospective Comparative Cohort Study.

BACKGROUND: Surgical-site infections (SSIs) are the commonest cause of healthcare-related infections. Although a surgical care bundle (SCB), defined as a group of preventative measures, is effective in reducing SSIs, it has not been well documented in breast cancer surgery. We aimed to investigate the impact of SCB on SSI. METHODS: A single-centre retrospective comparative cohort study between 2016 and 2020 was carried out. An SCB including eight different measures was implemented in October 2018 at Sahlgrenska University Hospital, Sweden. Patients who underwent non-reconstructive breast cancer surgery were included for analysis. The primary endpoint was SSI within 30 days after surgery. RESULTS: Overall, 10.4% of patients (100/958) developed SSI. After SCB implementation, the overall SSI rate reduced from 11.8% to 8.9% (p = 0.15). The largest SSI rate reduction was seen in the subgroup that underwent breast conservation and sentinel lymph node biopsy (SLNB), from 18.8% to 9.8% (p = 0.01). In this multivariable analysis adjusting for patient and treatment factors, the implementation of SCB resulted in a statistically significant reduction in SSI risk (OR 0.63, 95% CI 0.40-0.99, p = 0.04). CONCLUSIONS: The implementation of a SCB could reduce the incidence of SSI in breast cancer surgery.

How sharp is a "sharp scratch"? A mixed methods study of verbal warnings issued before venipuncture.

OBJECTIVES: Health care providers frequently issue a verbal warning before venipuncture. Communications that induce negative expectations in patients can lead to the "nocebo" response, defined as experiencing greater pain. But is this also true for "sharp scratch"? METHODS: The study was conducted across 4 U.K. hospitals. Two separate surveys of health care providers and patients explored the prevalence, phraseology, rationale, and reaction to verbal warnings before venipuncture. Blinded adult patients already attending an outpatient department during a 2-week period were randomized to hearing a "sharp scratch" or the verbal cue "ready?" immediately before venipuncture. They were also asked to rate their pain (the primary outcome). RESULTS: 77% of 117 health care providers surveyed issued a verbal warning before venipuncture; 73% used "sharp scratch". Of 62 patients surveyed, 56% agreed that "sharp scratch" accurately describes venipuncture, and 64% agreed that they prefer "sharp scratch" to no warning. With increasing age, a preference came for an alternative warning to "sharp scratch" (P = 0.039) and to be distracted by conversation (P = 0.002). Of 192 patients in the randomized study, there was no difference in pain between the "sharp scratch" and "ready" groups. The numeric rating scores were 0.74 SD 1.06 vs. 0.88 SD 1.18, respectively. (P = 0.493). CONCLUSIONS: Most health care providers use the verbal warning "sharp scratch" before venipuncture. Most patients find this acceptable and prefer it to no warning. An exception may be elderly patients, who may prefer to be distracted by conversation. "Sharp scratch" makes no difference to the pain experienced compared with a verbal cue.

Nematode infection: A rare mimic of acute appendicitis.

INTRODUCTION: Acute appendicitis is a common condition seen in all surgical units. One rare condition that can mimic acute appendicitis is a nematode infection of the bowel. There have been few reported cases of nematode infection within the appendix and none that have been accompanied by intra-operative pictures. PRESENTATION OF CASE: A 16-year-old female presented with a 12h history of right iliac fossa pain and mild pyrexia. Bloods showed a neutrophilia and normal C-reactive protein. Laparoscopy was performed which revealed a non-inflamed appendix. The appendix was dissected and a live nematode was visualised exiting the base of the appendix. Anti-helminthics were given and the infection resolved. DISCUSSION: Nematode infection is most commonly seen in Africa, Asia and South America. When seen within the United Kingdom (UK), it is seen most commonly within high-risk populations. Testing for these infections is not routine within the UK and when they are performed, the results take a considerable amount of time to return. These tests should be considered within high-risk populations so that unnecessary surgery can be avoided. CONCLUSION: This case highlights the importance of considering rare causes of right iliac fossa pain including nematode infection in a young patient. The case highlights this by giving intra-operative pictures of live nematodes upon dissection of the appendix.

The perception of online work-based assessments.

BACKGROUND: Work-based assessments (WBAs) and the associated online feedback are fundamental parts of clinical training. Despite years of clinical use there is little evidence suggesting that they have a positive impact on learning or performance. AIMS: This observational pilot study investigates the perceptions of online WBAs (OnWBAs) across specialties in an attempt to establish why these tools are not meeting their full academic potential. METHODS: Structured questionnaires were given to 90 clinicians. Responses were analysed in excel, and spss 17 was used to test for statistical significance. RESULTS: All responders felt that OnWBAs were a poor reflection of clinical competency, and did not enhance learning significantly. Consultant OnWBAs rated poorly against those performed by other grades. Consultant OnWBAs were significantly more difficult to obtain and took significantly longer to complete than those from other grades. Several consultants were inadequately trained in the use of OnWBAs, and most were unaware of the number of assessments required by trainees. DISCUSSION: This study highlights several issues that may detract from the functionality of OnWBAs. Pockets of consultants are inadequately trained in the use of OnWBAs, and many lack knowledge of trainee requirements. In addition the delay between assessment and completion of feedback is a concern that goes against current recommendations. Simple measures in the workplace and the involvement of educational bodies could remedy some of these issues. Further studies investigating a wider population would help to establish the true extent of the problem and isolate the main causative factors behind these issues.

An efficient technique for drainage of seromas after breast cancer surgery.

Seroma formation is a frequent sequelae following breast cancer surgery. Current methods for seroma drainage often involve repeated needle aspiration that requires multiple passes, and is time consuming. We describe a technique that uses a needle attached to a high vacuum wound drainage system. We believe that this technique is aseptic, relatively cheap, and efficient. It can easily and safely be adopted in the outpatient setting.