Surgical Outcome Parameters in Breast Cancer: A Survey Comparing Oncoplastic and Non-Oncoplastic Surgeons as well as Certified with Non-Certified Breast Health Centers

There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period. The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria. The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%. No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Localising the Tumour Bed in Breast Radiotherapy

Oncoplastic surgeons: heros or villains?

In Australia, the rate of immediate breast reconstruction (IBR) following breast cancer surgery is highly variable. This study aimed to identify the rate of IBR within an Australian public tertiary breast oncology referral centre and analyse the tumour and demographic factors that impact upon IBR uptake. A retrospective cohort study of 288 admissions of women requiring mastectomy between January 2012 and March 2015 was performed. Data collected included demographic data, tumour pathology, operative details and neoadjuvant therapy. Demographic data included a Socioeconomic Index for Area score, based on individual residential postcode, country of birth and need for an interpreter. Our study demonstrated an IBR rate of 41.3% and included a wide variety of reconstructions. Factors that increased the IBR rate included younger age and negative lymph node status. Our patient population was ethnically and linguistically diverse, with over 50 different countries of birth represented and with 53 patients requiring interpreters in 19 different languages. Our analysis shows that the requirement for an interpreter is negatively correlated with having an IBR. Our research demonstrates a high rate of IBR that includes a wide range of autologous and alloplastic reconstructions. Our study represents a unique opportunity to identify socioeconomic barriers that influence patient choice for reconstruction following mastectomy. This can lead to improved health care provision for our patients. This is particularly important in tertiary services with a strong multicultural and multi-linguistic population.

Exploring breast surgeons’ reasons for women not undergoing immediate breast reconstruction

Quality indicators in surgery for cancer: not just the operation.

Comparison of robotic versus open pancreaticoduodenectomy: achieving a textbook oncologic operation for pancreatic ductal adenocarcinoma

Background: Breast-conserving surgery for palpable breast cancer is worldwide associated with a high rate of tumour-involved margins and excessive healthy tissue resection. This results in additional treatment and poor cosmetic outcome. Ultrasound-guided surgery (USS) may resolve both problems by improving surgical accuracy. A randomised controlled trial was initiated to compare USS with the standard palpation-guided surgery (PGS) for palpable breast cancer. Methods: A total of 134 eligible patients with palpable T1-T2 invasive breast cancer were randomised to either USS (n = 65) or PGS (n = 69). Outcome measures included resection margin status, re-excision rates, mastectomy rates and additional radiotherapy. A calculated resection ratio (CRR) was derived from specimen volumes and tumour diameters, indicating healthy tissue resection. Secondary outcome measures were operative time, complications cosmetic outcome and cost-effectiveness. The costs of purchasing the US-system were included in the USS-group. The mean total costs per patient were calculated and compared between both study groups. Results: In the USS-group, 3.1% of margins were involved, compared with 17.4% in the PGS-group (p = 0.009). The use of intra-operative US resulted in a significant reduction in additional therapies (p = 0.015); in the PGS-group re-excisions were necessary in 3 patients (4.3%) and in 1 patient (1.5%) in the USS-group, mastectomies were performed in 5 patients (7.2%) of the PGS-group and in none of the patients of the USS-group, and additional radiotherapy boosts in 11 patients (15.9%) of the PGS-group and 6 patients in the USS-group (9.2%). Excision volumes and CRR were both reduced with USS (38cc vs. 58cc and 1.0 vs. 1.7, respectively; both P &amp;lt; 0.002). Analysis of cosmetic self-evaluation after 3 months showed better nipple position in the USS-group compared to the PGS-group (p = 0.016). Furthermore, 3 months after surgery, patients in the USS were more satisfied with the appearance of their breasts than in the PGS group (p = 0.015). Panel evaluation of cosmetic outcome will be conducted in the future. Mean extra costs per patient due to margin involvement in the PGS-group were 446€ compared with 169€ in the USS-group. Yearly costs of a US-system are 8,286€. Therefore, USS for palpable breast cancer can save a breast unit 277€ per patient after the first 30 operated patients (on a yearly basis). A breast unit operating 200 patients per year can achieve 47.090€ of cost savings. Conclusion: USS can prevent the unacceptably high rate of tumour-involved resection margins in palpable breast cancer excision, thus not only improving oncological and cosmetic outcomes by avoiding subsequent surgery or radiotherapy, but also considerably reducing treatment costs. In addition to palpable breast cancer surgery, USS might be used for non-papable breast cancer surgery, mastectomies and oncoplastic procedures. Therefore even greater cost-savings might be achieved by using a US-system for breast cancer surgery. Long term results of cosmetic outcome and quality of life of this trial are expected in 2013. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD04-01.

