The NeST (Neoadjuvant systemic therapy in breast cancer) study: National Practice Questionnaire of United Kingdom multi-disciplinary decision making

BACKGROUND

Neoadjuvant systemic therapy (NST) is increasingly used in the treatment of breast cancer, yet it is clear that there is significant geographical variation in its use in the UK. This study aimed to examine stated practice across UK breast units, in terms of indications for use, radiological monitoring, pathological reporting of treatment response, and post-treatment surgical management.

METHODS

Multidisciplinary teams (MDTs) from all UK breast units were invited to participate in the NeST study. A detailed questionnaire assessing current stated practice was distributed to all participating units in December 2017 and data collated securely usingREDCap. Descriptive statistics were calculated for each questionnaire item.

RESULTS

Thirty-nine MDTs from a diverse range of hospitals responded. All MDTs routinely offered neoadjuvant chemotherapy (NACT) to a median of 10% (range 5-60%) of patients. Neoadjuvant endocrine therapy (NET) was offered to a median of 4% (range 0-25%) of patients by 66% of MDTs. The principal indication given for use of neoadjuvant therapy was for surgical downstaging. There was no consensus on methods of radiological monitoring of response, and a wide variety of pathological reporting systems were used to assess tumour response. Twenty-five percent of centres reported resecting the original tumour footprint, irrespective of clinical/radiological response. Radiologically negative axillae at diagnosis routinely had post-NACT or post-NET sentinel lymph node biopsy (SLNB) in 73.0 and 84% of centres respectively, whereas 16% performed SLNB pre-NACT. Positive axillae at diagnosis would receive axillary node clearance at 60% of centres, regardless of response to NACT.

DISCUSSION

There is wide variation in the stated use of neoadjuvant systemic therapy across the UK, with general low usage of NET. Surgical downstaging remains the most common indication of the use of NAC, although not all centres leverage the benefits of NAC for de-escalating surgery to the breast and/or axilla. There is a need for agreed multidisciplinary guidance for optimising selection and management of patients for NST. These findings will be corroborated in phase II of the NeST study which is a national collaborative prospective audit of NST utilisation and clinical outcomes.

Abstract P2-16-04: National utilisation of neoadjuvant systemic therapy and impact on surgical treatment - A prospective multi-centre cohort study

Introduction: Potential advantages of neoadjuvant systemic therapy (NST) include downstaging disease to minimise surgery, and in vivo assessment of tumour sensitivity to therapeutic drugs. Considerable variation in NST use remains, however, and it is unclear whether pathological response rates reflect those reported in trials, or whether downstaging achieved impacts on surgical decision-making. The NeST prospective multicentre study will address these questions through investigating patterns of care in the UK.

Methods: Women undergoing NST as their primary breast cancer treatment (chemotherapy (CT), endocrine (ET) and targeted therapies) in UK centres between December 2017 and November 2018 were included. Anonymised data was collected at 37 participating centres, and uploaded to REDCap.

Results: 1179 patients received neoadjuvant treatment during the study period. 41% had HER2+ disease, 28% TNBC and 31% ER+ HER2- disease. 48% were node positive and 52% node negative. Cited indications for neoadjuvant treatment were (more than one option applicable to each patient):

Downstaging (mastectomy to breast conservation) 37%

Facilitate dual antiHER2 therapy 33%

Inoperable disease 19%

Improved cosmesis (reduced volume of excision) 17%

Facilitate BRCA testing 9%

Inflammatory breast cancer 6%

In patients recommended to receive NST, the MDT decision was for neoadjuvant CT in 87% of cases and neoadjuvant ET in 13%. For ER+ disease, the commonest reasons for prescribing CT were high grade disease and pre-menopausal status. The majority were treated with anthracycline-taxane combinations. 21% of TNBC patients were treated with platinum-containing regimens. In HER2+ disease, 54% were treated with dual antiHER2 therapies/chemotherapy, with 10% receiving chemotherapy/single antiHER2 agent (trastuzumab).

