Specialist Breast Surgeon Research Articles

A series of the first 13 combined Magseed and Magtrace cases in a single centre in regional Victoria.

The standard journey for a patient with impalpable breast cancer wishing to undergo breast-conserving surgery involves placement of a guidewire and lymphoscintigraphy pre-operatively. Access to these procedures is limited in the regional centres, this scheduling can require overnight stays away from home and can delay theatre which can increase patient distress. The Sentimag technology uses magnetism for localisation of preoperatively inserted Magseeds (for impalpable breast lesions) and Magtrace (for sentinel node biopsy), avoiding guidewire placement and nuclear medicine. This study evaluates the first 13 cases using this combined technique by a single specialist breast surgeon in a regional centre. Thirteen consecutive patients were enrolled with ethics approval. Magseeds were placed under ultrasound guidance preoperatively, and Magtrace was injected at the time of pre-operative consultation. The median age of patients was 60 (range 27-78). The average distance from hospital was 81.63 km (2.8-238 km). The average operating time was 1h54m (range 1 h 17 m-2 h 39 m) and the mean total journey time was 8h54m (range 6-23 h). The earliest time-out was 8:40 am. Re-excision rate was 23% (n= 3), however, in each re-excision case the lesions were in the axilla, were small (<15 mm) and were in patients with dense breasts on mammography. There were no significant adverse outcomes. In this preliminary study Sentimag localisation appears to be safe and reliable when used in combination. Re-excision rates were only slightly higher than reported in the literature and predicted to downtrend with ongoing learning curve.

A Comparison of Local Infiltration Analgesia and PECS II Block for Analgesia in Mastectomy with Axillary Dissection—A Randomised Equivalence Study

Objective: Various analgesic techniques can be used for a mastectomy with axillary dissection with varying degrees of efficacy. In our institution, local anaesthesia infiltration (LIA) is commonly performed by surgeons. In this study, we hypothesise that the relatively novel PECS II block is equivalent to the analgesic profile of LIA. Methodology: In this single center, prospective, randomised control trial, 40 patients undergoing unilateral mastectomy with axillary dissection were randomly assigned to receive either 30 ml 0.5% ropivacaine before skin via LIA by a specialist breast surgeon during surgery or 30 ml 0.5% ropivacaine via PECS II block, before skin incision. Fentanyl was used as rescue analgesia intraoperatively, and all patients received morphine via patient-controlled analgesia (PCA) device postoperatively. The primary outcome was the difference in total morphine consumption in 24 hours between the 2 groups after surgery with equivalency set at ±1 mg. Secondary outcomes included time to rescue analgesia after block administration, post-operative pain score over 24 hours, adverse effects encountered, total intraoperative opioid usage, effect on operative time, block performance time as well as block and surgery related complications. Results: Unadjusted mean PCA morphine consumption over 24 hours post-operatively comparing local infiltration analgesia (LIA) to that of PECS II at 95% confidence interval was -1.22 mg (95% CI: -3.77, 1.33). Total IV Fentanyl use comparing LIA to PECS II was 2.53 ± 0.98 mcg/kg and 1.96 ± 0.57 mcg, P = 0.035. There were no other significant differences in the secondary outcome. Conclusion: We conclude there is a lack of equivalence between that of LIA and PECS II block, with the PECS II block providing superior analgesia.

Pregnancy Associated Breast Cancer: An Institutional Review from a Dedicated Cancer Hospital of Pakistan

