Surgical margin and local recurrence of ductal carcinoma in situ

PURPOSE

This study aims to evaluate the association between surgical margin status and local recurrence of DCIS.

METHODS

A retrospective analysis of a prospectively maintained 20-year DCIS database was performed. >=2 mm margin was defined as clear margin. Local relapse rate between the patients with clear versus close margins were analyzed with Kaplan-Meier analyses.

RESULTS

654 patients were analyzed. Median age was 46.5 (Range 18 - 80). 205 (31.3%) were high grade, 194 (29.7%) were intermediate grade, 143 (21.9%) were low grade. 112 (18.3%) were unknown. 202 (30.9%) were estrogen receptor positive, 49 (7.4%) were negative, 403 (61.6%) patients were unknown. 403 (61.6%) patients received mastectomy while 251 (38.4%) patients received BCS and radiotherapy. 549 (83.9%) patients had clear surgical margin, 50 (7.7%) patients had involved (positive) resection margin, 55 (8.4%) had close margin (<2 mm margin). All patients with involved margin received re-excision of margin, while 21 patients (out of 55 who had close resection margins) received re-excision of margin. Negative surgical margins were achieved after the re-excision. 34 patients with close resection margin decided not to receive re-excision but to undergo adjuvant radiotherapy. After median follow-up of 128 months, the 10-year ipsilateral breast tumor relapse (IBTR) was 4.5% (N = 28), Of which 27 (96.4%) patients had clear margin after the initial surgical treatment of DCIS. 1 (3.6%) patient had close surgical margin. Difference in IBTR between the two groups was not statistically significant (p = 0.692).

CONCLUSION

Close surgical margin for DCIS is not associated with increased risk of IBTR.

Pregnancy-related breast cancer: 14-year experience in a tertiary institution in Hong Kong

BACKGROUND

The incidence of pregnancy-associated breast cancer (PABC) is increasing. Its tumor characteristics and overall survival compared with those in nonpregnant patients remain controversial. While there have been suggestions that PABC patients have a 40 % increase in the risk of death compared to non-pregnant patients, other studies suggested similar disease outcomes. This study aims to review our local experience with PABC.

METHODS

Twenty-eight patients diagnosed with PABC and twenty-eight patients diagnosed at premenopausal age randomly selected by a computer-generated system during the same period were recruited. Background characteristics, tumor features, and survival were compared.

RESULTS

Among the twenty-eight pregnant patients, seventeen were diagnosed during pregnancy, and eleven were diagnosed in the postpartum period. Compared to the non-pregnant breast cancer patients, they presented with less progesterone receptor-positive tumor (35.7 % vs. 64.2 %, p = 0.03). Although there was no statistically significant difference in tumor size (p = 0.44) and nodal status (p = 0.16), the tumor tended to be larger in size (2.94 +/- 1.82 vs 2.40 +/- 1.69 cm) and with more nodal involvement (35.7 % vs 25.0 %). There was also a trend of delayed presentation to medical attention, with a mean duration of 13.1 weeks in the PABC group and 8.6 weeks in the control group. However, the overall survival did not differ (p = 0.63).

CONCLUSION

PABC is increasing in incidence. They tend to have more aggressive features, but overall survival remains similar. A multidisciplinary approach is beneficial for providing the most appropriate care.

Extended reality in surgical education: A systematic review

BACKGROUND

This review aims to evaluate the effectiveness of extended reality-based training in surgical education.

METHODS

This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 33 studies were included in the qualitative analysis. Nine studies evaluated the effectiveness of virtual reality-based training against no substitutional training. Seven studies looked at training for laparoscopic surgery, and the results were contradicting. Two studies focused on orthopedics training, and the outcomes were positive. Fourteen studies compared the outcomes of virtual reality-based training to conventional didactic teaching, all demonstrating superior outcomes for virtual reality-based training. Nine studies compared the outcomes of virtual reality simulation training to dry lab simulation training. The inferior outcomes of virtual reality simulation training were demonstrated by 5 studies for laparoscopic surgery, 1 study for arthroscopic procedures, 1 study for robotic surgery, and 1 study for dental procedures. One study found potential benefits of virtual reality simulation training on orthopedics surgeries. One study found virtual reality simulation training to be superior to cadaveric training, and 3 studies found augmented reality and virtual reality-based training to be comparable to supervised operative opportunities.

CONCLUSION

Extended reality-based training is a potentially useful modality to serve as an adjunct to the current physical surgical training.

