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Introduction Wire guided localization has been widely utilized as the standard method of pre-operative localization of breast lesions. Magnetic seeds were developed to counter some of the disadvantages associated with wires. This aim of this study was to assess outcomes following the introduction of magnetic seeds at a tertiary specialist breast centre. Methods A retrospective review of a prospective database of the first 100 patients who underwent magnetic seed (Magseed) guided breast surgery between November 2018 and November 2019. Data was collected from 17 wire guided cases completed during the trial phase for comparison. The primary outcome measures were successful excision of index lesion and retrieval of the magnetic seed. Secondary outcomes analyzed included time ready for theatre, post-operative complications and breast margin re-excision rate. Results Of these 100 cases, 85 patients underwent Magseed guided wide local excision for invasive or in-situ carcinoma and 15 underwent Magseed guided diagnostic excision. The primary lesion was excised, and Magseed was retrieved in all 100 cases. 54% of patients were ready to proceed as the first scheduled theatre case of the day, compared to 0% of wire-guided cases. Amongst therapeutic Magseed guided cases, the re-excision rate for margin clearance was 9.4%. Conclusion Magseed guided breast excision is a new technology that has been implemented with relative ease in our unit. We have shown that magnetic seed guided surgery reliably localizes lesions, is associated with low re-excision rates without an increase in patient morbidity or mortality and results in improvements in theatre planning and efficiency.

Introduction Lobular neoplasia is a term encompassing both atypical lobular hyperplasia and lobular carcinoma in situ. These pathological findings are of uncertain malignant potential and predispose to a higher lifetime risk of breast cancer. Debate surrounds the management of such lesions, with the rationale for diagnostic excision based on the possibility of upgrading to malignancy. In this study, we report the upgrade rate of these lesions and risk of subsequent development of breast cancer. Methods This is a retrospective review of a prospectively maintained data base of all biopsies of breast screening-detected abnormalities in a single Irish breast-screening unit. We included all patients with lobular neoplasia on core needle biopsy who underwent diagnostic excision from 2005 to 2012. We excluded those who had concurrent high-risk lesions on biopsy. End points included upgrade rate and subsequent diagnosis of malignancy on follow-up. Results During the study period, 66 patients met criteria for inclusion, with a mean age of 53.74 years. Upgrade rate following excision was 13.64% (n = 9/66). Of those not upgraded, 7.02% (n = 4/57) were subsequently diagnosed with malignancy. Median time to diagnosis was 59.61 months (range = 10.5-124.4). Conclusion There is a significant rate of upgrade following diagnostic excision of lobular neoplasia, supporting the practice of diagnostic excision. There is an increased lifetime risk of breast cancer for women with a diagnosis of lobular neoplasia, with many of these cancers occurring outside the standard five-year monitoring period, suggesting a potential benefit in extending surveillance.

Nipple-sparing mastectomy with immediate implant reconstruction is an increasingly popular technique for both treatment of breast cancer and risk-reducing surgery, with an evolving body of evidence confirming low complication rates and satisfactory patient outcomes. Immediate implant reconstruction usually requires use of one of many available meshes for complete implant coverage. The aim of this study was to assess outcomes after nipple-sparing mastectomy using synthetic absorbable TIGR mesh. A retrospective review of a prospectively maintained database of 164 skin and nipple-sparing mastectomies with immediate implant reconstruction using TIGR mesh was performed. Data was retrieved and cross-checked with electronic patient records. Data was analysed with regard to patient demographics, indications for surgery, surgical procedure, complication rates and locoregional recurrence rates. Of 164 implant reconstructions, forty-three were performed after nipple-sparing mastectomy. No differences in outcomes were seen between the two groups except for a higher incidence of skin or nipple necrosis in the nipple-sparing group (12% versus 2%). There was no nipple loss in this cohort. Infection rate in the nipple-sparing group was 9% versus 11% in the skin-sparing group, with implant loss rates of 9% and 6%, respectively. Mean follow-up was 23.6 months. Our study has shown that immediate implant reconstruction after nipple-sparing mastectomy using TIGR mesh is safe and feasible, with low rates of early and medium-term complications. Level of evidence: Level III, therapeutic study.

In many centers internationally, current standard of care is to excise all papillomas of the breast, despite recently reported low rates of upgrade to malignancy on final excision. The objective of this study was to determine the upgrade rate to malignancy in patients with papilloma without atypia. A retrospective review of a prospectively maintained database of all cases of benign intraductal papilloma in a tertiary referral symptomatic breast unit between July 2008 and July 2018 was performed. Patients with evidence of malignancy or atypia on core biopsy and those with a history of breast cancer or genetic mutations predisposing to breast cancer were excluded. One hundred and seventy-three cases of benign papilloma diagnosed on core biopsy were identified. Following exclusions, the final cohort comprised of 138 patients. Mean age at presentation was 51. Mean follow-up time was 9.6 months. The most common symptom was a lump (40%). Of the 124 patients who underwent excision, three had ductal carcinoma in situ and there were no cases of invasive disease, giving an upgrade rate to malignancy of 2.4%. Upgrade to other high-risk lesions (atypical lobular and ductal hyperplasia and lobular carcinoma in situ) was demonstrated in 15 cases (12.1%). Benign papilloma was confirmed in 100 cases (81.5%), and 6 (4.8%) had no residual papilloma found on final excision. Twelve patients (8.7%) were managed conservatively. Of those, one later went on to develop malignancy. Patients with a diagnosis of benign papilloma without atypia on core biopsy have a low risk of upgrade to malignancy on final pathology, suggesting that observation may be a safe alternative to surgical excision. Further research is warranted to determine which patients can be safely managed conservatively.

