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Breast conserving surgery versus mastectomy: cancer practice by general surgeons in Iran
Massoome Najafi, Mandana Ebrahimi, Ahmad Kaviani, Esmat Hashemi, Ali Montazeri
BMC Cancer , 2005, DOI: 10.1186/1471-2407-5-35
Abstract: A structured questionnaire was mailed to 235 general surgeons chosen from the address list of the Iranian Medical Council. The questionnaire elicited information about the general surgeons' characteristics and about their work experience, posts they have held, number of breast cancer operations performed per year, preferences for mastectomy or breast conserving surgery, and the reasons for these preferences.In all, 83 surgeons returned the completed questionnaire. The results indicated that only 19% of the surgeons routinely performed breast conserving surgery (BCS) and this was significantly associated with their breast cancer case load (P < 0.01). There were no associations between BCS practice and the other variables studied. The most frequent reasons for not performing BCS were uncertainty about conservative therapy results (46%), uncertainty about the quality of available radiotherapy services (32%), and the probability of patients' non-compliance in radiotherapy (32%).The findings indicate that Iranian surgeons do not routinely perform BCS as the first and the best treatment modality. Further research is recommended to evaluate patients' outcomes after BCS treatment in Iran, with regard to available radiotherapy facilities and cultural factors (patients' compliance).Many randomized clinical trials have demonstrated that patient survival rates are similar after treatment by mastectomy or by conservative surgery and radiotherapy [1-4]. However, the National Institute of Health Consensus Conference concluded that for most women with early-stage breast cancers (stages I and II), breast conservation surgery (BCS) is an appropriate method of treatment [5]. Despite these findings, mastectomy remains the most prevalent surgical treatment for early-stage breast cancer in many parts of the world. In Iran, BCS is an uncommon modality for this condition. For example, in one study in Isfahan University of Medical Sciences, 386 breast cancer patients were reviewed and maste
Surgical Site Infection Complicating Breast Cancer Surgery in Kuwait  [PDF]
Abeer A. Omar,Haifaa H. Al-Mousa
ISRN Preventive Medicine , 2013, DOI: 10.5402/2013/295783
Abstract: Background and Objectives. Surgical site infection (SSI) is the most common postoperative complication associated with breast cancer surgery. The present investigation aimed to determine the SSI rate after breast cancer surgeries and the causative microorganisms. Patients and Methods. All patients who underwent breast surgery in Kuwait Cancer Control Center as a treatment for breast cancer from January 2009–December 2010 were prospectively followed for the development of SSI. Indirect detection was used to identify SSIs through medical record to review and discussion with the treating surgeons. Results. The number of operations was 438. Females represented 434 (99.1%) cases while males constituted only 4 (0.9%) cases. SSIs were diagnosed after 10 operations, all for female cases. Most of the SSIs (8 cases; 80%) were detected after patients were discharged, during outpatient followup. Out of those 5/8; (62.5%) were readmitted for management of SSI. Nine patients (90%) received systemic antibiotic therapy for management of their wound infection. The SSI rate was 2.3%. The main causative organism was Staphylococcus aureus (S. aureus) which was responsible for 40% of infections. Gram negative bacteria were isolated from 40% of the cases. Conclusion. SSI is an important complication following breast cancer surgery. Microbiological diagnosis is an essential tool for proper management of such patients. 1. Introduction Breast cancer is one of the most frequent malignancies in women worldwide [1]. In Kuwait, it ranked first among both Kuwaiti and non-Kuwaiti women. During the period from 2000 to 2008, it constituted 36.0% and 39.5% from the newly diagnosed cancer cases in Kuwaiti and non-Kuwaiti females, respectively [2]. Excision of the primary tumor (by mastectomy or breast conserving surgery) and sentinel lymph node or axillary lymph node dissection are standard procedures for the treatment of most cases [1]. Surgical site infection (SSI) is the most common postoperative complication associated with breast cancer surgery [3]. The development of SSI can lead to prolonged hospital stay with increased costs, poor cosmetic results, psychological trauma, and, occasionally, a delay in postoperative adjuvant therapies [4]. To the best of our knowledge, no published studies reported SSI rate after breast cancer surgery in Kuwait. Hence, the present investigation was aiming to determine the SSI rate after breast cancer surgeries and the causative microorganisms as a step to improve the management and the outcome of such patients. 2. Subjects and Methods All patients