Clinical Outcomes of Conservative Treatment for Low-Risk Ductal Carcinoma in Situ: A Systematic Review and Pooled Analysis

AIMS

The current gold standard of treatment for ductal carcinoma in situ (DCIS) is surgical resection with or without adjuvant radiotherapy. However, the increased detection and radical treatment of DCIS did not result in a declined incidence of invasive breast cancers, leading to the debate if DCIS has been overtreated. While ongoing randomised controlled trials on active surveillance of DCIS are still in progress, this systematic review aims to evaluate the best evidence on conservative treatment for DCIS from the literature.

MATERIALS AND METHODS

This systematic review was conducted in line with the PRISMA statement. We included all relevant studies published up to June 2022 for analysis. The primary outcomes were overall survival and breast cancer-specific survival (BCSS) of conservative treatment for DCIS.

RESULTS

Three studies, with a total of 34 007 women with low-risk DCIS, were included in the analysis. Active and conservative treatments both resulted in excellent 10-year BCSS, with no statistically insignificant difference (98.6% versus 96.0%, 31 478 women). One study comparing 5-year BCSS of active and conservative treatments only in subjects aged over 80 years also reported [AQ1]an insignificant difference (98.2% versus 96.0%, 2529 women). One study measuring 5- and 10-year overall survival between the treatment groups also reported [AQ1]an insignificant difference (5-year: 96.2% versus 92.4%; 10-year: 85.6% versus 86.7%, 31 106 women).

CONCLUSION

BCSS between active and conservative treatment for women with low-risk DCIS is both excellent and comparable, suggesting that conservative treatment is a possible alternative without compromising survival.

Prospective Clinical Trial on Expanding Indications for Cryosurgery for Early Breast Cancers

INTRODUCTION

This is a prospective single arm clinical trial on cryosurgery for early breast cancers, to evaluate the expanded criteria to tumors larger than 1.5 cm and non-luminal breast cancers.

METHODS

Inclusion criteria include Solitary T1 breast cancers of any immunohistotypes. Cryosurgery was performed using the IceCure ProSense Cryoablation System. Lumpectomy of the cryoablated tumor was then performed 8 weeks after cryosurgery.

RESULTS

Fifteen patients underwent cryosurgery followed by lumpectomy (BCS). Median age was 53 years old 5 (33.3%) patients had ductal carcinoma in situ (DCIS), while 10 (66.7%) patients had invasive ductal carcinoma (IDC), of which 5 (50%) patients had luminal type cancers of which 3 (60%) were luminal A and 2 (40%) luminal B, 3 (30%) patients had HER2 enriched invasive carcinoma and 2 (20%) patients had triple negative IDC. Median tumor size was 13mm (Range 8.6-18mm). Seven (46.7%) patients were found to have residual cancer in the post-cryosurgery lumpectomy specimen. All residual cancers were found at the periphery of the cryoablated breast tissue. All breast cancers were otherwise completely ablated centrally as confirmed by routine histopathology, immunochemistry and TUNEL assay for evaluation of cell viability. None of the tumor factors such as tumor biology, as well as surgical factors such as ablation time and iceball size, were associated with risk of residual cancer. None of the 15 patients developed post-operative complications.

CONCLUSION

Residual cancer occurs at the periphery of the cryoablation site, careful pre-operative planning and intra-operative monitoring is crucial to ensure complete cryoablation.

Perception from students regarding online synchronous interactive teaching in the clinical year during COVID-19 pandemic

AIM

The global pandemic of COVID-19 has led to extensive practice of online learning. Our main objective is to compare different online synchronous interactive learning activities to evaluate students' perceptions. Moreover, we also aim to identify factors influencing their perceptions in these classes.

METHODS

A cross-sectional, questionnaire-based study focusing on clinical year medical students' perceptions and feedback was conducted between February 2021 -June 2021 at the University of Hong Kong. Online learning activities were divided into bedside teaching, practical skill session, problem-based learning (PBL) or tutorial, and lecture. A questionnaire based on the Dundee Ready Education Environment Measure (DREEM) was distributed to 716 clinical year students to document their perceptions.

RESULTS

One hundred responses were received with a response rate of 15.4% (110/716, including 96 from bedside teaching, 67 from practical skill session, 104 from PBL/tutorial, and 101 from lecture). For the mean score of the DREEM-extracted questionnaire, online PBL/tutorial scored the highest (2.72 ± 0.54), while bedside scored the lowest (2.38 ± 0.68, p = 0.001). Meanwhile, there was no significant difference when we compared different school years (p = 0.39), age (p = 0.37), gender (p = 1.00), year of internet experience (<17 vs ≥17 years p = 0.59), or prior online class experience (p = 0.62). When asked about students' preference for online vs face-to-face classes. Students showed higher preferences for online PBL/tutorial (2.06 ± 0.75) and lectures (2.27 ± 0.81). Distraction remains a significant problem across all four learning activities. A multivariate analysis was performed regarding students' reported behavior in comparison with their perception through the DREEM-extracted questionnaire. The results showed that good audio and video quality had a significant and positive correlation with their perception of online bedside teaching, practical skill sessions, and PBL/tutorial. It also showed that the use of the video camera correlated with an increase in perception scores for lectures.