INTRODUCTION: Atypical intraductal epithelial proliferation (AIDEP) is a breast lesion categorised as “indeterminate” if identified on core needle biopsy (CNB). The rate at which these lesions are upgraded following diagnostic excision varies in the literature. Women diagnosed with AIDEP are thought to be at increased risk of breast cancer. Our aim was to identify the rate of upgrade to invasive or in situ carcinoma in a group of patients diagnosed with AIDEP on screening mammography and to quantify their risk of subsequent breast cancer. METHODS: We conducted a retrospective review of a prospectively maintained database containing all patients diagnosed with AIDEP on CNB between 2005 and 2012 in an Irish breast screening centre. Basic demographic data was collected along with details of the original CNB result, rate of upgrade to carcinoma and details of any subsequent cancer diagnoses. RESULTS: In total 113 patients were diagnosed with AIDEP on CNB during the study period. The upgrade rate on diagnostic excision was 28.3% (n = 32). 6.2% (n = 7) were upgraded to invasive cancer and 22.1% (n = 25) to DCIS. 81 patients were not upgraded on diagnostic excision and were offered 5 years of annual mammographic surveillance. 9.88% (8/81) of these patients went on to receive a subsequent diagnosis of malignancy. The mean time to diagnosis of these subsequent cancers was 65.41 months (range 20.18–145.21). CONCLUSION: Our data showing an upgrade rate of 28% to carcinoma reflects recently published data and we believe it supports the continued practice of excising AIDEP to exclude co-existing carcinoma.

INTRODUCTION: Phyllodes tumours represent 0.3–1% of breast tumours, typically presenting in women aged 35–55 years. They are classified into benign, borderline and malignant grades and exhibit a spectrum of features. There is significant debate surrounding the optimal management of phyllodes tumour, particularly regarding appropriate margins. METHODS: This is a retrospective review of a prospectively maintained database of patients who underwent surgical management for phyllodes tumours in a single tertiary referral centre from 2007–2017. Patient demographics, tumour characteristics, surgical treatment and follow-up data were analysed. Tumour margins were classified as positive (0 mm), close (≤2 mm) and clear (>2 mm). RESULTS: A total of 57 patients underwent surgical excision of a phyllodes tumour. The Mean age was 37.7 years (range: ages 14–91) with mean follow-up of 38.5 months (range: 0.5–133 months). There were 44 (77%) benign, 4 (7%) borderline and 9 (16%) malignant phyllodes cases. 54 patients had breast conserving surgery (BCS) and 3 underwent mastectomy. 30 (53%) patients underwent re-excision of margins. The final margin status was clear in 32 (56%), close in 13 (23%) and positive in 12 (21%). During follow-up, 4 patients were diagnosed with local recurrence (2 malignant, 1 borderline and 1 benign pathology on recurrence samples). CONCLUSION: There are no clear guidelines for the surgical management and follow-up of phyllodes tumours. This study suggests that patients with malignant phyllodes and positive margins are more likely to develop local recurrence. There is a need for large prospective studies to guide the development of future guidelines.

e12571 Background: There is increasing reliance on data provided by genomic risk assessment assays to guide therapeutic decisions. The objective of this prospective study was to assess the impact of the Oncotype DX Breast DCIS Score assay on radiation treatment recommendations in patients with DCIS undergoing BCS. Methods: This decision impact study is a prospectively enrolled observational study of newly diagnosed patients (n = 135) following BCS for removal of DCIS of all grades 30mm or less with clear margins (i.e. 2 mm or normal re-excised margins). Only patients who were candidates to receive radiation therapy were considered. Fifteen patients withdrew from the study or had insufficient volume of DCIS for assay analysis. Radiation Oncologists were blinded to the Oncotype DX Breast DCIS Score assay prior to recording their recommendation for radiotherapy or not. IRB approval was granted following review of study protocol and informed consent was obtained from all patients. Results: Among 120 patients tested, the Oncotype DX Breast DCIS Score assay determined that 58/120 (48.3%) of patients had a low score (LS) (0-38), 30/120 (25%) had an intermediate score (IS) (39-54) and 32/120 (26.7%) had a high score (HS) (>55). The Oncotype DX Breast DCIS Score assay concurred with the Radiation Oncologists recommendation to proceed with radiation treatment in 96.7% of patients (i.e. 60/62 patients with an IS or HS). The Oncotype DX Breast DCIS Score assay altered treatment decisions in 12.5% (4/32) of patients with a HS and in 7.1% (2/28) patient with an IS. In patients where the Oncotype DX Breast DCIS Score assay altered treatment recommendation all had a low volume (i.e. less than 10mm) of high/intermediate grade DCIS with an IS or HS. Conclusions: This study demonstrates that Oncotype DX Breast DCIS Score assay accurately supports the selection of patients with DCIS for radiation treatment and equally can be helpful in selecting a subgroup of patients with small volumes of intermediate/high grade DCIS who can potentially avoid radiotherapy.

