The unifying concepts of the sick lobe hypothesis, field cancerisation and breast conservation treatment for multiple ipsilateral breast cancers: a narrative review.

Background and Objective: In the past, it was conventionally thought that multiple ipsilateral breast cancer (MIBC) was a contraindication to breast conservation surgery, especially if multicentric foci in different quadrants of the breast were present. However, over time, there has been a growing body of evidence in the literature demonstrating no survival detriment or poorer local control with breast conservation for MIBC. There is, however, a paucity of information integrating anatomy, pathology with surgical treatment of MIBC. Understanding mammary anatomy, pathology of the sick lobe hypothesis and molecular impact of field cancerisation contributes significantly to the understanding of the role of surgical treatment of MIBC. The purpose of this narrative overview is to review the paradigm shifts over time in the use of breast conservation treatment (BCT) for MIBC, and how the concepts of the sick lobe hypothesis and field cancerisation interact with this therapeutic strategy. A secondary objective is to explore the feasibility of surgical de-escalation for BCT in the presence of MIBC. Methods: A PubMed search was performed for articles relating to BCT, multifocal, multicentric and MIBC. A separate literature search was performed for sick lobe hypothesis and field cancerisation and their interaction for surgical treatment for breast cancer. The available data was then analysed and synergised into a coherent summary of how the molecular and histologic aspects of MIBC interact with surgical therapy. Key Content and Findings: There is a growing body of evidence supporting the use of BCT for MIBC. However, there is scant data connecting the basic science aspects of breast cancer in terms of pathology and genetics to adequacy of surgical extirpation of breast malignancies. This review bridges this gap by demonstrating how information on basic sciences available in contemporary literature can be extrapolated for use in artificial intelligence (AI) systems to assist in BCT for MIBC. Conclusions: This narrative review connects several aspects of the surgical treatment for MIBC: historical perspectives of therapy compared with contemporary philosophy based on clinical evidence, anatomy/pathology (sick lobe hypothesis) and molecular findings (field cancerisation) as potential indicators of adequate surgical resection, and how current technology can be used to forge future AI applications in breast cancer surgery. These form the foundation for future research to safely de-escalate surgery for women with MIBC.

Are breast conservation treatment rates optimized for Asian women with symptomatic malignancies?

BACKGROUND: Published data indicate that 20-40% of patients undergo breast conservation treatment (BCT) in Asia, which is below an indicative benchmark of 50%. With an increasing body of evidence suggesting that BCT might be associated with improved survival outcomes, it is exigent to increase BCT utilization. This study was therefore undertaken to evaluate BCT rates for women presenting with symptomatic breast cancer and potential for de-escalation of surgical treatment. METHODS: All patients who presented with symptomatic tumours and underwent surgical treatment at the authors' healthcare facility between January 2009 and December 2011 were included in this retrospective study. Standard wide excision was performed to achieve clear margins and reasonable cosmetic outcomes for BCT-eligible patients. Oncoplastic techniques such as therapeutic mammoplasty or volume replacement with flaps were not employed. RESULTS: A total of 116 women presented with symptomatic breast cancer. The majority (92.2%) were Asian. Mean age at diagnosis was 48.3 years and mean tumour size was 23.4 mm. Ninety-five patients (81.9%) underwent BCT. Of the 22 patients, 13 (59%) who underwent neoadjuvant chemotherapy had sufficient tumour size downstaging to successfully undergo BCT instead of mastectomy. CONCLUSION: It is possible for more than 80% of Asian women with symptomatic breast malignancies to undergo BCT, with the appropriate use of neoadjuvant medical therapy and surgical techniques. As increasing data indicate improved survival with BCT, this should be offered as the treatment of choice.

Optimising Breast Conservation Treatment for Multifocal and Multicentric Breast Cancer: A Worthwhile Endeavour?