CONCLUSION

The present analysis has demonstrated that students' perception of different online synchronous interactive learning activities varies. Further investigations are required on minimizing distraction during online classes.

Axillary Reverse Mapping in the Prevention of Lymphoedema: A Systematic Review and Pooled Analysis

BACKGROUND

This is a systematic review of randomized controlled trials (RCT) comparing the use of axillary reverse mapping (ARM) with conventional technique for axillary dissection (AD) in breast cancer surgery.

METHODS

This review was written in line with the PRISMA protocol. Articles were retrieved from PubMed, EMBASE, CINAHL and Cochrane databases, using keywords ..úaxillary reverse mapping..Ñ and "axillary lymph node dissection". Non-RCT were excluded. Abstracts were screened independently by 2 reviewers. Data from eligible studies were retrieved for qualitative synthesis and pooled analysis. 73 publications were identified for initial screening.

RESULTS

68 articles were excluded from analysis according to the pre-defined systematic review protocol. 5 RCTS with 1696 subjects were included for analysis. 802 patients received ARM, 894 patients received AD. Pooled ARM node detection rate was 84.9% (Range 79.2 - 94.9%). There was a lower rate of post-operative lymphedema in ARM group patients across all 5 RCTs. The pooled lymphedema incidence in the ARM group was 4.8% (37/766) when compared to 18.8% (164/873) in the AD group (P < .0001). Axillary recurrence rate with median followof 37 months was 1.03% (8/778) in the ARM group, which was identical to 1.03% (9/870) in the AD group (P = 1).

CONCLUSION

ARM resulted in decreased incidence of lymphedema. There was no significant increase in axillary recurrence at 37 months post-operation.

Using clinical history taking chatbot mobile app for clinical bedside teachings - A prospective case control study

Introduction

A novel chatbot mobile app for training of undergraduate medical students' clinical history taking skills was developed in 2021. Students were able to take clinical history from the virtual patient for bedside teaching. A case-control study was conducted to evaluate the effectiveness of learning with chatbot mobile app, versus conventional bedside teachings with real patients.

Methods

132 final year medical students were randomized into two groups - Conventional bedside teaching with clinical history taken from a real patient, and Bedside teaching with clinical history taken from the Chatbot. Independent blinded assessment of students' history taking skills was conducted. Students' performance were assessed by standardized marking scheme.

Results

Median age was 23 years old (Range 21-30 years old). There were 62 female and 70 male students.64 students were randomized into conventional group while 68 students were randomized into the chatbot group. Baseline demographic data were comparable between the two groups.Blinded assessment of students' performance in clinical history taking were comparable between the conventional group and chatbot group (p > 0.05).

Conclusion

With the promising results we have demonstrated in this study, we believe training of history taking skills by chatbot will be a feasible alternative to conventional bedside teaching.

"Catch, Flip, and Remove" Technique for Retrieval of a Hypermobile Detached Leadless Pacemaker: A Case Report and Literature Review

Leadless pacemaker (LP) detachment is a rare but life-threatening complication that may occur during implantation. While different snaring techniques have been described to remove partially or completely detached LPs, there are currently no reports of snaring a hypermobile LP that travels between different cardiac chambers. This report describes a technique to successfully snare a hypermobile detached LP by first “catching” onto the tines for stabilization with the help of a multi-loop snare, followed by using a second snare for the proximal retrieval feature.

COVID-19 vaccine associated axillary lymphadenopathy - A systematic review

INTRODUCTION

; COVID-19 vaccines are commonly administered intramuscularly to the arm. Axillary lymphadenopathy has been reported as an adverse event after COVID-19 vaccination. In patients with breast cancers who received COVID-19 vaccination, presence of ipsilateral (or contralateral) lymphadenopathy poses diagnostic dilemma. This systematic review aims to evaluate the incidence and clinical characteristics of vaccine associated axillary lymphadenopathy.

METHODS

; The systematic review was conducted with accordance to the PRISMA statement. The search terms used were "Vaccine" OR "Vaccination" AND "Lymphadenopathy" OR "Lymph node" AND "Covid-19″.