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities. Three key recommendations emerged from the meeting. First, the effect of oncoplastic breast-conserving surgery on quality of life and the optimal type and timing of reconstruction after nipple-sparing or skin-sparing mastectomy with planned radiotherapy should be addressed by prospective cohort studies at an international level. Second, the role of adjunctive mesh and the positioning of implants during implant-based breast reconstruction should ideally be investigated by randomised controlled trials of pragmatic design. Finally, the BREAST-Q questionnaire is a suitable tool to assess primary outcomes in these studies, but other metrics to measure patient-reported outcomes should be systematically evaluated and quality indicators of surgical morbidity should be further assessed.

Triple negative breast cancers (TNBCs) represent a distinct subgroup of breast cancers with an immunohistochemical phenotype that is negative for oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2). The aim of this article is to provide a broad overview of recent developments in the diagnosis and management of TNBC for surgical oncologists. This overview discusses the subtypes of TNBC and the relationship between this type of breast cancer and the BRCA1 gene. In addition, the article explores recent advances in the treatment of TNBC from a surgical, radiation, and medical oncology point of view. Lastly, evolving therapeutic strategies that have potential to enhance outcomes for patients with TNBC are also discussed.

Purpose Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion. Methods The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology. Results Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference. Conclusions In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques. Electronic supplementary material The online version of this article (10.1007/s10549-018-4937-1) contains supplementary material, which is available to authorized users.

High-risk breast cancer screening for BRCA1/2 mutation carriers with clinical breast exam, mammography and MRI has reported sensitivity of 100 %, but BRCA1/2 mutation carriers still present with interval cancers. We investigated the presentation and screening patterns of an Irish cohort of BRCA1/2 mutation carriers with breast cancer. BRCA1/2 mutation carriers with breast cancer were identified in this retrospective cohort study. Records were reviewed for BRCA1/2 mutation status, demographics, screening regimen, screening modality, stage and histology at diagnosis. Fifty-three cases of breast cancer were diagnosed between 1968 and 2010 among 60 Irish hereditary breast ovarian cancer (HBOC) families. In 50 of 53 women, the diagnosis of breast cancer predated the identification of BRCA1/2 mutations. Breast cancer detection method was identified in 47 % of patients (n = 25): 80 % (n = 20) by clinical breast exam (CBE), 12 % by mammography (n = 3), 8 % by MRI (n = 2). Fourteen women (26 %) developed a second breast cancer. Ten of these patients (71 %) were involved in regular screening; 50 % were detected by screening mammography, 20 % by MRI and 30 % by CBE alone. Six patients (43 %) had a change in morphology from first to second breast cancers. There was no change in hormone receptor status between first and second breast cancers. In this cohort of Irish BRCA1/2 mutation carriers, compliance with screening was inconsistent. There was a 30 % incidence of interval cancers occurring in women in high-risk screening. Preventive surgery may be a more effective risk reduction strategy for certain high-risk women.

Management of axillary disease in breast cancer has evolved significantly over the last two decades with the introduction of SLNB and a trend towards less radical surgery. Data from the American College of Surgeons Oncology Group Z0011 trial proposes that not all patients with positive axillary lymph nodes require completion axillary dissection. The aim of this study was to determine whether there has been a change in practice patterns for axillary management in Ireland since the publication of this ‘practice-changing’ trial. A review of breast cancers managed in the 12 months prior to publication of Z0011 (pre-Z0011) and comparison with those managed in the following 12 months (post-Z0011) was undertaken in three tertiary referral breast cancer centres. Patients with a positive SLNB were identified, and clinicopathologic data and subsequent management was compared between the two cohorts. There were 708 SLNB performed during the study period; 326 pre-Z0011 and 382 post-Z0011. There was no difference in the rate of SLN positivity between the two cohorts: 29.1 % had a positive SLN pre-Z0011 and 29.3 % were positive post-Z0011. There were a significantly lower number of axillary clearances performed in SLN-positive patients in the post-Z0011 period (71.4 %) compared to the pre-Z011 period (93.7 %, p = 0.0022 Chi-square). Of the patients with tumour characteristics meeting the Z0011 inclusion criteria in the initial 12 months of the study, 92.3 % underwent ALND compared with 65.6 % in the final 12 months of the study (p = 0.0006 Chi-square). There has been a change in clinical practice since the publication of the Z0011 trial, illustrated by a decrease in the rate of axillary clearance in node-positive breast cancers.