Introduction Breast cancer during pregnancy or diagnosed during lactation or 1 year after delivery comes under Pregnancy associated breast cancer (PABC). PABC are diagnosed in age ranging from 32-38 years. It has been noted that PABC is associated with larger tumors and higher incidence of lymph nodes metastases at presentation. Methodology It is a retrospective analysis of PABC patients presented at our hospital in year 2020. All patients with PABC are included while Non-PABC and male breast cancer are excluded. Calculations were performed with Statistical Package for the Social Sciences (SPSS Ver20) for Windows. The study is in compliance with the SKMCH&RC guidelines on research involving human subjects. Results A total of 899 patients presented with breast cancer at SKMCH in the year 2020. Of these patients, 41 patients (4.56%) had PABC. Mean age at presentation was 33.76 (range 24-41). Except for one patient, all the patients presented with palpable lump in breast. Seven patients (17%) had metastases at the time of presentation. Triple negative disease was observed in 16 patients (39%). We identified only one histological subtype among all patients i.e. invasive ductal carcinoma (IDC), however, five patients (12.2%) had a component of ductal carcinoma in situ along with IDC. More than half of the patient had advanced T stage i.e. 56.1%. Neo-adjuvant chemotherapy was offered in 31 patients (75.6%). 18 patients underwent breast conservation surgery, and 14 patients had mastectomy for the management of disease. Conclusion PABC is not very common tumor but it is an aggressive one with unfavorable histological and immunophenotypic characteristics. If any abnormality is noted for more than 2 months, patient should consult a specialist breast surgeon.

Surgeon-Performed Vacuum-Assisted Biopsy of the Breast: Results from a Multicentre Australian Study.

Image-guided interventional techniques such as vacuum-assisted biopsy are being increasingly utilised in the diagnosis and management of breast conditions. The purpose of this study was to report the outcome of a series of vacuum-assisted biopsies and vacuum-assisted excisions performed by specialist breast surgeons in a largely outpatient setting. An Australian multicentre trial of ultrasound-guided surgeon-performed vacuum-assisted biopsy (VAB) and vacuum-assisted excision (VAE) of breast lesions was conducted involving three surgeons in three participating centres. VAEs were performed for presumed or proven benign breast lesions only. A total of 225 surgeon-performed ultrasound-guided vacuum-assisted procedures were undertaken in 197 patients. Of the 225 VAB procedures, 51 (22.7%) were performed as diagnostic cores and 174 (77.3%) were undertaken as core excisions. Of the 174 VAE procedures undertaken with intent of completely excising the lesion, successful excision of the lesion was achieved in 165 of these cases (94.8%), with complete excision being judged by the absence of any lesion seen on ultrasound following the procedure or the absence of the lesion on a subsequent interval ultrasound examination. A total of 199 procedures were performed in the outpatients setting under local anaesthesia, and 26 procedures were performed in an operating theatre setting under neurolept anaesthesia. The average size of lesions was 19.3mm in the diagnostic core group and 10.6mm in the core excision group. The average time for either procedure was approximately 14min. Specialist breast surgeons familiar with ultrasound can be readily upskilled to perform vacuum-assisted procedures safely and expeditiously. VAE represents a minimally invasive method of breast lesion management and is a technique with which breast surgeons should become adept.

How Can We Improve Education of Breast Surgeons Across Europe?

European Board of Surgery Qualification in Breast Surgery (EBSQ in BS): phase 1-eligibility assessment (CV, logbook, references); phase 2- test; phase 3- oral examination with 2 clinical cases and 1 critical review of academic paper. The applicant must hold a current license to practice as a surgeon (general or plastic or gynaecologist), demonstrate work for one year in a breast surgery unit with at least 150 new primary breast cancer cases per year, attended at least one national/ international training course in breast surgery and has attended at least one well recognized international congress. The applicant should present a signed log book for breast surgery with application; published either one paper or book chapter on breast disease Conclusions 1. The need for certified breast units: Standardised techniques by specialist breast surgeons across Europe should be the aim. 2. No man'™s land. Across Europe oncoplastic reconstruction is performed by specialist breast, general or plastic surgeons, sometimes in collaboration with each other. There may be dispute as who should or should not be involved. This needs to be addressed. 3. Oncoplastic reconstruction technique expansion. Significant expansion in number, variety and complexity of available techniques is a fact. A good example would be a 6-fold increase together with a low rate of complications in some Eastern European countries over the last decade 4. CME. European breast surgeons want to improve their skills, as evidenced by fully or overbooked ESSO-endorsed breast surgery courses and other high quality workshops. Applications for the European Examination in Breast Surgery (EBSQBS) continue to increase.