RESULTS

; 31 studies or reports were identified using the predefined keywords from the systematic review protocol. After excluding irrelevant papers (such as guidelines, reviews, opinions and commentaries), 10 studies or reports were included in the review.Pooled incidence of clinically detectable lymphadenopathy after COVID-19 vaccination was 91/22,532 (0.4%). Mean size of the vaccine associated axillary lymphadenopathy was 18.2 mm (Range 16 - 21 mm). Mean duration from vaccination to occurrence of axillary lymphadenopathy was 6.9 days (Range 2 - 18 days). In a study on 119 patients, enlarged axillary lymphadenopathy resolves in 4 to 5 weeks.

CONCLUSION

; Vaccine associated axillary lymphadenopathy is not uncommon. Management of it is based on multidisciplinary decision with patient demographics, vaccination history and radiological finding being taken into account. Additional imaging and biopsy may lead to unnecessary healthcare burden. Proper arrangement of vaccination and imaging regarding timing and laterality should be advocated to avoid confusion and patient anxiety.

Prospective clinical trial on the learning curve of high-intensity-focused ultrasound for the treatment of breast fibroadenoma

INTRODUCTION

High-intensity-focused ultrasound (HIFU) is a safe and feasible treatment option for breast fibroadenoma. However, its learning curve has not been described in the medical literature.

METHODS

All patients with biopsy-proven fibroadenoma considered indicated for HIFU were screened for eligibility for HIFU treatment. A total of 60 patients were recruited according to the pre-defined sample size calculation.

RESULTS

Sixty consecutive patients were divided into three cohorts in chronological order. The mean tumor volume shrinkage rates in cohorts 1, 2, and 3 at 6 months post-HIFU ablation were 38%, 34%, and 59%, respectively. Significant tumor shrinkage was observed from case 41 onward (p < 0.0001). Similarly, the mean tumor volume shrinkage rates in cohorts 1, 2, and 3 at 12 months post-HIFU ablation were 45%, 51%, and 71%, respectively. Significant tumor shrinkage was observed from case 41 onwards (p < 0.0473). The mean procedure time for the first 20 patients was 48.5 (range 45-75) minutes, while that in the second 20 patients was 39.7 (range 20-60) minutes, and that in the last 20 patients was 28.9 (range 15-45) minutes. The treatment time was significantly shorter from case 41 onwards (p = 0.0481).

CONCLUSION

Treatment outcomes and treatment time improved significantly after performing approximately 40 HIFU procedures.

A prospective case-control study on online teaching of ultrasonography skills to medical students during COVID-19 pandemic

Introduction

A new Online interactive Ultrasound Teaching (OUT) was developed in our institution in March 2021 during COVID-19 outbreak.

Methods

This is a case control study on 65 final year medical students to compare OUT with conventional face-to-face ultrasound tutorials. There were 31 female and 34 male students. Median age was 23 years old (Range 21–30). Students were randomly assigned into two different teaching groups. Competency in conducting ultrasonic exam was assessed by Objective Structured Assessment of Ultrasound Skills (OSAUS).

Results

32 students were randomized into the control group (face to face teaching) while 33 students were randomized into the case group (OUT). Baseline demographic characteristics were comparable between the two groups (p > 0.05).

The median score of the blinded OSAUS assessment was 5.5 (Range 3–7). There were 4 (6.2%) students who failed in the assessment (scored <4 out of 7), and 10 (15.4%) students scored full marks in the assessment.

The medians scores were 5.5 (Range 3–7), and 6 (Range 3–7) (p = 0.8057) in the control and case groups respectively. 6 (18.8%) students in the control group scored full mark, comparing to 4 (12.1%) students in the case group (p = 0.5105). 2 students from each group failed the assessment (p = 1).

Conclusion

Ultrasonographic skills performance was comparable between students who were taught by OUT and conventional face-to-face tutorial.

Cross-sectional case-control study on medical students' psychosocial stress during COVID-19 pandemic in Hong Kong

INTRODUCTION

COVID-19 pandemic has resulted in significant changes in pedagogy for undergraduate medical curriculum. Many physical clinical teachings have been replaced by online pedagogy. This study aims to evaluate the relation between medical students' stress during COVID-19 pandemic and their academic performance at the final examination.

METHODS

This is a cross-sectional questionnaire-based study. Student's stress level were evaluated by the COVID-19 Student Stress Questionnaire (CSSQ). Correlation of stress level and students' performance at the final examination was performed.

RESULTS

110 out of 221 (49.8%) final-year medical students responded to the questionnaire, 13 students failed in the final examination (case) while 97 students passed in the final MBBS examination (control).Baseline demographic data between case and control were comparable. The median age for both cases and controls were 24 years.Compared to controls, cases reported higher levels of stress in all domains, namely in relation to risk of contagion, social isolation, interpersonal relationships with relatives, university colleagues and professors, academic life, and sexual life. Notably, a significantly higher proportion of cases reported academic-related stress compared to controls (p < 0.01), with 100% of cases perceiving their academic studying experience during the COVID-19 pandemic to be "very" or "extremely" stressful, compared to 35.1% of controls.

