Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery

Background

Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery.

Methods

This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice.

Results

Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit.

Conclusions

Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

TP8.1.6 Why do people remain in hospital after mastectomy?

Aims

Mastectomy is established as a safe day-case procedure. Amidst the ongoing COVID-19 pandemic it is essential to find ways to continue elective surgery with greater efficiency. The aim of this study is to establish factors associated with overnight admission after simple mastectomy, enabling more effective pre-operative planning.

Methods

All patients undergoing simple mastectomy in our unit between January and October 2020 were included. Those undergoing immediate reconstruction were excluded. The electronic case notes were reviewed to include procedure performed and patient characteristics. Basic statistical analysis was performed.

Results

95 patients underwent simple mastectomy (28 with axillary clearance and 58 with sentinel node biopsy). 56% of procedures were day-case. Axillary clearance was more common in the inpatient compared to the day-case surgery group (24% vs 45%). Both average age and ASA were significantly lower in the day-case compared to the inpatient group (p < 0.05). There was no significant difference in BMI or specimen weight between groups. 16 patients underwent simple mastectomy without drain insertion, none required admission. Of the patients admitted overnight following surgery, 50% were pre-planned admissions. 57% of these were for patients identified as high surgical or anaesthetic risk at pre-operative assessment. Overall 5 patients stayed in hospital due to patient preference.

Conclusions

In addition to axillary surgery performed, age, ASA and perceived pre-operative risk are associated with overnight admission following simple mastectomy. Knowledge of these factors can better inform pre-operative planning. Providing enhanced post-operative support at home may enable more patients to be discharged on day of surgery.

108 Developing A Non-Biopsy Protocol for The Female Cohort 25-29 Years with Clinically Typical Fibroadenoma Conforming to Maxwell Criteria on Ultrasound – Our Peninsular Experience in Wirral

Introduction

The aim of this study was to introduce a non –biopsy protocol in our department for benign breast lump referrals confirmed as typical U2/3 fibroadenoma on imaging. Current UK guidance is not to biopsy sonographically typical fibroadenoma in women under 25 years. We have studied our population extending the radiological Maxwell criteria reflecting benign outcomes in 25-29 years cohort.

Method

Retrospectively data was collected of all women between 25-29 years of age undergoing core biopsies for ultrasound confirmed fibroadenoma between 2014 and 2019 over a period of five years. The number of cancers picked up was compared with the number of referrals and the discordance between radiological diagnosis of fibroadenoma and histopathological confirmation of malignancy was recorded.

Results

A total of 1707 referrals were made across five years. n = 175 image guided core biopsies were carried out for U2, U3, U4 lesions appearing as fibroadenoma on ultrasound. Out of these (n = 175), all lesions coded U2/3 (n = 165) based on Maxwell criteria on ultrasound were negative for cancer. U4 lesions on ultrasound were confirmed as cancers mimicking fibroadenoma(n = 10).

Conclusions

This retrospective audit of 1707 patients provides sound evidence for non-biopsy of typical fibroadenoma in 25–29 years cohort sonographic features meet strict criteria.

109 Game Changing Magnetic Experience in Rural and Urban Wirral Peninsula - Our Experience with Magseed Localisation of Impalpable Breast Tumours and Axillary Nodes

Introduction

Magseed is a novel localization technology in which a tiny seed is inserted to accurately mark the site of breast tumour. These can be detected intra-operatively by sentimag localization system. It aids localization of impalpable breast lesions improving margin clearance rates.

Method

A prospective study of first fifty Magseed localised breast tumour and axillary node excisions in Clatterbridge General Hospital.

Results

A total of 50 patients had 52 Magseed inserted. n = 14 was symptomatic, n = 35 was screen detected and n = 1 was an incidental finding on surveillance mammogram for a B3 lesion. 30 seeds were inserted on the right and 22 were inserted on the left (two were bilateral). 44 seeds were inserted under ultrasound guidance and the rest were targeted under stereo guidance (n = 8). Deployment of two resulted in malposition requiring wire localization. Mean age of subjects was 59.76 (range 31-81) years. Mean time to surgery after magseed insertion was 8.04 (range 1-27) days. Mean weight of the specimen was 48.57(range 10-264) gm. Mean size of the lesions was 20.32 (range 8-65) mm. Redo surgery for margin clearance was performed bringing the re-excision rate to 15.38% (n = 8).