Improving quality of breast cancer surgery through development of a national breast cancer surgical outcomes (BRCASO) research database
Erin J Aiello Bowles, Heather Feigelson, Tom Barney, Katherine Broecker, Andrew Sterrett, Kimberly Bischoff, Jessica Engel, Gabrielle Gundersen, Johanna Sheehey-Jones, Richard Single, Adedayo Onitilo, Ted A James, Laurence E McCahill
BMC Cancer , 2012, DOI: 10.1186/1471-2407-12-136
Abstract: We included 4524 women ≥18 years diagnosed with breast cancer between 2003-2008. All women with initial breast cancer surgery performed by a surgeon employed at the University of Vermont or three Cancer Research Network (CRN) health plans were eligible for inclusion. From the CRN institutions, we collected electronic administrative data including tumor registry information, Current Procedure Terminology codes for breast cancer surgeries, surgeons, surgical facilities, and patient demographics. We supplemented electronic data with medical record abstraction to collect additional pathology and surgery detail. All data were manually abstracted at the University of Vermont.The CRN institutions pre-filled 30% (22 out of 72) of elements using electronic data. The remaining elements, including detailed pathology margin status and breast and lymph node surgeries, required chart abstraction. The mean age was 61 years (range 20-98 years); 70% of women were diagnosed with invasive ductal carcinoma, 20% with ductal carcinoma in situ, and 10% with invasive lobular carcinoma.The BRCASO database is one of the largest, multi-site research resources of meaningful breast cancer surgical quality data in the United States. Assembling data from electronic administrative databases and manual chart review balanced efficiency with high-quality, unbiased data collection. Using the BRCASO database, we will evaluate surgical quality measures including mastectomy rates, positive margin rates, and partial mastectomy re-excision rates among a diverse, non-voluntary population of patients, providers, and facilities.The Institute of Medicine report "Crossing the Quality Chasm", emphasized high quality care should be safe, timely, effective, efficient, equitable, and patient-centered [1]. The common measures of surgical quality are 30-day morbidity and mortality, which are not ideal metrics for breast cancer procedures that have extremely low morbidity and < 0.5% mortality. These measures only refl
Atypical Ductal Hyperplasia at the Margin of Lumpectomy Performed for Early Stage Breast Cancer: Is there Enough Evidence to Formulate Guidelines?  [PDF]
Jennifer L. Baker,Farnaz Hasteh,Sarah L. Blair
International Journal of Surgical Oncology , 2012, DOI: 10.1155/2012/297832
Abstract: Background. Negative margins are associated with a reduced risk of ipsilateral breast tumor recurrence (IBTR) in women with early stage breast cancer treated with breast conserving surgery (BCS). Not infrequently, atypical ductal hyperplasia (ADH) is reported as involving the margin of a BCS specimen, and there is no consensus among surgeons or pathologists on how to approach this diagnosis resulting in varied reexcision practices among breast surgeons. The purpose of this paper is to establish a reasonable approach to guide the treatment of ADH involving the margin after BCS for early stage breast cancer. Methods. the published literature was reviewed using the PubMed site from the US National Library of Medicine. Conclusions. ADH at the margin of a BCS specimen performed for early stage breast cancer is a controversial pathological diagnosis subject to large interobserver variability. There is not enough data evaluating this diagnosis to change current practice patterns; however, it is reasonable to consider reexcision for ADH involving a surgical margin, especially if it coexists with low grade DCIS. Further studies with longer followup and closer attention to ADH at the margin are needed to formulate treatment guidelines. 