CONCLUSION

Increased stress to academic and study during COVID-19 was associated with worse examination outcome at the final examination. Extra academic support will be needed to cater students' need during the pandemic.

Distance education for anatomy and surgical training - A systematic review

Rapid development of COVID-19 has resulted in a massive shift from traditional to online teaching. This review aims to evaluate the effectiveness of distance learning on anatomy and surgical training.

This systematic review was conducted in line with the PRISMA statement and current methodological literature. The databases CINAHL, Cochrane, EMBASE and Pubmed were searched using the search terms “Distant learning” OR “Distance learning” AND “Anatomy OR Surgery”. 182 non-duplicate studies were identified. 20 studies were included for qualitative analysis.

10 studies evaluated students' performance with distance learning. 3 studies suggested that students’ learning motivation improved with distance learning pedagogy. 5 studies found improved student performance with distance learning (performance or task completion time) when compared to conventional physical method. While 2 other studies found non-inferior student performance.

10 studies evaluated students’ feedback on distance learning. Most feedbacks were positive, with flexibility, efficiency, increased motivation and better viewing angles as the most-liked features of distance teaching. 4 studies pointed out some limitations of distance learning, including the lack of personal contact with tutor, poor network and reduced student concentration.

7 studies evaluated tutors’ feedback on distance learning. Tutors generally liked online platforms for the ease of tracking silent students, monitoring performance and updating fast-changing knowledge. Yet the lack of hands-on experience for students, technical issues and high costs are the main concerns for tutors.

In conclusion, distance learning is a feasible alternative for anatomy and surgical teaching.

Autism-linked gene FoxP1 selectively regulates the cultural transmission of learned vocalizations

Autism spectrum disorders (ASDs) are characterized by impaired learning of social skills and language. Memories of how parents and other social models behave are used to guide behavioral learning. How ASD-linked genes affect the intertwined aspects of observational learning and behavioral imitation is not known. Here, we examine how disrupted expression of the ASD gene FOXP1, which causes severe impairments in speech and language learning, affects the cultural transmission of birdsong between adult and juvenile zebra finches. FoxP1 is widely expressed in striatal-projecting forebrain mirror neurons. Knockdown of FoxP1 in this circuit prevents juvenile birds from forming memories of an adult song model but does not interrupt learning how to vocally imitate a previously memorized song. This selective learning deficit is associated with potent disruptions to experience-dependent structural and synaptic plasticity in mirror neurons. Thus, FoxP1 regulates the ability to form memories essential to the cultural transmission of behavior.

Online teaching of basic surgical skills to medical students during the COVID-19 pandemic: a case-control study

Purpose

Medical education has been disrupted by the COVID-19 pandemic in many countries, with face-to-face lectures replaced by pre-recorded videos. However, surgical skills training cannot be replaced easily by videos, as a high level of tutor–student interaction is required. Thus, we developed a new web-based surgical skill learning session (WSSL). This case–control study evaluates the surgical skills competency of medical students taught by the WSSL.

Methods

This case–control study compares WSSL with face-to-face tutorials. Students were assigned randomly to one of two groups according to the teaching method. Independent blinded assessment was performed by a standardized marking scheme, modified from the Objective Structured Assessment of Technical Skills (OSATS) global rating scale.

Results

We recruited 62 final-year medical students into the study, with 33 randomized to the face-to-face teaching group (control group), and 29 to the WSSL group(case group) according to their student number. The baseline demographic characteristics of the two groups were comparable. The mean score at the clinical competency assessment of the control group was 4.8/5 (range 4–5) and that of the case group was 4.7/5 (range 4–5) (p = 1). There were no difficulties with program or hardware installation reported by the WSSL students.

Conclusions

Surgical skills performance was comparable between students who were taught by the WSSL and those taught by conventional face-to-face tutorials.