Conclusions

We conclude that Magseed localization of breast tumours is a safe and reliable technique

Abstract PS2-39: A peninsular experience - developing a non-biopsy protocol for the female cohort 25-29 years with clinically typical fibroadenoma conforming to maxwell criteria on ultrasound

Abstract.Abstract1:

IntroAim: The aim of this study was to introduce a non -biopsy protocol in our department for benign breast lump referrals confirmed as typical U2/3 fibroadenoma on imaging. The cohort of women between 25-29 years of age with sonographic features (Maxwell non-biopsy criteria) U2/3 typical of fibroadenoma does not miss malignancy. Current UK guidance is not to biopsy sonographically typical fibroadenomas in women under 25 years. We have studied our population extending the radiological Maxwell criteria reflecting histologically benign outcomes even in this group of 25-29 years.MethodsMethods: Retrospectively data was collected of all women between 25-29 years of age undergoing core biopsy for ultrasound confirmed both simple and complex fibroadenomas at Clatterbridge General Hospital between 2014 and 2019 over a period of five years. The number of cancers picked up was compared with the number of referrals and the discordance between radiological diagnosis of fibroadenoma and histopathological confirmation of malignancy was recorded.ResultsResults: We saw increment in referrals in this group of young women from n=260 to n=386 over the five year study period. A total of 1707 referrals were made across five years. n=175 image guided core biopsies were carried out for U2,U3,U4 lesions appearing as fibroadenoma on ultrasound. Out of these (n=175), all lesions coded U2/3 (n=165) based on Maxwell criteria on ultrasound were negative for cancer. U4 lesions on ultrasound were confirmed as cancers mimicking fibroadenoma(n=10).ConclusionConclusion: This retrospective audit of 1707 patients provides sound evidence for safe non-biopsy of typical fibroadenomas in women 25-29 years when clinical and sonographic features meet strict criteria. We started using the non-biopsy protocol using Maxwell criteria for U2/3 lesions. We discharged women in this group if they met all the protocol criteria, i.e., their lesion does not appear suspicious clinically, has all the ultrasound appearances typical of a fibroadenoma U2/3, and they do not have any compounding circumstances (e.g., family history, genetic predisposition). As routine, we advise all women who are discharged without follow-up to examine their breasts regularly and return if they detect any changes including increase in lesion size. We need data to be audited prospectively and provide level 1 evidence to the same effect.

Citation Format: Tahera Arif, Mohammed Shameem Absar, Raman Vinayagam. A peninsular experience - developing a non-biopsy protocol for the female cohort 25-29 years with clinically typical fibroadenoma conforming to maxwell criteria on ultrasound [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-39.

Breast conservation surgery by round block mammoplasty

BACKGROUND

Round block mammoplasty (RBM) is a type of Oncoplastic procedure to facilitate breast conservation surgery for breast cancer.

METHODS

Retrospective study of 270 patients who underwent this surgery. The surgical and oncological outcomes of RBM were studied.

RESULTS

The median age was 61 years and median follow-up 39 months. Most cancers (59%) were screen-detected. The location of the cancer was commonly in the upper outer quadrant followed by upper inner quadrant (20%). The average tumor size was 18 mm and in 48% of patients the whole tumor size increased to 23.5 mm due to associated DCIS. The median specimen weight was 41 gm. Forty patients (14.8%) had positive margins. Postoperative complications were seen in 18 patients (6.6%). There were 4 local and 1 axillary recurrences, and 8 distant metastasis. Contralateral symmetrising surgery was required in 13 patients (4.8%).

CONCLUSION

RBM is a robust and easily adaptable technique which provides good exposure for a safe oncological excision. The surgical and oncological outcomes are good and contralateral symmetrising surgery is rarely required.