1. Introduction Breast conserving surgery (BCS) is a widely accepted treatment option for early-stage breast cancer based on several prospective, randomized trials that demonstrate equivalent survival after BCS compared to that after mastectomy [1–7]. The recent 20-year followup of the NSABP B-06 trial recognizes an increased risk of ipsilateral breast tumor recurrence (IBTR) after BCS; however, this risk is decreased with the addition of whole breast irradiation and obtaining negative margins [1]. While the validation of BCS requires that a negative margin be obtained, there is still no consensus definition of what constitutes an adequate negative margin width resulting in marked variation in BCS reexcision practices among surgeons [8–10]. While all agree it is not appropriate to have tumor cells involving the inked margin, there is no compelling or consistent evidence to indicate how widely free a margin should be [11–15]. Accordingly, margin width alone may not be sufficient to prove adequacy of excision and qualitative and quantitative pathologic characteristics of the cells within the margins may be important to consider [16]. One of those factors is proliferative lesions and in particular atypical ductal hyperplasia (ADH) at the margin of BCS specimens [17]. Interestingly, despite the high volume of studies investigating the
Learning styles of medical students, general surgery residents, and general surgeons: implications for surgical education
Paul T Engels, Chris de Gara
BMC Medical Education , 2010, DOI: 10.1186/1472-6920-10-51
Abstract: The Kolb Learning Style Inventory, which divides individual learning styles into Accommodating, Diverging, Converging, and Assimilating categories, was administered to the second year undergraduate medical students, general surgery resident body, and general surgery faculty at the University of Alberta.A total of 241 faculty, residents, and students were surveyed with an overall response rate of 73%. The predominant learning style of the medical students was assimilating and this was statistically significant (p < 0.03) from the converging learning style found in the residents and faculty. The predominant learning styles of the residents and faculty were convergent and accommodative, with no statistically significant differences between the residents and the faculty.We conclude that medical students have a significantly different learning style from general surgical trainees and general surgeons. This has important implications in the education of general surgery residents.Educating surgeons is an age-old tradition that has existed since the development of surgery and is now entrenched within our modern Hippocratic Oath[1]. Modern surgical education has been crafted and shaped by visionaries such as Halsted who have helped evolve the historical model of apprenticeship into the current organized system of surgical education that we know as Residency[2]. However, the demographics of the next generation of surgeons[3] and the methods by which they are trained are rapidly evolving[4], especially with the evolution of surgical simulation[5]; it has recently been suggested that the role for this historic apprenticeship no longer exists in the era of modern surgical education[6].Current surgical trainees now originate from a diverse educational, cultural, ethnic, and gender background[2], and are responsible for developing skills not only in the role as a medical expert, but in the role as a professional, scholar, health advocate, manager, collaborator, and communicator[7]
Quantifying Potential Error in Painting Breast Excision Specimens  [PDF]
Thomas Fysh,Alex Boddy,Amy Godden
International Journal of Breast Cancer , 2013, DOI: 10.1155/2013/854234
Abstract: Aim. When excision margins are close or involved following breast conserving surgery, many surgeons will attempt to reexcise the corresponding cavity margin. Margins are ascribed to breast specimens such that six faces are identifiable to the pathologist, a process that may be prone to error at several stages. Methods. An experimental model was designed according to stated criteria in order to answer the research question. Computer software was used to measure the surface areas of experimental surfaces to compare human-painted surfaces with experimental controls. Results. The variability of the hand-painted surfaces was considerable. Thirty percent of hand-painted surfaces were 20% larger or smaller than controls. The mean area of the last surface painted was significantly larger than controls (mean 58996 pixels versus 50096 pixels, CI 1477–16324, ). By chance, each of the six volunteers chose to paint the deep surface last. Conclusion. This study is the first to attempt to quantify the extent of human error in marking imaginary boundaries on a breast excision model and suggests that humans do not make these judgements well, raising questions about the safety of targeting single margins at reexcision. 