Prognostic Value of Left Ventricular Global Strain Analysis by Two-Dimensional Speckle-Tracking Echocardiography in Non-Hemodynamically Significant Intermediate Coronary Lesions

Intermediate coronary lesions represent a major challenge for the invasive and noninvasive cardiologist. Left ventricular strain calculation by speckle tracking echocardiography has the capacity to analyze the motion of the cardiac tissue. This study aimed to evaluate its usefulness and prognostic significance in nonhemodynamically significant intermediate coronary lesions. We studied 247 patients who underwent a clinically indicated coronary angiogram. Each of the patients had a single nonrevascularized nonhemodynamically significant intermediate severity coronary lesion (ISCL) with a fractional flow reserve greater than 0.80. The left ventricular global longitudinal strain (GLS) was calculated using speckle-tracking echocardiography with TomTec 2D Cardiac Performance Analysis (Unterschleissheim, Germany). An abnormal GLS was defined as less than -20%. The primary endpoints were revascularization of the target lesion, admissions for major adverse cardiac events (MACE), and cardiac-related mortality, all within 2 years. On multivariate logistic regression data analysis, we found that patients with an ISCL and abnormal GLS had an increased risk for admissions due to MACE (odds ratio [OR] 1.06, P < 0.05, confidence interval [CI] 95%, 1.005-1.120], and an increased risk of cardiac-related death (OR 1.12, P < 0.05, CI 95% 1.012-1.275). There was no difference in the need for target lesion revascularization among individuals with normal and abnormal GLS (1.00, P 0.88, CI 95% .950-1.061). Left ventricular strain analysis by speckle-tracking echocardiography showed an independent prognostic value in patients with nonrevascularized nonhemodynamically significant coronary lesions.

Clinical outcomes of patients with ductal carcinoma in situ in Hong Kong: 10-year territory-wide cancer registry study

BACKGROUND

Incidence of ductal carcinoma in situ (DCIS) has increased in recent decades because of breast cancer screening. This study comprised a long-term survival analysis of DCIS using 10-year territory-wide data from the Hong Kong Cancer Registry.

METHODS

This study included all patients diagnosed with DCIS in Hong Kong from 1997 to 2006. Exclusion criteria were age <30 years or ≥70 years, lobular carcinoma in situ, Paget's disease, and co-existing invasive carcinoma. Patients were stratified into those diagnosed from 1997 to 2001 and those diagnosed from 2002 to 2006. The 5- and 10-year breast cancer-specific survival rates were evaluated; standardised mortality ratios were calculated.

RESULTS

Among the 1391 patients in this study, 449 were diagnosed from 1997 to 2001, and 942 were diagnosed from 2002 to 2006. The mean age at diagnosis was 49.2±9.2 years. Overall, 51.2% of patients underwent mastectomy and 29.5% received adjuvant radiotherapy. The median follow-up interval was 11.6 years; overall breast cancer-specific mortality rates were 0.3% and 0.9% after 5 and 10 years of follow-up, respectively. In total, 109 patients (7.8%) developed invasive breast cancer after a considerable delay. Invasive breast cancer rates were comparable between patients diagnosed from 1997 to 2001 (n=37, 8.2%) and those diagnosed from 2002 to 2006 (n=72, 7.6%).

CONCLUSION

Despite excellent long-term survival among patients with DCIS, these patients were more likely to die of breast cancer, compared with the general population of women in Hong Kong.

Non-surgical treatment for ductal carcinoma in situ of the breasts - a prospective study on patient's perspective

INTRODUCTION

Several ongoing trials are currently investigating the feasibility and non-inferiority of active surveillance for managing low-risk DCIS. However, little is known on the proposed non-surgical treatment for DCIS from patient's perspective.

METHODS

A prospective cohort study was performed on 1000 consecutive patients aged 18 to 90 years old with various breast disorders between 1st July 2019 and 31st December 2019. Patients were asked about their opinions on non-surgical treatments for DCIS after thorough explanation of the clinical scenario.

RESULTS

Median age was 55 years old (Range 18 - 87). 692 patients had past history of breast cancer, 279 patients had benign breast conditions, 29 patients had borderline breast lesions. 891 (89.1%) patients opted for standard surgical excision for low-risk DCIS, most of them (N = 757, 85.0%) decided for operative management for DCIS to avoid life-time anxiety of disease progression. Patients of older age and with history of malignant breast conditions are more likely to choose surgical treatment for DCIS (p<0.0001). Of note, 112 (11.2%) patients in the cohort had history of DCIS with excision done, 111 (99.1%) patients would still decide for surgical excision as the treatment of DCIS, only 1 patient expressed the wish for conservative treatment for DCIS.

CONCLUSION

Majority of patients decided for surgical treatment for DCIS despite being offered the condition that conservative treatment could be oncologically safe. Patient anxiety and cost of extensive breast surveillance are two important factors.

Distant surgical teaching during COVID-19 - A pilot study on final year medical students

Introduction

Due to the COVID‐19 outbreak, all on‐site undergraduate medical teaching activities in Hong Kong have been suspended. A new web‐based surgical skills learning (WSSL) for basic surgical skills training that were normally taught face‐to‐face was developed.