Background Retrograde transcatheter aortic valve implantation (TAVI) can be performed under local anesthesia (LA) or general anesthesia (GA); however, a wide variation in practice exists. Methods PubMed was searched between 2009 and 2013. Data were extracted from eligible studies. Random-effects meta-analysis was performed using DerSimonian Laird between-study variance. Results There was no statistically significant difference identified between groups based on age or EuroSCORE. There was no statistically significant difference seen in all-cause mortality, or complication rates between groups. Mean procedural duration was 36 minutes shorter in the LA group ( p = 0.001). There was increased vasopressor use in the GA group (odds ratio 3.92; p = 0.017). Mean hospital stay was 3.41 days shorter in the LA group ( p = 0.018). Conclusion Results suggest that the use of LA for retrograde TAVI is feasible. There are several potential benefits associated, shorter procedural duration, and hospital stay with lower vasopressor requirements. Further studies and randomized trials are mandatory to confirm the presented findings and to identify those patients for whom LA would be appropriate.

Approximately 20 % of patients diagnosed with colorectal cancer will have distant metastases at first presentation (stage IV disease). The effect of removing the primary tumor on survival for patients with stage IV disease with unresectable metastases remains unclear. To address this a meta-analysis of all studies comparing primary tumor resection with chemotherapy alone in cases of stage IV colorectal cancer with unresectable metastases was performed.A comprehensive search for published studies examining the effect of primary tumor resection in the setting of colorectal cancer with unresectable metastases was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data.There were 21 studies including a total of 44,226 patients that met the inclusion criteria. Resection of the primary tumor in patients with unresectable metastases compared with chemotherapy alone was associated with a lower mortality risk (OR 0.28; 95 % CI 0.165-0.474; P 0.001), translating into a difference in mean survival of 6.4 months in favor of resection (95 % CI 5.025-7.858, P 0.001). Patients who underwent resection of the primary tumor were more likely to have liver metastasis only (OR 1.551; 95 % CI 1.247-1.929; P 0.001), were less likely to have ≥2 metastasis (OR 0.653; 95 % CI 0.508-0.839; P = 0.001), and were less likely to have rectal cancer (OR 0.495; 95 % CI 0.390-0.629; P 0.001). There was significant cross-study heterogeneity.Resection of the primary tumor may confer a survival advantage in stage IV colorectal cancer with unresectable metastases but significant selection bias exists in current studies. Randomized controlled trials are essential to validate these findings.

OBJECTIVES: Paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) is associated with poor survival. The two main valve delivery systems used to date differ significantly in both structure and deployment technique. The primary objective of this study was to perform a systematic review and meta-analysis of studies identifying PVR in patients post-TAVI using Medtronic CoreValve (MCV) and Edward Sapien (ES) valves in order to identify whether a significant difference exists between valve types. The secondary objective was to identify additional factors predisposing to PVR to provide an overview of the other associated considerations. METHODS: A systematic review and meta-analysis of the current literature to identify PVR rate in patients with MCV and ES valves was performed. We also sought to examine other factors predisposing to PVR. RESULTS: A total of 5910 patients were identified from 9 studies. PVR rates for MCV and ES were analysed. MCV was associated with a higher PVR rate of 15.75% [95% confidence interval (CI) 12.48–19.32] compared with ES 3.93% [95% CI 1.05–8.38]. We separately reviewed predisposing factors associated with PVR. A formal comparison of the MCV and ES valve leakage rates by mixed-effects meta-regression with a fixed-effect moderator variable for valve type (MCV or ES) suggested a statistically significant difference in leakage rate between the two valve types (P= 0.0002). CONCLUSIONS: Unfavourable anatomical and pathological factors as well as valve choice have an impact on rates of PVR. Additionally, certain anatomical features dictate valve choice. A direct comparison of all the predisposing factors at this time is not possible and will require prospective multivariate analysis. There is, however, a significant difference in the PVR rates between valves based on the published observational data available to date. The ES valve associated with a lower incidence of PVR overall; therefore, we conclude that valve choice is indeed a significant determinant of PVR post-TAVI.

Whole breast irradiation (WBI) over 5-7 weeks has long been considered standard adjuvant treatment after breast-conserving surgery. Recently the concept of irradiating the whole breast has been challenged by accelerated partial breast irradiation (APBI), which exclusively targets the lumpectomy site plus margin. We review the evidence supporting APBI from modern clinical trials, the pros and cons of various APBI techniques, and the controversies regarding the applicability of APBI to specific patient groups.

Background Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers. Methods Consecutive patients ( n = 282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates. Results From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education. Conclusion ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.

Background We hypothesized that the introduction of a short-stay pathway would result in a significant reduction in length of stay for patients undergoing unilateral mastectomy, without a negative impact on patient safety. Materials and methods As part of a quality improvement project, a multidisciplinary committee designed a 1-day stay program for unilateral mastectomy patients. The study period was the first year after the 1-day pathway had routinely been implemented. We report on consecutive patients undergoing unilateral mastectomy ± tissue expander at Memorial Sloan-Kettering Cancer Center from July 1, 2009 to June 30, 2010. The primary endpoint was the percentage of patients discharged on postoperative day 1. Secondary endpoints included the incidence of postoperative complications within 30 days of surgery, reoperations, readmissions, and urgent-care visits within 7 days. Results Over a 12-month period, 537 patients underwent unilateral mastectomy. Of those, 82.7% (444/537) were performed on a 1-day hospitalization basis, compared with 9.6% in 2008, before implementation of the 1-day plan. The 30-day complication rate was 6.1% (33/537). Overall, 2.6% of all patients had reoperation for hematoma (14/537), 0.9% had to be readmitted (5/537), and 1.5% (8/537) attended the urgent-care department. If all patients had stayed in the hospital for more than 1 day, none of the readmissions and only 2 urgent-care visits would have been prevented. Conclusions This study shows that a 1-day stay following mastectomy is easy to implement and safe for patients if a multidisciplinary team is involved in planning and implementation.

e22119Background: Breast reconstruction following mastectomy for breast cancer aims to maintain and promote health related quality of life (HR-QOL). This meta-analysis evaluates the effect of breas...