1. Introduction An enduring debate amongst breast surgeons concerns the adequacy of excision margins for both invasive and in situ carcinoma (DCIS). As yet, no unequivocal consensus has been reached as to what exactly comprises an adequate surgical margin after breast conserving surgery (BCS) [1]. Typically, a specimen is excised and then painted or marked according to a protocol to indicate laterality and boundaries. In theory, the histopathologist receives a specimen that can then be orientated such that the location of any residual disease can be identified. It has been shown that painting specimens at the time of excision are preferable to painting by the pathology department in terms of reexcision rates [2]. While the National Institute for Health and Clinical Excellence (NICE) suggests reexcision of DCIS if the margin is closer than 2?mm, local policies vary as to what is considered an acceptable margin. Surgeons may accept a closer deep margin since the pectoralis fascia is thought to provide and robust anatomical barrier to local spread. At the Royal Devon and Exeter Hospital NHS Trust, policy is to offer reexcision to patients with any margin of invasive cancer within 2?mm and 1?mm for DCIS. Only in special circumstances will reexcision be offered for close deep or superficial margins. It may be, however, that current practice is fundamentally
Preoperative Localization and Surgical Margins in Conservative Breast Surgery  [PDF]
F. Corsi,L. Sorrentino,D. Bossi,A. Sartani,D. Foschi
International Journal of Surgical Oncology , 2013, DOI: 10.1155/2013/793819
Abstract: Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer. The adequacy of surgical margins (SM) is a crucial issue for adjusting the volume of excision and for avoiding local recurrences, although the precise definition of an adequate margins width remains controversial. Moreover, other factors such as the biological behaviour of the tumor and subsequent proper systemic therapies may influence the local recurrence rate (LRR). However, a successful BCS requires preoperative localization techniques or margin assessment techniques. Carbon marking, wire-guided, biopsy clips, radio-guided, ultrasound-guided, frozen section analysis, imprint cytology, and cavity shave margins are commonly used, but from the literature review, no single technique proved to be better among the various ones. Thus, an association of two or more methods could result in a decrease in rates of involved margins. Each institute should adopt its most congenial techniques, based on the senologic equipe experience, skills, and technologies. 1. Introduction Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer [1, 2]. Various randomized trials have reported this approach to be safe and effective, thus determining a decrease in the adoption of mastectomy as the treatment of choice for early invasive breast cancer [3, 4]. BCS can almost be considered the gold standard of early stage invasive breast cancer treatment, allowing to achieve adequate surgical margins (SM) with an acceptable cosmetic outcome. Some studies have defined the adequacy of SM by its correlation with the locoregional recurrence rate (LRR) [5–14], but the precise definition of an adequate margins width remains controversial [15–17]. However, there is no doubt that obtaining negative margins decreases the risk of local recurrence [1]. Some clinical trials have demonstrated that systemic therapies may also improve the local control in breast cancer [18, 19]. Thus, there seems to be noted a recent trend of reconsideration of the importance of margin width on the incidence of local recurrences, in favour of other prognostic factors such as the biological behaviour of the tumor [15–19]. A requirement for successful BCS is a careful preoperative planning with proper localization of the lesion, especially in nonpalpable breast lesions [1]. In order to obtain adequate excisions, margins assessment techniques are also available. Wire-guided localization, radio-guided occult lesion localization (ROLL), carbon marking, intraoperative ultrasound-guided localization, cavity shave
Oncoplastic Breast Reduction: Maximizing Aesthetics and Surgical Margins  [PDF]
Michelle Milee Chang,Tara Huston,Jeffrey Ascherman,Christine Rohde
International Journal of Surgical Oncology , 2012, DOI: 10.1155/2012/907576
Abstract: Oncoplastic breast reduction combines oncologically sound concepts of cancer removal with aesthetically maximized approaches for breast reduction. Numerous incision patterns and types of pedicles can be used for purposes of oncoplastic reduction, each tailored for size and location of tumor. A team approach between reconstructive and breast surgeons produces positive long-term oncologic results as well as satisfactory cosmetic and functional outcomes, rendering oncoplastic breast reduction a favorable treatment option for certain patients with breast cancer. 