Methodology

Basic surgical skills were taught with normal face‐to‐face tutorial to 30 final year medical students prior to the outbreak. The same group of students were invited to join the online WSSL using Zoom. Evaluation of WSSL was performed by a standardized questionnaire.

Results

Thirty final year medical students (16 female, 14 male students) were recruited into the study. Median age was 23 (range 22‐24). Most of them believed that WSSL is easy to follow. When compared to face‐to‐face teaching. Most students (N = 22, 73.4%) felt that WSSL was just as difficult/easy as conventional teaching for learning instrumental knots. Students were asked to evaluate WSSL by using a Likert scale of 1 to 10 (with 10 being highly recommended). Twelve (40%) students highly recommended WSSL (Score 9 to 10), 15 students (50%) slightly recommended WSSL (Score 6‐8).

Conclusion

Web‐based surgical skills learning is a feasible alternative for face‐to‐face surgical skills teaching.

Delayed presentation, diagnosis, and psychosocial aspects of male breast cancer

Introduction

Male breast cancer is uncommon, delay in seeking medical attention often results in late presentation and poor prognosis.

Methods

Retrospective review of a prospectively maintained database was performed. Patients who were still having regular follow‐up were contacted for telephone interview.

Results

In this study, 56 male breast cancer patients were treated in our center from January 1998 to December 2018, accounting for 0.88% of all breast cancers treated during the same period of time. Median age of onset was 61 years old (Range: 33‐95). In this study, 6 (10.7%) patients presented with distant metastasis at the time of diagnosis and received palliative systemic treatment only. And, 50 patients were surgically treated and all had mastectomy. Axillary dissection was performed in 36 (72%) patients, while sentinel node biopsy was performed in 14 (28%) patients. Median tumor size was 23 mm (2‐100 mm). A Majority were diagnosed with invasive carcinoma (NOS), while 38 (67.8%) patients were node positive.Here 36 (64.3%) patients were alive at the time of the study, 31 (86.1%) patients responded to the telephone interview. More than 90% of our patients expressed various degrees of embarrassment at the time of breast symptom onset. Similarly, more than 90% of these patients experienced embarrassment while waiting in the breast center with predominant female patients. Most patients (N = 26) were not aware that breast cancer can occur in men prior to the diagnosis. Median duration from symptoms to the first medical consultation was 12.4 months (1‐120 months).

Conclusion

Male breast cancer is rare and patients usually present late, Lack of knowledge, public education, and embarrassment are the important related factors.

Breast Conserving Surgery for BRCA Mutation Carriers-A Systematic Review

Similar to mastectomy, breast conserving surgery (BCS) is currently the reference standard of surgical treatment of sporadic breast cancer in patients. However, its oncologic safety for BRCA mutation carriers has remained controversial. Thus, we conducted a systematic review to critically evaluate the best evidence from reported studies. A comprehensive search was performed of the Medline, EMBASE, CINAHL, and Cochrane databases using a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted for qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol for systematic reviews. No randomized controlled trial has directly compared BCS and mastectomy for BRCA mutation carriers. Of the 18 studies included in our review, the pooled analysis of overall survival at 5, 10, and 15 years were comparable between BCS and mastectomy (88.7%, 89.0% and 83.6% with BCS and 83%, 86.0%, and 83.2% with mastectomy, respectively). However, the pooled ipsilateral breast cancer recurrence rates at 5, 10, and 15 years were higher in the BCS group (8.2%, 15.5%, and 23%, respectively) than in the mastectomy group (3.4%, 4.9%, and 6.4%, respectively). BCS was associated with a greater rate of ipsilateral breast cancer recurrence in BRCA mutation carriers. However, it was not associated with adverse short- and long-term survival outcomes. BCS should be offered as an option to BRCA mutation carriers with proper preoperative counseling.

Sentinel Lymph Node Biopsy in Early Breast Cancer: Magnetic Tracer as the Only Localizing Agent

BACKGROUND

The combined use of radioisotope and blue dye is the gold standard in sentinel lymph node (SLN) localization in early breast cancer. Superparamagnetic iron oxide (SPIO) has recently emerged as a non-inferior new tracer in sentinel lymph node mapping with fewer disadvantages. This study represents the first and the largest cohort of superparamagnetic iron oxide application in Asian population.

METHODS

Retrospective analysis of a prospectively maintained database was performed from August 2016 to December 2017. All patients with SLN localization by SPIO were included in this study.