In India and other developing countries, breast conservation surgery (BCS) rates in breast cancer patients are low due to advanced disease at presentation and misconceptions about BCS outcomes. Many patients presenting with large or locally advanced breast cancers (LABC) can be offered post-neoadjuvant chemotherapy (NACT) BCS, safety of which is not as well established as that of primary BCS. This retrospective study compared pathological and surgical outcome parameters in patients undergoing primary and post-NACT BCS. All non-metastatic breast cancer patients undergoing BCS during 2011-2015 with 1-year follow-up were included. Outcome parameters in form of margin infiltration, ipsilateral breast tumor recurrence (IBTR) rates and IBTR-free survival were compared between primary and post-NACT BCS patients groups. One hundred and twenty-nine patients underwent BCS; 95 underwent primary and 34 post-NACT BCS. Patients in both groups underwent similar multimodality treatment as per institutional protocols. Post-NACT patients more frequently required oncoplastic volume displacement or replacement surgery (p=0.002). Re-excision of infiltrated margins was needed more frequently in primary BCS compared with post-NACT BCS group (14.4 vs. 8.8%; p=0.40). IBTR (Mean follow-up=30.7months) was seen in 8.8% post-NACT patients compared with 2.1% primary BCS (p=0.114). IBTR-free survival did not differ significantly between the groups in stage-wise comparison. Post-NACT BCS is safe even in large tumors and LABC, though many require oncoplastic procedures for satisfactory cosmesis. In a developing country where many patients present with large breast cancers or LABC, the benefits of BCS can be offered to a majority with the help of NACT, without compromising the chances of cure.

BackgroundSince April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM).MethodsWe retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into “uninsured” and “insured” groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR.ResultsOf 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38–48] vs. 45 [40–50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured.ConclusionIBR rate in patients undergoing TM increased after NHI reimbursement.

Artificial intelligence in action: Improving breast disease management through surgical robotics and remote monitoring

Abstract #5154 Background:&amp;#x2028; The phrase “Oncoplastic breast surgery” originated with the concept of avoiding mastectomy by means of wide tumour excision coupled with breast reconstruction. Oncoplastic procedures (OP) have been standardised in our institution. The surgical technique was defined according to the quadrant and the breast consistence of the patient, the pathological conditioning associated specimen orientation and inked breast margins.&amp;#x2028; Material and methods:&amp;#x2028; Each woman with a potentially large partial breast removal and a consequent risk of mastectomy has an OP proposed. Pre operative explanations underlined the oncological problem, the technical procedure, the post operative potential morbidity, the necessity to obtain definitive pathologic reports, the timing of controlateral surgery for symmetrization. An independent phone questionnaire was made in order to evaluate the main disorders felt by the patients, the quality of pre operative explanations and the cosmetic and psychological impact.&amp;#x2028; 133 women were operated between 2001 and 2007, the mean age was 51, the mean Bra size 95, the initial TNM staging noticed 40% T0 – 17% T1 – 30% T2 – 13% T3. 40% of tumors were pure DCIS, 40% of patients have had preoperative chemotherapy.&amp;#x2028; Results:&amp;#x2028; The operative technique was an OP alone in 54%. For the external quadrants, we performed mainly a Durfourmentel technique (54%), for the upper quadrants the batwing procedure (10%) and for the inferior quadrants a classic mammoplastic surgery (36%). The mean weight of the specimen was 166 g (20-530), the mean operative time 84' for unilateral surgery, 130' for bilateral, the mean hospital stay 3.8 d. 20% of patients needed a second surgery, twice for post operative morbidity, 25 times for R1 resection. In these cases, 14 second mastectomies were performed, 6 tumorectomies and 2 second OP.&amp;#x2028; The mean diameter of the tumor evaluated on pathology reports was 24.6 mm; the rate of positive margins was 21% for DCIS removal and 28% after neoadjuvant setting. With 33 months FU, we noticed 2 deaths due to the cancer, 5 local recurrences and 12 patients treated for metastases.&amp;#x2028; The independent phone questionnaire revealed a favourable cosmetic result in 70%, bad in 13%. 36% of women wished a second time plastic surgery but relinquished. 48% evaluated the preoperative explanation unsatisfactory. The main reproaches voiced by the patients were the risk of second step surgery according to the final pathological reports and the length of the scars. 75% of women were not afraid to conserve their breast but all were satisfied. 60% were worried due to the follow-up but 83% think that the mastectomy is not less frightening. 17% hesitated to have the same surgical approach.&amp;#x2028; Conclusion&amp;#x2028; OP procedure is a safe alternative to mastectomy in selected cases with acceptable morbidity and good cosmetic results. Pre operative explanations are essential. Since April 2007, we have initiated a prospective multicentric trial in order to evaluate the free margin rate according to the indication and the quality of life of these women. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5154.