Abstract P3-13-06: Breast conserving surgery by periareolar mammoplasty – Surgical and oncological outcomes

Background

Periareolar mammoplasty is a volume displacement oncoplastic technique for patients with small to medium sized breasts. This approach provides good access for a safe excision for both central and peripheral lesions, especially for those in the upper half of the breast. Cosmetically it allows good reshaping of the breast, and contralateral symmetrisation is rarely required. This technique has the potential to replace the standard wide local excision for breast cancer. There is scarcity of data about the results of this procedure in the literature. We present a single surgeon experience with this technique in terms of surgical and oncological outcomes.

Methods

Retrospective review of patients' records from October 2013 to December 2017 was performed. The patients' demographics, tumour characteristics and the early oncological outcomes were studied. The postoperative complications and rate of symmetrisation were also studied.

Results

-There were 110 patients in this study period. The median age was 60 years (range 36 – 82 years) and screen detected tumours accounted for 66% (72 patients) of cases.

-Neoadjuvant therapy was given in 14 patients (endocrine therapy – 12, chemotherapy – 1, dual targeted therapy – 1).

-Most patients had the lesion in the upper half of the breast (upper outer-71, upper inner-33).

-The average size of the tumour was 18.9mm (range 1.8 – 70mm) and the average weight of the excised specimen was 47.2gm (range 11-190gms). Invasive carcinoma was seen in 94 patients (85%) of which 86 patients had invasive ductal carcinoma, 4 had invasive lobular carcinoma and 4 had special type. Pure DCIS was present in 16 patients (15%). Most patients had grade 2 cancers (45%). DCIS was present with invasive carcinoma in 55% of cases.

-Thirteen patients had positive margins (<1mm) and DCIS coexisted with invasive carcinoma in 7 of 13 patients. Four patients with pure DCIS had positive margins.

-Of the 13 patients with positive margins: 5 required margin re-excision, 6 had completion mastectomy and 2 received only radiotherapy.

-The median follow-up was 25 months (range 3 – 53 months).

Seven patients developed complications which included 3 hematomas (2 requiring evacuation) and 4 wound infection which were treated with antibiotics. Only two patients required contralateral symmetrisation and no local recurrences were encountered in this study period.

Conclusion

Periareolar mammoplasty is a robust, easily adaptable and reproducible oncoplastic technique allowing for safe wide local excision of breast cancer. The margin re-excision, postoperative complication and recurrence rates in this study are acceptable and low compared to standard wide local excision. This technique gives excellent access, and allows better breast reshaping resulting in pleasing aesthetic outcome. Contralateral symmetrisation is rarely required with this technique.

Citation Format: Burrah R, Vinayagam R, James K. Breast conserving surgery by periareolar mammoplasty – Surgical and oncological outcomes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-06.

Sentinel lymph node biopsy for risk-reducing mastectomy

Risk-reducing mastectomy (RRM) confers 90-95% decreased risk of breast cancer, and may reduce mortality, especially in high-risk groups such as BRCA carriers. Risk of occult disease in RRM specimen is ~5%. This demands axillary staging: sentinel lymph node (SLN) biopsy is no longer possible, axillary clearance confers significant risks and may prove negative. Contemporaneous SLN biopsy allows axillary staging with minimal further dissection. Women undergoing RRM and SLN biopsy between June 2005 and July 2010 were reviewed retrospectively from our prospectively maintained database of 1,522 SLN procedures in 1,498 patients. SLN(s) localized using routine tracer methods. SLNs and mastectomy specimens underwent routine histologic examination. Eighty-three RRMs with SLN biopsy were performed in 71 patients (12 bilateral). Indications for RRM: contralateral invasive (55), in situ (5) disease, BRCA 1/2 mutation (12), and strong family history (10). Mean number of SLNs: 1.35. Occult disease was detected in four cases (4.8%), with one case of occult invasive lobular carcinoma (1.2%). Remaining occult disease was lobular in situ neoplasia (LISN). SLNs were negative in all cases. Our findings are comparable to those in the literature: 4.8% rate of occult disease overall, 1.2% invasive. The significant risk with SLN biopsy is lymphoedema, quoted around 7%. We have had no reports of symptomatic lymphoedema in patients undergoing RRM and SLN biopsy. We propose that SLN at the time of mastectomy requires only limited further dissection, and confers minimal risk compared with secondary axillary surgery.