Despite extensive clinical experience of breast implants, there is continued controversy regarding the optimum placement of the prosthesis. More importantly, there is insufficient data to accurately determine whether subglandular (SG) or submuscular (SM) placement of the prosthesis diminishes postoperative complications. A search of published trials (n = 34) examined complication rates following SG and SM implant placement was conducted. Pubmed (MEDLINE) database was used and the available data was then cross-referenced. Eligible trials (n = 6) were then reviewed and selected data extracted. Primary outcomes measured were postoperative haematoma, infection, capsular contracture and implant migration. 3603 patients were identified from relevant trials examining postoperative complication rates for both subglandular and submuscular implant planes. The submuscular implant plane was associated with a higher incidence of postoperative haematoma (OR 2.87, 95% CI, 1.44-6.11). The incidence of capsular contracture (OR 4.77) is more common when a subglandular plane is used. No significant difference was noted in the rate of postoperative infection (OR 1.20, 95% CI 0.57-2.58) or implant migration (OR 1.56, 95%CI 0.12-87.4) between the two groups. This meta-analysis confirms that subglandular augmentation results in lower short-term morbidity; however, submuscular placement appears to provide the best long-term outcome in terms of morbidity. In the absence of randomized controlled trials comparing these two techniques, this meta-analysis provides evidence to guide surgeons to achieve the best outcomes for their patients.

Axillary lymph node dissection (ALND) is associated with significant morbidity, whilst sentinel node biopsy (SNB) has the potential to minimize complications in the management of breast cancer. The aim of this study was to systematically appraise the outcome of SNB when compared to ALND. A comprehensive search for published trials examining outcomes after SNB for breast cancer was performed using medline and cross-referencing available data. Each study was reviewed and data extracted. Primary outcomes were nodal positivity and surgery-related morbidity. A total of 9,608 patients were identified from trials comparing ALND and SNB. The overall rate of axillary lymph node positivity for those with no clinically palpable nodes was 28.8% for ALND and 27.6% for SNB (OR = 1.00, 95% CI = 0.86-1.17, P = 0.956), though there was a trend for superior detection of metastatic disease with SNB when this was compared with ALND alone (OR = 1.22, 95% CI = 0.95-1.57, P = 0.122). Patients who undergo SNB are significantly less likely to suffer post-operative morbidity relative to ALND: risk of infection (OR = 0.58, 95% CI = 0.42-0.80, P = 0.0011), seroma (OR = 0.40, 95% CI = 0.31-0.51, P = 0.0071), arm swelling (OR = 0.30, 95% CI = 0.14-0.66, P = 0.0028) and numbness (OR = 0.25, 95% CI = 0.1-0.59, P = 0.0018). SNB is at least equivalent to ALND in detecting metastatic disease in the axilla. SNB is the optimum approach in terms of morbidity for the assessment of axillary metastasis in clinically node negative breast cancer.