What is the clinical significance of the volume of tissue excised in ROLL?

To the Editor, I read with great interest the article by Postma et al. [1], entitled, ‘Efficacy of ‘‘radioguided occult lesion localisation’’ (ROLL) versus ‘‘wire-guided localisation’’ (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial’, in Breast Cancer Res Treat (2012) 136:469–478. This is without doubt the most robust randomised controlled trial (RCT) out of the six RCTs performed to date comparing ROLL to WGL [1– 6]. The authors comprehensively reviewed this very important subject area of the management of non-palpable breast cancers. The authors concluded that ROLL cannot replace WGL as the standard of care because of larger volume excisions. This was based on their finding that the median volume of specimens excised was 71 versus 64 cm for the ROLL and WGL groups, respectively and this was statistically significant (P \ 0.017). However, what is the true clinical significance of this difference? Traditionally the concern has always been due to the risk of poor cosmetic outcomes. Postma et al. [1] state clearly that despite the differences in volumes of excised specimens, there is no measurable difference in cosmetic outcome. It is true that several studies have demonstrated the relationship between poor cosmetic outcome and greater volumes of excised tissue [7–9]. However, the latest of these studies was performed over 10 years ago [7–9] and the oldest nearly 20 years ago [8]. Twenty years in a rapidly evolving specialty like breast surgery is the equivalent of a lifetime. In particular, a dramatic shift from purely oncological considerations to also consideration of patient psychological morbidity from poor cosmetic outcome has evolved into the specialist breast surgeon’s mindset. This has led to a separation from the performance of breast surgery by the general surgeon who could achieve oncological control but was not trained in plastic reconstruction techniques, to the oncoplastic surgeon who has not only the skills to achieve oncological clearance but also the skills to achieve appropriate cosmetic outcomes. Indeed, one can consider extreme examples of breast-conserving surgery where oncoplastic techniques have been applied to achieve excellent cosmetic outcomes. Clough et al. [10] in their cohort of 101 patients requiring extensive resections in breast-conserving surgery were able to achieve favourable cosmesis in 82 % of patients who required extensive resections with mean weights of excised specimens of 222 g. Petit et al. [11] demonstrated that from 111 patients treated with quadrantectomy and concomitant oncoplastic surgery, the global outcome of cosmetic assessment was good in 77.5 %, fair in 17 %, and poor in only 5.5 % of their patients with median specimen weights of 157 g. Clough et al. [10] used contralateral symmetrization in all cases whereas Petit et al. [11] used it in 88.2 % of cases. Woerdeman et al. [12] in their breast-conserving treatment of 20 large T2 and T3 breast cancers were able to achieve a mean patient satisfaction cosmetic score of 2.8 out of 3 without contralateral symmetrization. It has to be accepted that the armoury of techniques available to the oncoplastic surgeon is now extensive, with the use of contralateral symmetrization available for extensive resections. Since some oncoplastic techniques can achieve satisfactory cosmetic outcomes with very large volume excisions, it is very unlikely that a median greater volume excision of 7 cm in ROLL as observed by Postma et al. [1] would be detrimental to cosmetic outcome, and even Postma et al. [1] concede M. Ahmed (&) M. Douek Department of Research Oncology, King’s College London, Guy’s Hospital Campus, Great Maze Pond, London SE1 9RT, UK e-mail: muneer.ahmed@kcl.ac.uk