Blinded comparison of faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation

AIM

To compare faecal loading on plain radiography versus radio-opaque marker transit studies in the assessment of constipation.

METHODS

The study group was a convenience sample of patients attending the Durham Constipation Clinic. All patients underwent transit studies according to an established protocol, and severity of constipation was assessed contemporaneously using a validated questionnaire (PAC-SYM). Transit studies were performed using radio-opaque markers that were ingested over 3 consecutive days, with a radiograph taken on the fourth day. Digital images of the radiograph were digitally altered to remove all traces of the transit markers without affecting the underlying pattern of faecal loading. Four observers assessed faecal loading independently; two clinicians (C1 and C2) and two radiologists (R1 and R2). C1 and R1 used a previously described formal scoring method of assessing faecal loading, whereas C2 and R2 assessed the images as if they were in a clinic or reporting session, grading the faecal loading as mild, moderate, or severe.

RESULTS

One hundred patients were recruited out of 186 presenting in a 2-year period. All patients completed assessments. The correlation between observers was only fair to moderate (r ranging from 0.34-0.51). There were some surprisingly marked disagreements in 10-18% of assessments. The correlation between faecal loading and transit was weak for all observers (r ranging from 0.261-0.311). Symptom severity did not correlate with faecal loading.

CONCLUSION

These results suggest that there is considerable inter-observer variation in the radiological assessment of faecal loading, irrespective of the training or method used by the observer, and that there is very poor correlation with colonic transit. The diagnosis of constipation, and the assessment of severity, is best performed clinically.

Association of oestrogen receptor beta 2 (ER beta 2/ER beta cx) with outcome of adjuvant endocrine treatment for primary breast cancer--a retrospective study

Background

Oestrogen receptor beta (ERβ) modulates ERα activity; wild type ERβ (ERβ1) and its splice variants may therefore impact on hormone responsiveness of breast cancer. ERβ2/ERβcx acts as a dominant negative inhibitor of ERα and expression of ERβ2 mRNA has been proposed as a candidate marker for outcome in primary breast cancer following adjuvant endocrine therapy. We therefore now assess ERβ2 protein by immunostaining and mRNA by quantitative RT-PCR in relation to treatment outcome.

Methods

ERβ2-specific immunostaining was quantified in 141 primary breast cancer cases receiving adjuvant endocrine therapy, but no neoadjuvant therapy or adjuvant chemotherapy. The expression of mRNA for ERβ2/ERβcx was measured in 100 cases by quantitative RT-PCR. Statistical analysis of breast cancer relapse and breast cancer survival was performed using Kaplan Meier log-rank tests and Cox's univariate and multivariate survival analysis.

Results

High ERβ2 immunostaining (Allred score >5) and high ERβ2 mRNA levels were independently associated with significantly better outcome across the whole cohort, including both ERα positive and negative cases (Log-Rank P < 0.05). However, only ERβ2 mRNA levels were significantly associated with better outcome in the ERα + subgroup (Log-Rank P = 0.01) and this was independent of grade, size, nodal status and progesterone receptor status (Cox hazard ratio 0.31 P = 0.02 for relapse; 0.17 P = 0.01 for survival). High ERβ2 mRNA was also associated with better outcome in node negative cases (Log Rank P < 0.001).

ERβ2 protein levels were greater in ERα positive cases (T-test P = 0.00001), possibly explaining the association with better outcome. Levels of ERβ2 protein did not correlate ERβ2 mRNA levels, but 34% of cases had both high mRNA and protein and had a significantly better outcome (Log-Rank relapse P < 0.005).

Conclusion

High ERβ2 protein levels were associated with ERα expression. Although most cases with high ERβ2 mRNA had strong ERβ2 immunostaining, mRNA levels but not protein levels were independently predictive of outcome in tamoxifen-treated ERα + tumours. Post-transcriptional control needs to be considered when assessing the biological or clinical importance of ERβ proteins.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.