BACKGROUND: Breast conservation treatment (BCT) is an accepted treatment modality for early breast cancer. However, multifocal and multicentric breast cancer (MFMCBC) is a relative contraindication to BCT. This study was performed to compare BCT rates in MFMCBC and unifocal tumours and its outcomes. METHODS: A retrospective analysis was performed for patients with breast malignancies who underwent operative treatment between 2009 and 2011. Successful BCT was defined as the ability to obtain clear margins for all tumour foci through a single incision with acceptable resultant cosmesis. RESULTS: A total of 160 patients were analysed, of which 40 were MFMCBC. Thirty-four of the 40 patients with MFMCBC underwent BCT (85 %). After a mean follow-up period of 55 months, there were no local recurrences in patients with MFMCBC. CONCLUSION: BCT was achieved in 85 % of the patients with MFMCBC in this cohort without evidence of poorer local control. Further investigation is needed to confirm this finding for its potential contribution to improved survival outcomes.

Perspectives of Cosmesis following Breast Conservation for Multifocal and Multicentric Breast Cancers.

Background. Contemporary data suggest that breast conservation treatment (BCT) for multifocal and multicentric breast cancer (MFMCBC) may be appropriate with noninferior local control rates. However, there is a paucity of data to evaluate patient's satisfaction with cosmetic outcomes after BCT for MFMCBC. This study was performed to bridge this information gap. Methods. All patients treated at the authors' healthcare facility were included in the study. Patients with MFMCBC who were assessed to be eligible for BCT underwent tumour resection using standard surgical techniques with direct parenchymal closure through a single incision. After at least three years of follow-up, they were invited to participate in a survey regarding their cosmetic outcomes. Results. Of a total of 160 patients, 40 had MFMCBC, of whom 34 (85%) underwent successful BCT. Five-year cancer-specific survival and disease-free survival were 95.7%. Twenty of the 34 patients responded to the survey. No patient rated her cosmetic outcome as "poor." Analysis indicated low agreement between patients' self-assessment and clinician-directed evaluation of aesthetic results. Conclusion. BCT for MFMCBC is feasible with acceptable survival and cosmetic outcomes. However, there appears to be a disparity between patient and clinician-directed evaluation of cosmetic results which warrant further research.

Factors affecting unplanned readmissions from community hospitals to acute hospitals: a prospective observational study.

INTRODUCTION: While the readmission rate from community hospitals is known, the factors affecting it are not. Our aim was to determine the factors predicting unplanned readmissions from community hospitals (CHs) to acute hospitals (AHs). MATERIALS AND METHODS: This was an observational prospective cohort study, involving 842 patients requiring post-acute rehabilitation in 2 CHs admitted from 3 AHs in Singapore. We studied the role of the Cumulative Illness Rating Scale (CIRS) organ impairment scores, the Mini-mental State Examination (MMSE) score, the Shah modified Barthel Index (BI) score, and the triceps skin fold thickness (TSFT) in predicting the rate of unplanned readmissions (UR), early unplanned readmissions (EUPR) and late unplanned readmissions (LUPR). We developed a clinical prediction rule to determine the risk of UR and EUPR. RESULTS: The rates of EUPR and LUPR were 7.6% and 10.3% respectively. The factors that predicted UR were the CIRS-heart score, the CIRS-haemopoietic score, the CIRS-endocrine / metabolic score and the BI on admission. The MMSE was predictive of EUPR. The TSFT and CIRS-liver score were predictive of LUPR. Upon receiver operator characteristics analysis, the clinical prediction rules for the prediction of EUPR and UR had areas under the curve of 0.745 and 0.733 respectively. The likelihood ratios of the clinical prediction rules for EUPR and UR ranged from 0.42 to 5.69 and 0.34 to 3.16 respectively. CONCLUSIONS: Patients who have UR can be identified by the admission BI, the MMSE, the TSFT and CIRS scores in the cardiac, haemopoietic, liver and endocrine/metabolic systems.

Evaluation of dementia: the case for neuroimaging all mild to moderate cases.