Centres were asked to indicate primary breast surgical treatment recommended prior to/without NST. At abstract submission, this data was available for 887 patients. 31 had inoperable disease. A total of 477 were considered to require mastectomy, with disease not amenable to breast conservation surgery (BCS). A further 379 patients were considered candidates for BCS. Data on final surgical procedure was available for 765 patients. Of those patients determined suitable only for mastectomy at diagnosis, 123 underwent BCS as their primary operation - a downstaging rate of 26%. The overall mastectomy rate in this cohort was 48%, with 33% having mastectomy and 15% mastectomy with immediate reconstruction.

Pathological response data was available in 672 patients, with an overall pathological complete response (pCR) rate of 29% (defined as no residual invasive or in situ disease). pCR rate according to molecular subtype was 37% for HER2+ disease, 35% for TNBC and 7% for ER+, HER2-ve disease. The pCR rate in patients downstaged from mastectomy to BCS was 27%.

Conclusions: This UK national prospective study suggests that surgical downstaging remains a key indication for the use of NST. This is reflected in the fact that 26% of patients in this series were downstaged from an original surgical plan for mastectomy, with NST enabling BCS in these patients. However, based on this data it appears that surgical downstaging is no more likely in those with pCR compared to those without a pCR.

Additional indications for NST are emerging, according to disease biology. There is widespread use of dual antiHER2 targeted therapies in this setting, with increasing use of platinum-containing regimens for TNBC. Neoadjuvant CT continues to be frequently used in the treatment of ER+ disease, despite known low pCR rates in this context, which are again confirmed. Low rates of neoadjuvant ET use are reported.

Data collection is ongoing; updated data will be presented in December 2019.

Citation Format: Stuart A McIntosh, Gareth W Irwin, Finian Bannon, Charlotte Coles, Ellen Copson, Ramsey Cutress, Rajiv Dave, Margaret Grayson, Chris Holcombe, Sheeba Irshad, Ciara O'Brien, Rachel O'Connell, Carlo Palmieri, Abeer M Shaaban, Nisha Sharma, Jagdeep Singh, Ian Whitehead, Shelley Potter. National utilisation of neoadjuvant systemic therapy and impact on surgical treatment - A prospective multi-centre cohort study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-16-04.

NUP98 - a novel predictor of response to anthracycline-based chemotherapy in triple negative breast cancer

Background

Triple Negative breast cancer (TNBC) is a poor outcome subgroup of breast cancer defined based on the absence of expression of ERα and PR and HER2 amplification. These hard to treat cancers lack targeted treatment options and are therefore treated with a standard of care (SoC) generic cocktail of DNA damaging chemotherapy, with a wide range of clinical responses. While a subset of TNBC patients respond very well to this treatment, others receive no clinical benefit and die from their disease within a short time period. We currently lack biomarkers to prospectively identify patients likely to relapse and we lack alternate treatment options.

Methods

NUP98 protein expression was investigated in patient samples using two independent tissue microarrays (TMAs), as well as a normal breast TMA. Correlation with pathological response to various chemotherapy regimens was investigated.

Results

We have shown that high NUP98 is significantly associated with poor outcome in TNBC patient samples both by gene expression and IHC-based protein analysis. While trends linking NUP98 expression with poorer outcomes were observed in breast cancer overall (and more specifically in the LuminalB Her2- subgroup), significant correlations were observed in TNBC. This appeared to be specific to anthracycline based regimens as the association between NUP98 and response was not observed in patients treated with taxane-based chemotherapy.

Conclusions

We have identified a novel biomarker, NUP98, that can predict response to anthracycline based chemotherapy in TNBC. The ability to prospectively identify patients who are less likely to respond to SoC chemotherapy is a vital step in improving the overall survival of these patients.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5407-9) contains supplementary material, which is available to authorized users.