Background The optimal treatment of gallstones with associated common bile duct stones in the laparoscopic era is controversial. Various reviews and decision based algorithms have been published, but the superior treatment modality is unclear. Therefore, a meta-analysis was conducted to compare the two most commonly used treatment strategies. Methods A systematic review was conducted to compare single stage laparoscopic cholecystectomy with common bile duct exploration versus a combined endoscopic and laparoscopic treatment. Eligible studies were identified using a search of Medline, Embase, Cochrane and Science Citation Index Expanded databases. Appropriately selected articles were independently reviewed and data was extracted and cross referenced. A meta-analysis was conducted of the pooled trial data to determine difference in outcomes. Results A total of seven randomized trials were identified with 746 patients with 366 in the laparoscopic only treatment group and 380 in the combined endoscopic and laparoscopic treatment arms. There was no significant difference in successful bile duct clearance between the two groups (OR 1.23; 95% CI 0.55 to 2.75, P = 0.61). There was no statistical difference in morbidity (RR 1.23; 95% CI 0.92 to 1.66; P = 0.17), mortality (RD -0.00; 95% CI -0.02 to 0.01, P = 0.59) or length of hospital stay (MD -0.31; 95% CI -1.68 to 1.06, P = 0.66). However, there was a statistically significant difference in the duration of procedure in favour of the single stage laparoscopic treatment (MD -6.83; 95% CI -9.59 to -4.07, P < 0.00001). Conclusion Both the laparoscopic alone or the combined endoscopic and laparoscopic treatment approaches show comparative efficacy in management of symptomatic gallstones with associated choledocholithiasis., Pozadina Optimalno liječenje žučnih kamenaca uz prateće žučne kamence u glavnom žučovodu u eri laparoskopske kirurgije je kontroverzno. Objavljeni su razni pregledni radovi i algoritmi odlučivanja, no pitanje odluke o odabiru preporučenog načina liječenja ostaje neriješeno. S ciljem usporedbe dva najčešće korištena načina liječenja provedena je meta-analiza. Metode Sistematsko istraživanje provedeno je kako bi se usporedila kolecistektomija s eksploracijom glavnog žučovoda u jednom aktu u odnosu na kombinirano endoskopsko i laparoskopsko liječenje. Dostupne studije nađene su pomoću sljedećih baza podataka: Medline, Embase, Cochrane i Science Citation Index Expanded. Probrani relevantni radovi zasebno su pregledani, a podaci izdvojeni i međusobno uspoređeni. Provedena je meta-analiza svih prikupljenih podataka da bi se odredila razlika u ishodima. Rezultati Pronađeno je sveukupno sedam randomiziranih studija sa 746 pacijenata od kojih je 366 u skupini liječenoj isključivo laparoskopski te 380 liječenih kombinirano endoskopski i laparoskopski. Nije utvrđena značajna razlika u uspješnom čišćenju žučnih vodova između dvije skupine (OR 1,23; 95% CI 0,55 do 2,75, P = 0,61). Nije nađena značajna razlika u morbiditetu (RR 1,23; 95% CI 0,92 do 1,66; P = 0,17), smrtnosti (RD -0,00; 95% CI -0.02 do 0,01, P = 0,59) ili trajanju hospitalizacije (MD -0,31; 95% CI -1,68 to 1,06, P = 0,66). Međutim, postojala je statistički značajna razlika u trajanju zahvata (MD -6,83; 95% CI -9,59 do -4,07, P < 0,00001). Zaključak Laparoskopski ili kombinirani endoskopski i laparoskopski pristup liječenju pokazuje značajnu učinkovitost u liječenju simptomatskih žučnih kamenaca s pratećom koledoholitijazom.

Breast cancer is the most common life threatening malignancy in women. Despite advances in molecular therapeutics, many patients with apparently early stage and curable disease still develop progressive and fatal systemic disease. Haffty et al. [1] demonstrated that despite conservative surgery and radiation followed by administration of chemotherapy in early-stage (T1 tumours) breast cancer patients, the distant metastasis-free survival rate was 71% at 5 years in patients with triple negative disease and 83% at 5 years in non-triple negative. These patients have potentially been under-staged by conventional staging, and therefore may not have received optimum therapy due to their misleading clinical disease profile. Conversely, patients receiving systemic therapy may not derive any additional benefit. Breast cancer is an intricate genetic milieu characterised by numerous molecular alterations that prevents standardising therapeutic strategies to all patients. Until recently, it has been difficult to accurately profile and predict the biological properties and clinical behaviour of breast tumours, however, with the development of DNA microarray technology, it is now possible to analyse the RNA expression of several thousands of genes simultaneously. The clinical application of this technology has the potential to signal a paradigm shift in patient selection for systemic therapy. First, it provided a new molecular classification of breast cancer. This classification was proposed by Perou et al. [2], and subdivided breast cancers into four classes. Luminal-A cancers are ER-positive and mostly low grade. Luminal-B cancers are also ER-positive but tend to be high grade. Basal-like cancers are triple negative and Her-2-like cancers are Her-2 positive and usually ER negative. Currently, there are a number of validated commercially available multigene assays that identify expression of distinct sets of genes in breast cancer: Mammaprint (Agendia), Oncotype DX (Genomic Health), MapQuant and H/I (AvariaDX) (see Table 1 for comparison of assays). Mammaprint uses DNA microarray technology, whereas Oncotype DX and H/I use real time PCR based assays. These assays accurately predict the potential for disease recurrence and enhance patient selection for chemotherapeutic strategies. Mammaprint uses a 70-gene predictor and is involved in the MINDACT (Microarray In Node negative Disease may Avoid ChemoTherapy) trial [3]. The objective is to administer chemotherapy to patients deemed at high risk of recurrence, and hormonal therapy only to low risk patients, as determined by the Mammaprint gene profile. Having recruited large numbers of patients who are stratified based on the clinical and pathological risks, it is hoped that this study will provide important information regarding the prognostic capabilities of the Mammaprint test and also validate its use in identifying women associated with improved survival. Previously, Buyse et al. [4] demonstrated that Mammaprint outperformed Adjuvant Online in predicting survival in an independent group of patients. Unfortunately, however, a major disadvantage of Mammaprint is that it requires fresh tissue for analysis, which may make its clinical integration difficult. The Oncotype DX and H/I assay, however, can use archival tissue (tissue from original biopsy) and may be more readily applied to the clinical setting. By analysing the expression of 21 known genes, Oncotype DX accurately determined the prognostic outcome in hormone receptor positive cancers post adjuvant tamoxifen in a retrospective cohort of 668 M. Barry M. R. Kell (&) Eccles Breast Screening Unit, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland e-mail: malcolm.kell@breastcheck.ie