CLINICAL IMPACT OF ONCOPLASTIC SURGERY IN A SPECIALIST BREAST PRACTICE

Oncoplastic breast surgery is an integral and fundamental component of the clinical management of breast cancer. The aim of this study was to determine the proportion of oncoplastic and reconstructive breast cancer procedures undertaken within a specialist breast practice. An audit of breast-related cancer procedures was undertaken for patients with early breast cancer between 1 January 2001 and 31 December 2005, treated at the Royal Adelaide Hospital and in private practice. The proportion of oncoplastic and breast reconstructive procedures was calculated to determine the clinical effects on a specialist breast-surgical practice. Breast cancer resection procedures accounted for 1514 of 2113 of operations (72%). Most of these (897 of 1514, 59.2%) were wide local excision or re-excision procedures. Total breast reconstruction operations (i.e. autogenous tissue flaps, tissue expander/implant reconstructions) accounted for 251 procedures. Of these, 67 (26.7%) were carried out at the time of simple mastectomy. Contralateral breast procedures (i.e. reduction mammaplasty, mastopexy and augmentation) accounted for 138 procedures and nipple-areola reconstruction/tattoo accounted for 153 procedures. Oncoplastic procedures, such as skin-sparing mastectomy, latissimus dorsi miniflap and therapeutic mammaplasty accounted for 57 of 599 procedures (9.5%). Breast reconstruction and oncoplastic operations accounted for 599 of 2113 procedures (28%). Specialist breast surgeons trained in breast reconstruction and oncoplastic techniques can expect a substantial proportion of their breast practice to include such operative procedures (28% in this series). Subspecialist training in breast surgery should incorporate experience in breast reconstructive and aesthetic surgery for trainees who wish to practise as specialist breast surgeons in the future.

Breast reconstruction - state of the art

Over the last 10–20 years breast surgery has undergone gradual but radical transformation, starting with the multicenter trials of mastectomy versus breast conservation in the 1980s. Surgical change has occurred in parallel with a substantial increase in the understanding of the biology of breast cancer, the mechanisms of estrogen action and blockade, more effective adjuvant chemotherapy and radiotherapy, and earlier diagnosis. The multidisciplinary team, the emergence of specialist breast surgeons from traditionally different historical surgical specialties, and an abandonment of the ‘one size fits all’ philosophy for oncological surgery and breast reconstructive surgery further enhance modern patient care. Better survival, quality of life issues, and increased patient and surgeon expectations have led not only to a surge in total breast reconstruction techniques, but also to the development of partial breast reconstruction after wide local excision for malignancy.

Breast cancer management: the perspective of general practitioners in inner and eastern Melbourne

This study sought to explore general practitioners' (GPs') experience with specialist breast services and to identify their communication, education and resource requirements regarding care of the breast cancer patient, by means of a self-administered questionnaire distributed to 450 GPs in inner and eastern Melbourne. Twenty-three per cent of questionnaires were returned. On average, GPs had one patient newly diagnosed with breast cancer per year. GPs were most likely to refer symptomatic patients to a private specialist breast surgeon. Their referral pattern was largely influenced by previous experience of referral to the service. Communication with specialist breast services was generally satisfactory during the initial stages of diagnosis and treatment; however discharge communication, phone communication with specialists, and admission notification was less satisfactory. When given a list of topics in which GPs may require further education, 65% of respondents identified "Recent advances in breast cancer management" as an area of interest, and the majority requested a directory listing breast services in their local area.