Automated Tumour Recognition and Digital Pathology Scoring Unravels New Role for PD-L1 in Predicting Good Outcome in ER-/HER2+ Breast Cancer

The role of PD-L1 as a prognostic and predictive biomarker is an area of great interest. However, there is a lack of consensus on how to deliver PD-L1 as a clinical biomarker. At the heart of this conundrum is the subjective scoring of PD-L1 IHC in most studies to date. Current standard scoring systems involve separation of epithelial and inflammatory cells and find clinical significance in different percentages of expression, e.g., above or below 1%. Clearly, an objective, reproducible and accurate approach to PD-L1 scoring would bring a degree of necessary consistency to this landscape. Using a systematic comparison of technologies and the application of QuPath, a digital pathology platform, we show that high PD-L1 expression is associated with improved clinical outcome in Triple Negative breast cancer in the context of standard of care (SoC) chemotherapy, consistent with previous findings. In addition, we demonstrate for the first time that high PD-L1 expression is also associated with better outcome in ER- disease as a whole including HER2+ breast cancer. We demonstrate the influence of antibody choice on quantification and clinical impact with the Ventana antibody (SP142) providing the most robust assay in our hands. Through sampling different regions of the tumour, we show that tumour rich regions display the greatest range of PD-L1 expression and this has the most clinical significance compared to stroma and lymphoid rich areas. Furthermore, we observe that both inflammatory and epithelial PD-L1 expression are associated with improved survival in the context of chemotherapy. Moreover, as seen with PD-L1 inhibitor studies, a low threshold of PD-L1 expression stratifies patient outcome. This emphasises the importance of using digital pathology and precise biomarker quantitation to achieve accurate and reproducible scores that can discriminate low PD-L1 expression.

Erythropoietin drives breast cancer progression by activation of its receptor EPOR

Breast cancer is a leading cause of cancer-related deaths. Anemia is common in breast cancer patients and can be treated with blood transfusions or with recombinant erythropoietin (EPO) to stimulate red blood cell production. Clinical studies have indicated decreased survival in some groups of cancer patients treated with EPO. Numerous tumor cells express the EPO receptor (EPOR), posing a risk that EPO treatment would enhance tumor growth, but the mechanisms involved in breast tumor progression are poorly understood.

Here, we have examined the functional role of the EPO-EPOR axis in pre-clinical models of breast cancer. EPO induced the activation of PI3K/AKT and MAPK pathways in human breast cancer cell lines. EPOR knockdown abrogated human tumor cell growth, induced apoptosis through Bim, reduced invasiveness, and caused downregulation of MYC expression. EPO-induced MYC expression is mediated through the PI3K/AKT and MAPK pathways, and overexpression of MYC partially rescued loss of cell proliferation caused by EPOR downregulation. In a xenotransplantation model, designed to simulate recombinant EPO therapy in breast cancer patients, knockdown of EPOR markedly reduced tumor growth.

Thus, our experiments in vitro and in vivo demonstrate that functional EPOR signaling is essential for the tumor-promoting effects of EPO and underline the importance of the EPO-EPOR axis in breast tumor progression.

Integrated tumor identification and automated scoring minimizes pathologist involvement and provides new insights to key biomarkers in breast cancer