The role of primary tumor excision in patients with stage IV breast cancer is unclear. Therefore, a meta-analysis of relevant studies was performed to determine whether surgical excision of the primary tumor enhances oncological outcome in the setting of stage IV breast cancer.A comprehensive search for relevant published trials that evaluated outcomes following excision of the primary tumor in stage IV breast cancer was performed using MEDLINE and available data were cross-referenced. Data were extracted following review of appropriate studies by authors. The primary outcome was overall survival following surgical removal of the primary tumor.Data from ten studies included 28,693 patients with stage IV disease of whom 52.8% underwent excision of the primary carcinoma. Surgical excision of the primary tumor in the setting of stage IV breast cancer was associated with a superior survival at 3 years (40% (surgery) versus 22% (no surgery) (odds ratio 2.32, 95% confidence interval 2.08-2.6, p0.01). Subgroup analyses for selection of patients for surgery or not, favored smaller primary tumors, less competing medical comorbidities and lower metastatic burden (p0.01). There was no statistical difference between the two groups regarding location of metastatic disease, grade of tumor, or receptor status.Patients with stage IV disease undergoing surgical excision of the primary tumor achieve a superior survival rate then their nonsurgical counterparts. In the absence of robust evidence, this meta-analysis provides evidence base for primary resection in the setting of stage IV breast cancer for appropriately selected patients.

Over the last 10 years, intra-operative radiotherapy (IORT) has been used extensively in the clinical trial setting but has yet to make a significant clinical impact on current breast cancer management strategies. This review discusses the rationale behind IORT, the benefits and limitations of this technique over conventional whole breast radiation (WBRT), and the indications, contraindications, and appropriate patient selection criteria. In addition, the most up-to-date trial data and the role of IORT in future breast cancer management strategies are discussed.

Contralateral mastectomy, in the setting of unilateral breast cancer, may only offer a survival benefit in selected patients. In fact, most women with a unilateral breast cancer will never develop a contralateral breast cancer. Despite this, there is a rapidly increasing trend of patients undergoing contralateral prophylactic mastectomy. The Society of Surgical Oncology has provided relative clinical indications for this prophylactic procedure; however, there are other clinical and more important patient factors that are relevant to the decision. In this article, we discuss the indications for this controversial procedure and also explore the patient's motivation to undergo this preventative measure. Nevertheless, the decision to perform a contralateral mastectomy should include a multidisciplinary team approach in conjunction with a patient who has been appropriately informed regarding the risks, benefits and alternatives of this procedure.

Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications.Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years.The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs.The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.

Introduction The American College of Surgeons Oncology Group (ACOSOG), Z0011 trial, demonstrated that there was no therapeutic benefit from completion lymphadenectomy in early stage breast cancer patients with positive sentinel node (SLN) biopsy. Patients with asymptomatic screen-detected tumors may represent a subgroup where completion axillary dissection with its attendant morbidities is unacceptable. Therefore, the aim of this study was to evaluate the role of ALND in an asymptomatic screen-detected breast cancer cohort. Methods Patients were recruited from the national screening program which offers women (aged 50 to 65) biannual digital mammography. Over a 1 year period 519 screen-detected breast cancer patients were recruited of which 110 had a positive SLN. Results Of 519 patients in a national screening program that were clinically/radiologically identified as axillary node negative, 110 (21.2%) had a positive SLN. All 110 (T1 = 68, T2 = 42) patients proceeded to have an axillary clearance. 68 (59%) had T1 tumors and of these 40 (60%), despite a positive SLN, had no metastatic nodes on final pathological analysis of their axilla. In addition, 21 (50%) patients with T2 tumors had no metastatic nodes except for a positive SNB. Furthermore, only 6 (8.8%) of T1 tumors with a positive SLN had 4 or more metastatic axillary lymph nodes. Conclusion 55.45% of patients with a screen-detected T1/T2 tumor had negative completion lymphadectomy. These findings compel us to re-evaluate the role of axillary dissection in the screen-detected asymptomatic breast cancer population to avoid unnecessary ALND with its attendant morbidities.

Recent results from the ACOSOG Z0011 trial question the use of intraoperative frozen section (FS) during sentinel lymph node (SLN) biopsy and the role of axillary dissection (ALND) for SLN-positive breast cancer patients. Here we present a 10-year trend analysis of SLN-FS and ALND in our practice.We reviewed our prospective SLN database over 10 years (1997-2006, 7509 SLN procedures) for time trends and variation between surgeons in the use of SLN-FS and ALND in patients with cN0 invasive breast cancer.Use of SLN-FS decreased from 100% to 62% (P 0.0001) and varied widely by surgeon (66% to 95%). There were no statistically significant trends in the performance of ALND for patients with SLN metastases detected by FS (n = 1370, 99-99%) or routine hematoxylin and eosin (HE) (n = 333; 69-77%), but only for those detected by serial section HE with or without immunohistochemistry (n = 438; 73-48%; P = 0.0054) or immunohistochemistry only (n = 294; 48-28%; P 0.0001). These trends coincided with an increase in the proportion of completion versus immediate ALND (30-40%; P = 0.0710).Over 10 years, we have observed a diminishing rate of SLN-FS and, for patients with low-volume SLN metastases, fewer ALND, trends that suggest a more nuanced approach to axillary management. If the Z0011 selection criteria had been applied to our cohort, 66% of SLN-FS (4159 of 6327) and 48% of ALND (939 of 1953) would have been avoided, sparing 13% of all patients the morbidity of ALND.