INTRODUCTION: The aim of this study was to assess the usefulness of 4 clinical prediction rules, the neuroimaging guidelines from the Canadian Consensus Conference on Dementia (CCCAD) and the modified Hachinski's Ischaemic Score (HIS) in identifying patients with suspected dementia who will benefit from neuroimaging. MATERIALS AND METHODS: Two hundred and ten consecutive patients were referred to the memory clinic in a geriatric unit for the evaluation of possible dementia. Sensitivity, specificity and likelihood ratios (LR) were calculated for each of the prediction rules and the CCCAD guidelines, in terms of their ability to identify patients with significant lesions [defined firstly as space-occupying lesions (SOL) alone and secondly as SOL or strokes] on neuroimaging. Similar analyses were applied for the HIS in the detection of strokes. RESULTS: When considering SOL alone, sensitivities ranged from 28.6% to 100% and specificities ranged from 21.7% to 88.4%. However, when strokes were included in the definition of significant lesions, sensitivities ranged from 16.2% to 79.0% and specificities ranged from 20.9% to 92.4%. The modified HIS had a similarly poor sensitivity and specificity (43.3% and 78.9% respectively). The LR for the clinical decision tools did not support the use of any particular instrument. CONCLUSIONS: Clinical decision tools do not give satisfactory guidance for determining the need for neuroimaging patients with suspected dementia, when the detection of strokes, in addition to SOL, is regarded as important. We recommend therefore that neuroimaging be considered for all patients with suspected mild or moderate dementia in whom the potential benefits of any treatment outweigh the potential risks.

Clinical significance of cerebral white matter lesions in older Asians with suspected dementia.

BACKGROUND: cerebral white matter lesions are commonly seen on neuroimaging in older people and have been associated with clinical features such as gait abnormalities, urinary incontinence and depression. The significance of cerebral white matter lesions in older people with dementia remains uncertain. OBJECTIVES: to study the association between cerebral white matter lesions and the presence or absence of dementia in a group of elderly Asian patients; and to determine the clinical significance of cerebral white matter lesions in patients who are diagnosed to have dementia in terms of associated clinical features and the impact of cerebral white matter lesions on cognitive status. METHODS: for the first objective, the records of 141 older people of Asian ethnicity presenting to a memory clinic for the evaluation of suspected dementia were reviewed to compare the prevalence of cerebral white matter lesions in patients who did not fulfil the criteria for dementia, patients diagnosed to have Alzheimer's disease and patients diagnosed to have vascular dementia. For the second objective, 115 of these patients who were diagnosed to have dementia were studied to determine if demented patients with cerebral white matter lesions were more likely to have urinary incontinence, Parkinsonism, depression and greater severity of dementia. In addition, a comparison was made between demented patients with cerebral white matter lesions and those without cerebral white matter lesions in terms of psychometric assessment scores. RESULTS: cerebral white matter lesions were more common in Asian patients with vascular dementia. Demented patients with cerebral white matter lesions were also found to have more severe dementia and greater functional disability. CONCLUSION: cerebral white matter lesions are common, and are associated with greater functional disability in elderly Asian patients with dementia.

Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided.

OBJECTIVES: To determine fall risk factors in nursing home and intermediate-care residents who can and cannot stand unaided. DESIGN: Prospective cohort study. SETTING: Residential elderly care facilities in Sydney, Australia. PARTICIPANTS: One thousand people aged 65 to 103 (mean age +/- standard deviation: 85.0 +/- 7.4). MEASUREMENTS: Accidental falls. RESULTS: Fall rates were highest in those with fair standing balance, intermediate in those with the best standing balance, and lowest in those with the worst standing balance. This nonlinear pattern was even more striking when subjects were categorized according to their standing balance and ability to rise from a chair. Using this dual classification, fall rates were highest in those who could rise from a chair but could not stand unaided (81%) and lowest in those who could neither rise from a chair nor stand unaided (48%). In residents who could stand unaided, risk factors included increased age, male sex, higher care classifications, incontinence, psychoactive medication use, previous falls, and slow reaction times. In contrast, quite different risk factors were evident in residents who could not stand unaided, with a number of known fall risk factors (previous stroke, reduced ability to rise from a chair, slow reaction times) being associated with fewer falls. In this group, risk factors were intermediate versus nursing home care, poor health status, psychoactive medication use, Parkinson's disease, previous falls, and being able to get out of a chair. CONCLUSION: The findings indicate that there are different risk factors for falls for people living in residential aged care facilities who can and cannot stand unaided. These findings provide important information for developing fall-prevention strategies and suggest that those who can stand unaided but have multiple falls risk factors constitute the highest priority group for such interventions.