Digital image analysis (DIA) is becoming central to the quantitative evaluation of tissue biomarkers for discovery, diagnosis and therapeutic selection for the delivery of precision medicine. In this study, automated DIA using a new purpose-built software platform (QuPath) is applied to a cohort of 293 breast cancer patients to score five biomarkers in tissue microarrays (TMAs): ER, PR, HER2, Ki67 and p53. This software is able to measure IHC expression following fully automated tumor recognition in the same immunohistochemical (IHC)-stained tissue section, as part of a rapid workflow to ensure objectivity and accelerate biomarker analysis. The digital scores produced by QuPath were compared with manual scores by a pathologist and shown to have a good level of concordance in all cases (Cohen's κ>0.6), and almost perfect agreement for the clinically relevant biomarkers ER, PR and HER2 (κ>0.86). To assess prognostic value, cutoff thresholds could be applied to both manual and automated scores using the QuPath software, and survival analysis performed for 5-year overall survival. DIA was shown to be capable of replicating the statistically significant stratification of patients achieved using manual scoring across all biomarkers (P<0.01, log-rank test). Furthermore, the image analysis scores were shown to consistently lead to statistical significance across a wide range of potential cutoff thresholds, indicating the robustness of the method, and identify sub-populations of cases exhibiting different expression patterns within the p53 and Ki67 data sets that warrant further investigation. These findings have demonstrated QuPath's suitability for fast, reproducible, high-throughput TMA analysis across a range of important biomarkers. This was achieved using our tumor recognition algorithms for IHC-stained sections, trained interactively without the need for any additional tumor recognition markers, for example, cytokeratin, to obtain greater insight into the relationship between biomarker expression and clinical outcome applicable to a range of cancer types.

Outcomes of Sacral Nerve Stimulation For Faecal Incontinence in Northern Ireland

BACKGROUND

Sacral nerve root stimulation (SNS) is an effective and developing therapy for faecal incontinence, a debilitating condition that can result in social and personal incapacitation.

OBJECTIVES

The objectives of this study are to assess the morbidity of the procedure, improvement in the incontinence scores and Quality of Life (QoL) following SNS.

MATERIALS AND METHODS

Patients were identified from the Northern Ireland regional SNS service from 2006 to 2012. Numbers of patients who had temporary placement and permanent placement were collated. Pre and postoperative assessment of severity of incontinence and QoL was performed using Cleveland Clinic Incontinence Score (CCIS) and Short Form-36 (SF-36) respectively. Statistical analysis was undertaken using Wilcoxon signed rank test. Morbidity was assessed by retrospective review of patient records.

RESULTS

Seventy-five patients were considered for trial of a temporary SNS. Sixty-one proceeded to insertion of a temporary SNS and, of these, 40 elected to have a permanent SNS. There was a significant reduction in the pre-SNS and post-SNS Cleveland Clinic Incontinence Scores from median of 14 to 9 respectively (p=0.008). There was a significant improvement in Role Physical (p=0.017), General Health (p=0.02), Vitality (p=0.043), Social Functioning (p=0.004), Role Emotional (p=0.007), Mental Health (p=0.013) and Mental Health Summary (p=0.003). However, this is not reflected in the bodily pain and physical functional domains.

CONCLUSION

Permanent sacral nerve stimulation is effective and results in significant improvement of faecal incontinence scores and quality of life.

Haemoperitoneum secondary to intrahepatic gallbladder perforation

A 70-year-old man presented to the accident and emergency department with a 1-day history of right upper quadrant pain and nausea. Examination revealed mild tenderness in the right upper quadrant but no evidence of peritonism or haemodynamic instability. The patient was admitted to the general surgical ward with a diagnosis of cholecystitis and remained stable overnight. In the morning, he developed acute severe pain in the upper abdomen. Examination found him to be tachycardic, tachypnoeic and to have peritonism in the upper abdomen. An urgent CT scan demonstrated cholecystitis but also a small amount of fluid in the pelvis, with Hounsfield units suggestive of blood. The patient proceeded to laparotomy and was found to have massive haemoperitoneum secondary to intrahepatic gallbladder perforation causing liver capsule tear. Cholecystectomy was performed and the liver packed until haemostasis was achieved. The patient made an uneventful recovery.

PICan: An integromics framework for dynamic cancer biomarker discovery

Modern cancer research on prognostic and predictive biomarkers demands the integration of established and emerging high-throughput technologies. However, these data are meaningless unless carefully integrated with patient clinical outcome and epidemiological information. Integrated datasets hold the key to discovering new biomarkers and therapeutic targets in cancer. We have developed a novel approach and set of methods for integrating and interrogating phenomic, genomic and clinical data sets to facilitate cancer biomarker discovery and patient stratification. Applied to a known paradigm, the biological and clinical relevance of TP53, PICan was able to recapitulate the known biomarker status and prognostic significance at a DNA, RNA and protein levels.