Management of benign disease of the breast

The management of benign breast disease provides the majority of the workload for a specialist breast surgeon in the outpatient setting. Ninety percent of referrals to the symptomatic breast clinic will be for the assessment of the signs and symptoms of benign breast conditions. It is essential not to underestimate the impact of these signs and symptoms and to rapidly make the correct diagnosis and reassure the exclusion of an underlying breast cancer. Nipple discharge may account for 8% of referrals and is perceived by the public to be closely associated with breast cancer. Often a well taken clinical history will direct one to the appropriate diagnosis before examination or breast imaging. The common causes of discharge (physiological, duct ectasia, periductal mastitis, epithelial hyperplasia, intraductal papilloma) often have characteristic features. However, the clinician must maintain an index of suspicion to prevent an underlying breast carcinoma (associated with 10% of cases of nipple discharge) from being overlooked. The incidence of acute infections of the breast has declined in the UK due to improved personnel hygiene. The early prescription of appropriate antimicrobial agents has also reduced the presentation of established breast abscesses. Traditionally, breast infection is classified as lactational and non-lactational, the latter being closely associated with cigarette smoking. The aggressive inflammatory breast cancer may present with a clinical picture identical to a florid infection; suspicion being raised when there is no response to appropriate treatment. Mastalgia is a common and sometimes debilitating problem that affects many women. It is vital to establish whether the pain is cyclical or non-cyclical or located in the chest wall. There are many preparations available for the management of mastalgia, although little decisive evidence for efficacy. An underlying carcinoma is a very rare cause for pain and exclusion of this fear may result in acceptance of symptoms in the majority of cases.

A survey of surgical management of the axilla in UK breast cancer patients

The aim of our study was to survey management of the axilla by specialist breast surgeons in the United Kingdom (UK). The questionnaire was returned by 371 surgeons, 366 (99%) were consultants and 96% treated more than 50 cases of breast cancer every year. 28% treated patients with invasive breast cancer by axillary clearance (AxCl) alone, 5% used sampling alone (AxNS), 40% used both AxCl and AxNS, 10% AxCl and sentinel lymph node (SLN) biopsy and 17% AxCl, AxNS and SLN biopsy. 9% cleared to level I, and sometimes to level II, 42% to level II and 49% to level III. 56% tried to preserve one or multiple intercostal nerves and 44% routinely divided the intercostalbrachial nerves. 52% performed SNB within trials alone and 36% out side of trials only. A range of techniques were described for the SLN biopsy procedure. There is no consistent practice of managing the axilla in the UK and standardisation is required. SLN biopsy is performed both within and outside of trials and a variety of techniques are used.

Testicular tumours presenting as gynaecomastia

Aim: Gynaecomastia is the commonest benign breast condition seen in men. It is usually due to age, co-existing disease, drugs or idiopathic factors. Rarely is the cause a testicular tumour. We have assessed those men who were subsequently diagnosed as having a testicular tumour in a population of men referred to a specialist breast surgeon. Methods: A retrospective review of 175 men who had presented with breast enlargement and/or ‘lumps’ over seven years (1993–2000) to a specialist breast surgeon was performed. All patients were investigated by a protocol including biochemical assessment. Results: 175 men, median age 44 years (range 18–89) who presented to the breast clinic were assessed. 127 men had gynaecomastia (39 bilateral), 8 had breast cancer and 4 had testicular cancer. Of the men with testicular tumours, two had bilateral gynaecomastia; a testicular mass was palpable in two and the diagnosis confirmed on scrotal ultrasound in all four. Conclusion: The possibility of a testicular tumour must be considered in any male presenting with gynaecomastia. Clinical testicular examination is essential and the determination of serum tumour markers useful in the overall assessment of those presenting with ‘true gynaecomastia’.

Audit of patient's waiting time to see their family doctor prior to referral to a fast-access breast clinic in the era of a guaranteed 2-week wait

Purpose: A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley. Methods: Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18–84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology. Results: Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the ‘2-week wait’ period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days. Conclusion: A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.

Audit of patient's waiting time to see their family doctor prior to referral to a fast-access breast clinic in the era of a guaranteed 2-week wait

Purpose: A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley. Methods: Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18–84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology. Results: Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the ‘2-week wait’ period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days. Conclusion: A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.

Breast cancer management: is volume related to quality? Clinical Advisory Panel.