Management options for colorectal cancer have expanded in recent years. We estimated average lifetime cost of care for colorectal cancer in Ireland in 2008, from the health care payer perspective. A decision tree model was developed in Microsoft EXCEL. Site and stage-specific treatment pathways were constructed from guidelines and validated by expert clinical opinion. Health care resource use associated with diagnosis, treatment and follow-up were obtained from the National Cancer Registry Ireland (n=1,498 cancers diagnosed during 2004–2005) and three local hospital databases (n=155, 142 and 46 cases diagnosed in 2007). Unit costs for hospitalisation, procedures, laboratory tests and radiotherapy were derived from DRG costs, hospital finance departments, clinical opinion and literature review. Chemotherapy costs were estimated from local hospital protocols, pharmacy departments and clinical opinion. Uncertainty was explored using one-way and probabilistic sensitivity analysis. In 2008, the average (stage weighted) lifetime cost of managing a case of colorectal cancer was €39,607. Average costs were 16% higher for rectal (€43,502) than colon cancer (€37,417). Stage I disease was the least costly (€23,688) and stage III most costly (€48,835). Diagnostic work-up and follow-up investigations accounted for 4 and 5% of total costs, respectively. Cost estimates were most sensitive to recurrence rates and prescribing of biological agents. This study demonstrates the value of using existing data from national and local databases in contributing to estimating the cost of managing cancer. The findings illustrate the impact of biological agents on costs of cancer care and the potential of strategies promoting earlier diagnosis to reduce health care resource utilisation and care costs.

The optimum sequencing of breast reconstruction (BR) in patients receiving postmastectomy radiation therapy (PMRT) is controversial. A comprehensive search of published studies that examined postoperative morbidity following immediate or delayed BR with combined radiotherapy was performed. Medical (MEDLINE & EMBASE) databases were searched and cross-referenced for appropriate studies where morbidity following BR was the primary outcome measured. A total of 1,105 patients were identified from 11 appropriately selected studies. Patients undergoing PMRT and BR are more likely to suffer morbidity compared with patients not receiving PMRT (OR = 4.2; 95% CI, 2.4–7.2 [no PMRT vs. PMRT]). Reconstruction technique was also examined with outcome when PMRT was delivered after BR, and this demonstrated that autologous reconstruction is associated with less morbidity in this setting (OR = 0.21; 95% CI, 0.1–0.4 [autologous vs. implant-based]). Delaying BR until after PMRT had no significant effect on outcome (OR = 0.87; 95% CI, 0.47–1.62 [delayed vs. immediate]). PMRT has a detrimental effect on BR outcome. These results suggest that where immediate reconstruction is undertaken with the necessity of PMRT, an autologous flap results in less morbidity when compared with implant-based reconstruction.

Aromatase inhibitors (AIs) are now regarded as the optimum hormonal therapy for postmenopausal women with hormone receptor positive breast cancer. However, it is unclear which of the currently available AIs offers patients the most effective and the best-tolerated treatment strategy. We performed a systematic review and meta-analysis of randomized-controlled trials that compared AIs (as first-line agents) with standard hormonal treatment in patients with breast cancer. The results suggest that letrozole offers a more favorable side-effect profile particularly in terms of musculoskeletal adverse events. However, the available data suggests a small survival benefit from the use of anastrozole although patients treated with anastrozole appear to have a more favorable disease profile at study entry. Examination of survival data on adjuvant tamoxifen therapy from these trials supports this observation.

Dual-energy X-ray absorptiometry (DEXA) is reported to be inferior to computed tomography (CT) to measure changes in appendicular soft tissue composition. We compared CT- and DEXA-measured thigh muscle and fat mass to evaluate the random and systematic discrepancies between these two methods. Thigh skeletal muscle area (single-slice CT) was suboptimally ( r2= 0.74, P < 0.0001) related to DEXA-measured thigh fat-free mass (FFM). In contrast, thigh muscle and adipose tissue volumes (multislice CT) were highly related to DEXA-measured thigh FFM and fat (both r2= 0.96, P < 0.0001). DEXA-measured leg fat was significantly less than multislice-CT-measured leg adipose tissue volume, whereas multislice-CT-measured leg muscle mass was less ( P < 0.0001) than DEXA-measured leg FFM. The systematic discrepancies between the two approaches were consistent with the 10–15% nonfat components of adipose tissue. In conclusion, CT and DEXA measures of appendicular soft tissue are highly related. Systematic differences between DEXA and CT likely relate to the underlying principles of the techniques.

Breast reconstruction is challenging to optimise in the face of optimum adjuvant therapy and we commend Thiruchelvam and colleagues on their recent review.1 However, one of their summary points says: “If radiotherapy is needed, delayed reconstruction minimises the risk of complications and improves aesthetic outcomes,” yet no …