TBX2 represses CST6 resulting in uncontrolled legumain activity to sustain breast cancer proliferation: a novel cancer-selective target pathway with therapeutic opportunities

TBX2 is an oncogenic transcription factor known to drive breast cancer proliferation. We have identified the cysteine protease inhibitor Cystatin 6 (CST6) as a consistently repressed TBX2 target gene, co-repressed through a mechanism involving Early Growth Response 1 (EGR1). Exogenous expression of CST6 in TBX2-expressing breast cancer cells resulted in significant apoptosis whilst non-tumorigenic breast cells remained unaffected. CST6 is an important tumor suppressor in multiple tissues, acting as a dual protease inhibitor of both papain-like cathepsins and asparaginyl endopeptidases (AEPs) such as Legumain (LGMN). Mutation of the CST6 LGMN-inhibitory domain completely abrogated its ability to induce apoptosis in TBX2-expressing breast cancer cells, whilst mutation of the cathepsin-inhibitory domain or treatment with a pan-cathepsin inhibitor had no effect, suggesting that LGMN is the key oncogenic driver enzyme. LGMN activity assays confirmed the observed growth inhibitory effects were consistent with CST6 inhibition of LGMN. Knockdown of LGMN and the only other known AEP enzyme (GPI8) by siRNA confirmed that LGMN was the enzyme responsible for maintaining breast cancer proliferation. CST6 did not require secretion or glycosylation to elicit its cell killing effects, suggesting an intracellular mode of action. Finally, we show that TBX2 and CST6 displayed reciprocal expression in a cohort of primary breast cancers with increased TBX2 expression associating with increased metastases. We have also noted that tumors with altered TBX2/CST6 expression show poor overall survival. This novel TBX2-CST6-LGMN signaling pathway, therefore, represents an exciting opportunity for the development of novel therapies to target TBX2 driven breast cancers.

BRCA1 deficiency exacerbates estrogen-induced DNA damage and genomic instability

Germline mutations in BRCA1 predispose carriers to a high incidence of breast and ovarian cancers. BRCA1 functions to maintain genomic stability through critical roles in DNA repair, cell-cycle arrest, and transcriptional control. A major question has been why BRCA1 loss or mutation leads to tumors mainly in estrogen-regulated tissues, given that BRCA1 has essential functions in all cell types. Here, we report that estrogen and estrogen metabolites can cause DNA double-strand breaks (DSB) in estrogen receptor-α-negative breast cells and that BRCA1 is required to repair these DSBs to prevent metabolite-induced genomic instability. We found that BRCA1 also regulates estrogen metabolism and metabolite-mediated DNA damage by repressing the transcription of estrogen-metabolizing enzymes, such as CYP1A1, in breast cells. Finally, we used a knock-in human cell model with a heterozygous BRCA1 pathogenic mutation to show how BRCA1 haploinsufficiency affects these processes. Our findings provide pivotal new insights into why BRCA1 mutation drives the formation of tumors in estrogen-regulated tissues, despite the general role of BRCA1 in DNA repair in all cell types.

Well-differentiated papillary mesothelioma: peritoneal implants are not always metastases in the presence of cancer

Introduction

Well-differentiated papillary mesothelioma is a rare condition that can cause diagnostic uncertainty. Its appearance resembles metastatic deposits and in the presence of a known primary can often be confused for such.

Case presentation

In this case, we present a patient who had WDPM in the presence of gastric cancer and emphasise the difficulties in making the diagnosis.

Conclusion

We highlight the need for a high index of suspicion, biopsies at staging laparoscopy and undertake a review of the literature regarding this uncommon condition.