A method of carrying out region-wide audit for breast cancer was developed by collaboration between the cancer registry, providers and purchasers as part of work to fulfill the 'Calman-Hine' recommendations. In order to test the audit method, a retrospective audit in North Thames East compared practice in 1992 against current guidelines. The analysis compared care in specialist and non-specialist centres. A stratified random sample comprising 28% of all breast cancer patients diagnosed in 1992 was selected from the population-based Thames Cancer Registry. The data for 309 patients with stage I-III tumours were analysed by hospital type using local guidelines. No difference between specialist (high volume) and non-specialist centres was detected for factors important in survival. Pathological staging was good with over 70% reporting tumour size and grade. A small number of patients were undertreated; after conservative surgery, 10% (19) of women did not receive radiotherapy, and 15% (8) of node-positive premenopausal women did not receive chemotherapy or ovarian ablation. In contrast, a significant trend with hospital volume was found for several quality of life factors. These included access to a specialist breast surgeon and specialist breast nurses, availability of fine-needle aspiration (FNA), which ranged from 84% in high-volume to 42% in low-volume centres, and quality of surgery (axillary clearance rates ranged from 51% to 8% and sampling of less than three nodes from 3% to 25% for high- and very low-volume centres respectively). Confidential feedback of results to surgeons was welcomed and initiated change. The summary information gave purchasers information relevant to the evaluation of cancer services. While the audit applied present standards to past practice, it provided the impetus for prospective audit of current practice (now being implemented in North Thames).

Breast cancer management: a rural perspective.

Audit of a general surgical practice in the rural Victorian town of Echuca identified 28 new patients with breast cancer between September 1992 and August 1995 (10% of those with breast conditions). The rural setting was no impediment to breast conservation (achieved in 68% of the 25 who had surgery) or to a multidisciplinary approach (management was planned in conjunction with an oncologist and/or specialist breast surgeon for 26 of the 28 patients).

Breast reconstruction after mastectomy

<h2>Abstract</h2> The management of the woman with breast cancer who requires mastectomy should involve a multidisciplinary approach which includes close collaboration between the oncological surgeon, the medical oncologist, the radiation oncologist and the reconstructive surgeon. The reconstructive surgeon can be a useful source of information for the patient with respect to the available options for breast reconstruction as well as appropriate techniques and timing. Current evidence supports the use of immediate breast reconstruction which can be performed either by specialist breast surgeons who are trained in both oncological and reconstructive surgery, or by a plastic surgeon. Advances have made reconstruction possible for almost all patients. The goals of breast reconstruction include creation of a long lasting, natural breast which meets the psychological and aesthetic needs of the patient without major morbidity at the donor site or compromise of sound oncolgic management. Autologous tissue reconstruction using the TRAM flap has become the preferred method in the USA due to the excellent results which are achieved without the need for silicone implants. Although these procedures are not without complications, careful patient selection and modifications of the technique have added to breast reconstruction safety and reliability. Current evidence supports the use of immediate breast reconstruction which can be performed either by specialist breast surgeons who are trained in both oncological and reconstructive surgery or by a plastic surgeon.

Specialist breast surgeons perform less benign breast operations

Objective: to determine the effect a specialist breast surgeon working in a team with a radiologist, cytopathologist and nurse specialist has on surgery for benign breast disease compared with non-specialist surgeons working in the same district general hospital. Data was collected prospectively between 1987 and 1992. Main outcome measures: the accuracy of pre-operative assessment and the number of operations performed for benign disease. Results: clinical assessment is uncertain in 50% of cases. Mammography has a sensitivity of 87% with a specificity of 99.7%. Fine needle aspiration cytology had a specificity of 97% with a sensitivity of 94% if an adequate sample was provided. Using all three malignancy can be predicted with a sensitivity of >99%. Using a policy of leaving benign lumps alone the specialist breast team has reduced the number of benign operations from 19% of new patients seen to 12% of new patients seen (p < 0.01 chi square). Conclusion: patients with breast disease should be seen by a specialist surgeon working in a team with a radiologist, cytopathologist and clinical nurse specialist. Every effort should be made to make a pre-operative diagnosis, and if the lump is benign on clinical, imaging, and cytological assessment it need not be removed.