1. Introduction Surgeons who treat breast cancer strive to perform operations that are aesthetically pleasing without compromising oncologic outcome. Patients are more informed than ever and are encouraging their surgical teams to continue to evolve [1]. For treatment of their breast cancer, many women elect breast conservation therapy (BCT). BCT combines lumpectomy with postoperative radiation allowing a woman to preserve her breast. Factors leading to a greater use of BCT versus mastectomy include improved screening and earlier mammography which have resulted in an increased identification of small, early-stage breast cancers, an increased use of neoadjuvant chemotherapy which can shrink large tumors, and the patient’s own preference to preserve her breast [2]. With breast preservation, cancer survival is affected by local control defined by appropriate clear margins. Despite a higher local recurrence rate, disease-free long-term survival is equivalent for patients undergoing total mastectomy and BCT. The premise of BCT involves both surgical excision and reconstruction, including an oncologically sound resection of the tumor, radiation of the resection bed, and preservation of the breast for enhanced aesthetic outcome [2]. To ensure clear margins of tumor resection in BCT, large volumes of breast tissue may need to be removed, leading to asymmetry, scarring, and deformity. Up to 30% of patients who have undergone BCT end up with a poor cosmetic outcome [3, 4]. Subsequent irradiation often then further compromises already suboptimal surgical results. 2. Oncoplastic Surgery The initial reports of aesthetic techniques coupled with oncologic treatment were published in the 1990s [5]. The term “oncoplastic breast surgery” was coined in the mid-1990s [6]. Oncoplastic methods enable large tumor resections by marrying extirpative surgery with breast reduction surgery. Procedures are designed to anticipate and prevent unfavorable aesthetic outcomes, decreasing the rates to below 7% [7]. In addition,
Breast Necrosis Following Coronary by Pass Graft Surgery: Report of Two Cases & Review of Literature  [PDF]
Maha Abdel Hadi, Yasir Ghonemi, Mohammed Regal, Saeed Al Shomimi
World Journal of Cardiovascular Surgery (WJCS) , 2013, DOI: 10.4236/wjcs.2013.37042
Abstract: Breast is an external organ with abundant blood supply which renders it vulnerable to many inflammatory or neoplastic conditions, yet it remains immune to ischemia. Various chest wall surgical procedures may directly or indirectly affect the breast or its overlying skin. Cardiac surgery with its designed incisions is closely related to the breast terrain. Breast necrosis is very rare and only few cases were reported in the literature. We report two cases of breast necrosis in diabetic patients following cardiac bypass surgery. This emerging quandary is an alert to cardiothoracic surgeons to generate special preparation for a subset of patients prior to cardiac surgical procedures in order to minimize the occurrence of ischemia.
A Modified Enhanced Recovery after Surgery (ERAS): Use and Surgical Outcome in Breast Cancer Patients  [PDF]
Tajudeen A. Wahab, Hanna Uwakwe, Maher Jumah, Rilwan Aransi, Humayun Kabir Khan
Journal of Biosciences and Medicines (JBM) , 2018, DOI: 10.4236/jbm.2018.63002
Abstract: Background: ERAS protocols are perioperative interventions aimed at reducing postoperative complications, length of hospital stay (LOS) and early return to normal activities. This has improved outcome in many surgical specialties, including breast surgery. We present the surgical outcome of breast cancer (BC) patients treated over a 12-month period following the principle of ERAS protocols and highlight the underpinning evidence. Methods: A retrospective analysis of all BC patients diagnosed and had breast cancer surgery over 12 months. Data collected included patient’s demographics, type of surgery, LOS, other perioperative care and significant postoperative complications. Excluded were patients with bilateral cancer surgeries, diagnostic excision, margin clearance or breast reconstruction. Results: There were 621 BC diagnosed including 5 male and 12 bilateral female BC. The ages ranged from 25 to 93 years. Excluding bilateral BC, 351 patients (70.2 %) had breast conserving surgery (BCS) while 149 (29.8%) patients had mastectomy as index cancer surgery. Sixteen (4.5%) of the women who initially underwent BCS subsequently had a completion mastectomy. The overall rate of successful BCS was 335/500 (67%). 441 (85.5%) of patients were discharged same or next day. 12 (7.2%) cases of postoperative haematoma, 6 cases of wound infection and a case of seroma requiring surgical/radiological drainage recorded. Conclusion: ERAS protocol in BC surgery is associated with decreased LOS and low complication rate. Delayed discharges are mostly due to adverse social factors and medical comorbidity rather than post-operative surgical complications.
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