Abstract P5-03-14: Low dose ionising radiation effects in normal breast progenitor sub-populations

The human breast is a radiosensitive tissue and radiation exposure is proposed to contribute to mammary gland carcinogenesis through changes to stem and progenitor cells that result in aberrant proliferation, differentiation and genome instability. However, little is known about the low dose radiation response (LD IR) under conditions of relevance to environmental and occupational and medical imaging exposures.

This study utilises 2-D and 3-D breast models derived from two normal breast cell lines (MCF10A and HME1) and primary human mammary epithelial cells from reduction mammoplasty surgery, to investigate the mechanisms underpinning sensitivity of normal breast to LD IR and elucidate its role in breast cancer initiation and progression.

We have shown that DNA damage can be detected in both cell lines after doses &lt;50 mGy and that an increased level of DNA damage foci at 1 h post LD IR is observed in a subpopulation of cells.

Using antibodies to cell surface markers suggested to be putative breast stem cell markers, we have performed Fluoresence Activated Cell Sorting (FACS) to isolate subpopulations from the MCF10A cell line. CD49fhi, EpCAM-, MUC1- cells thought to be progenitor like cells were found to be more resistant to LD IR than the EpCAM+, MUC1+ population.

As the pathways that govern survival/proliferation of stem and progenitor cells versus differentiation are interconnected, we have investigated if radiation resistance is also correlated with changes to breast cell differentiation. It was observed that LD IR modulated breast cell lineage markers in 2D cultures of both cell lines.

We subsequently found that radiation induces a decrease in MUC1 mRNA expression levels which coincides with increased Lef1 expression. Lef1 has been shown to promote Mre11 expression thereby conferring elevated DNA repair and radiation resistance in tumour cells.

Based on our findings, we hypothesize that progenitor cell populations within normal breast cell lines may be more efficient at detecting DNA DSBs resulting from LD IR leading to a pro-survival response. We are currently investigating these effects in primary mammary epithelial cell samples, using FACS to isolate progenitor subpopulations.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-03-14.

Abstract P6-04-14: Impact of Estrogen Receptor Alpha Signalling in the Molecular Profiling of FFPE Derived BRCAl-Deficient Breast Tumours

Background: Approximately 5-10% of all breast cancers are hereditary and the majority of these arise due to germline mutations in the BRCA1 and BRCA2 tumour suppressor genes. BRCA1 is involved in multiple cellular pathways including DNA damage signalling, DNA repair, cell cycle regulation, protein ubiquitination, chromatin remodelling, transcriptional regulation and apoptosis. Several distinct pathological features can be used to estimate the likelihood of the presence of a BRCA1 mutation, however, it is not yet possible to fully categorise a BRCA1 mutated tumour. BRCA1-associated breast cancers are generally defined as being ER (Estrogen Receptor) negative and indeed triple negative for ER, PR and HER2. However, approximately 10-36% of BRCA1 mutated breast cancers are, in fact, ER positive. These tumours less frequently demonstrate the characteristics more commonly associated with BRCA 1 -associated breast cancers. Initial molecular evidence also suggests that there is heterogeneity within BRCA1-associated breast tumours and this is dependent on the presence or absence of the estrogen receptor. The aims of this study are to investigate the underlying biology of BRCA1-mutated (ER positive) and BRCA1-mutated (ER negative) breast tumours. Methods: Extensive gene expression profiling and data analysis was performed on a cohort of 70 FFPE (Formalin Fixed Paraffin Embedded) derived BRCA1 mutated breast tumours and matched sporadic controls using the ALMAC Breast Cancer DSA™ research tool. Within this dataset we have generated molecular profiles of: (1) BRCA 1 -mutated ER positive and (2) BRCA1-mutated ER negative breast cancer. Functional analysis was performed using DAVID and METACORE. Validation of gene targets was performed by qRT-PCR and Western blotting. Results: A list of differentially expressed transcripts was derived from the comparison of 35 BRCA1 mutant breast tumours and 35 matched sporadic controls. Further analysis based on the presence and absence of ER identified a set of transcripts defining BRCA1-mutated (ER positive) and BRCA1-mutated (ER negative) breast cancer. Functional analysis of these two datasets has identified the main pathways and processes that are deregulated. Specifically, BRCA1-deficiency in the absence of ER was associated with deregulation of pathways implicated in immune response whereas BRCA 1 deficiency in the presence of ER was associated with pathways implicated in cell adhesion and cytoskeletal remodelling. Validation of the key genes underlying these two BRCA1-deficient breast cancer subtypes has been performed.