Purpose The purpose of our study is to compare the results of spinal decompression using the full-endoscopic interlaminar technique, tubular retractor, and a conventional microsurgical laminotomy technique and evaluate the advantages and clinical feasibility of minimally invasive spinal (MIS) lumbar decompression technique in the lumbar canal and lateral recess stenosis. Methods The authors retrospectively reviewed clinical and radiological data from 270 patients who received microsurgical (group E: 72 patients), tubular (group T: 34 patients), or full-endoscopic decompression surgery (group E: 164 patients) for their lumbar canal and lateral recess stenosis from June 2016 to August 2017. Clinical (VAS, ODI, and Mcnab criteria), radiologic (spinal canal diameter, segmental dynamic angle, and disc height), and surgical outcome parameters (CPK level, Operative time, blood loss, and hospital stay) were evaluated pre- and postoperatively and compared among the three groups by means of statistical analysis. Failed cases and complications were reviewed in all groups. ResultsThe mean follow-up period was 6.38 months. The Overall clinical success rate was 89.4%. All groups showed favorable clinical outcome. The clinical and radiologic results were similar in all groups. Regarding surgical outcome, group E showed longer operation time than group M and T (group E: 84.17 minutes/level, group M: 52.22 minutes/level, and group T: 66.12 minutes/level) (p<0.05). However, groups E and T showed minimal surgical invasiveness compared with group M. Groups E and T showed less immediate postoperative back pain (VAS) (group E: 3.13, group M: 4.28, group T: 3.54) (p<0.05), less increase of serum CPK enzyme (group E: 66.38 IU/L, group M: 120 IU/L, and group T: 137.5 IU/L) (p<0.05), and shorter hospital stay (group E: 2.12 days, group M: 4.85 days, and group T: 2.83 days) (p<0.05). The rates of complications and revisions were not significantly different among the three groups. ConclusionsMIS decompression technique is clinically feasible and safe to treat the lumbar canal and lateral recess stenosis, and it has many surgical advantages such as less muscle trauma, minimal postoperative back pain, and fast recovery of the patient compared to traditional open microscopic technique.

Learning Curve of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy – an Analysis of Critical Perioperative and Surgical Outcomes among 155 Peritoneal Surface Malignancy Patients Treated at a Tertiary Care Cancer Centre

Most of the papers published on spigelian hernia are either case reports or small retrospective series. In this prospective multicenter study, we aimed to outline the specific features of spigelian hernias and patients' characteristics more clearly. Surgeons enrolled patients to be entered into the database as they diagnosed and treated the hernias at will. The baseline and surgical outcome parameters were noted in each patient. A painful mass was the main presenting complaint in half of 34 patients. Accurate preoperative diagnosis was possible in 31 patients. Open intraperitoneal mesh repair was the preferred technique. The mean hospital stay and time until return to normal daily activities were 4.1 and 15.6 days. Although a rare condition, diagnosis of a spigelian hernia is not difficult once remembered. Its surgical repair seems to cause few complications and is very well tolerated by the patient.