Discussion: This approach has revealed significant heterogeneity within BRCA1 mutated breast cancer based on the presence or absence of ER. Significant differences in the transcripts and molecular processes underlying BRCA1-mutated (ER positive) and BRCA1-mutated (ER negative) breast tumours have been identified. The ability to identify BRCA 1 -deficiency by gene expression profiling from FFPE derived breast tissue may also have significant clinical application.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-04-14.

RBF principal manifolds for process monitoring

This paper describes a novel means for creating a nonlinear extension of principal component analysis (PCA) using radial basis function (RBF) networks. This algorithm comprises two distinct stages: projection and self-consistency. The projection stage contains a single network, trained to project data from a high- to a low-dimensional space. Training requires solution of a generalized eigenvector equation. The second stage, trained using a novel hybrid nonlinear optimization algorithm, then performs the inverse transformation. Issues relating to the practical implementation of the procedure are discussed, and the algorithm is demonstrated on a nonlinear test problem. An example of the application of the algorithm to data from a benchmark simulation of an industrial overheads condenser and reflux drum rig is also included. This shows the usefulness of the procedure in detecting and isolating both sensor and process faults. Pointers for future research in this area are also given.

Ambulatory laparoscopic cholecystectomy outcomes

BACKGROUND

Outpatient laparoscopic cholecystectomy is an established practice in the United States, but it is not well established in the United Kingdom, and evidence of experience is scarce. The aim of this study was to evaluate the effect of ambulatory laparoscopic cholecystectomy on postoperative morbidity and possible cost savings. We tried to elucidate possible predictors of unplanned admission and readmission rates after discharge.

METHODS

This study was conducted in 2 phases. The first phase involved 112 patients and was a retrospective analysis from January 2002 to July 2003 (19 months). The second was a prospective study involving 86 patients from August 2003 to April 2005 (21 months). Consultants, associate specialists, or higher surgical trainees performed the surgeries in a dedicated outpatient procedure unit. The study ended 6 weeks after the operation.

RESULTS

Hospital mortality was zero. Overall, 29 (15%) patients required unplanned admissions. Three (1.5%) patients required conversion to open cholecystectomy. Other causes included simple observations (7), wound pain (6), nausea and vomiting (6), suction drain (2), urinary retention (2), operation in the afternoon (2), and shoulder pain (1). Of the patients discharged, 7 (3.5%) required readmission after the initial discharge. Five of the 7 readmissions were wound related and treated conservatively. Two patients underwent laparotomy.

CONCLUSION

Ambulatory laparoscopic cholecystectomy appears to be safe, feasible, and cost-effective with a low conversion rate. The unplanned admission rate can be reduced by better training, criteria for discharge, and improvement in anesthesia. This will have implications for surgical training and healthcare resources.

Connected and disconnected support: the impact on the caregiving process in Alzheimer's disease

The findings of this grounded theory study of Eastern Canadian family caregiving for persons with Alzheimer's disease (AD) provide additional evidence that the presence of both formal and informal social support often fails to make caregiving easier. At family, community, and professional levels, caregiver perception of the helpfulness of support in meeting needs emerged as the indicator of whether support is connected or disconnected. In this paper, we demonstrate and discuss the impact of connected and disconnected support on caregiver progression on the continuum from intimacy to alienation in the process of becoming strangers, the basic social process identified in the study. Implications for further research and practice are discussed.