RESULTS

A total of 328 breast cancer patients with 333 SLNB procedures were included in this study. Median age was 54 years (range 32-86). Median tumor size was 1.9 cm (range 0.1-12 cm).There were 138 breast-conserving surgeries and 195 mastectomies. All patients received injection of SPIO 1 day prior to operation. A total of 329 successful sentinel lymph node biopsy (SLNB) procedures were undertaken with 1514 sentinel lymph nodes (SLNs) identified. One hundred and fifty-three (10.1%) of the SLNs were positive for malignancy. There were 54 patients with macrometastases, 26 with micrometastases and 24 with isolated tumor cells. Sixty-seven patients underwent subsequent axillary dissection. Four patients failed sentinel lymph node identification with SPIO. The success rate of SPIO in sentinel lymph node localization was 98.8%.

CONCLUSION

SPIO represents a feasible alternative in sentinel lymph node mapping with comparably high nodal detection rate.

De-novo metastatic breast cancers with or without primary tumor resection - A 10-year study

BACKGROUND

Treatment of de novo metastatic breast cancer is usually palliative with systemic treatment; surgical excision of the primary tumour is reserved in patients with significant symptoms from the primary tumour. Survival benefit of surgical removal of the primary tumour remains controversial.

METHODS

All patients treated with de novo metastatic breast cancer (MBC) between 2007 and 2016 were retrieved from a prospectively-maintained database. Demographic and tumour characteristics were compared. Overall survival (OS) was analysed using Kaplan-Meier Method and log rank tests. Multivariate analysis was performed to evaluate the prognosticators of OS in de novo MBC.

RESULTS

Median age of diagnosis was 53 years old (Range 24-91 years old). 91 patients received resection of the primary tumour, including 86 mastectomies and 5 breast conserving surgeries (surgical group). 81 patients were never treated surgically (non-surgical group). Baseline demographic data were comparable apart from being younger age in the surgical group. 5-year OS in surgical group was significantly better than non-surgical group (43.9% vs. 33.9%, p = 0.026). Multivariate analysis found that advanced age (Hazard ratio: 1.034, p = 0.005, 95% CI 1.010-1.058) and presence of visceral metastasis (Hazard ratio: 1.672, p = 0.038, 95% CI 1.028-2.719) were significant adverse prognosticators through multivariate analysis; while positive oestrogen receptor (ER) status was the only positive prognosticator in the analysis (Hazard ratio: 0.42, p = 0.001, 95% CI 0.256-0.688).

CONCLUSION

Surgical excision of primary breast tumour may confer survival benefit in de novo MBC.

Idiopathic granulomatous mastitis: a 10-year study from a multicentre clinical database

Idiopathic granulomatous mastitis (IGM) is an uncommon, chronic inflammatory breast disease with elusive aetiology, simulating malignancy clinically and radiologically. Here we present our 10-year review on a region-wide multicentre IGM database. A retrospective study was performed on a prospectively maintained database from three University affiliated hospitals in Hong Kong and Shenzhen, China. All patients with biopsy proven IGM were included while patients with positive culture of Mycobacterium tuberculosis were excluded. Disease recurrence rate and its prognosticators were evaluated. A total of 102 patients were included between January 2007 and December 2017. Median age was 33 years (range 20-54). Most patients presented with painful inflammatory mass (n = 57); median size at presentation was 37 mm (6-92 mm). Sixty-three patients had bacterial culture performed on the pus sample: eight patients had Corynebacterium kroppenstedtii while four had Corynebacterium species not otherwise specified. Seventy-seven (75.5%) patients received conservative treatment with oral corticosteroid (±antibiotics) and drainage only, while 25 (24.5%) patients received breast lump excision after initial medical treatment. Twelve (11.8%) patients developed recurrence after a median follow-up interval of 14 months (4-51 months). Univariate analysis revealed that abscess on presentation, history of smoking, and presence of C. kroppenstedtii were significant prognosticators for recurrence. Subsequent multivariate analysis with logistic regression revealed cigarette smoking and isolation of C. kroppenstedtii as independent risk factors for disease recurrence (p < 0.05). In conclusion, IGM is uncommon with a recurrence rate of 12%, especially in patients with history of smoking and isolation of C. kroppenstedtii.

Air Travel Safety in Postoperative Breast Cancer Patients: A Systematic Review

Air travel has long been a dilemma in post-breast cancer surgery patients. Anecdotal reports have described adverse outcomes on surgical wound, implants, and lymphedema during air travel. This review aims to evaluate the best evidence from the literature concerning the air travel safety in breast cancer patients. A comprehensive review was performed of the Medline, Embase, CINAHL, and Cochrane databases using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by 2 researchers. We reviewed the best evidence on air travel safety in postoperative breast cancer patients. Evidence was limited in the current literature to suggest adverse effects on postoperative mastectomy wounds and drains by high-altitude travel. Similarly, adverse effects on breast implants were limited to case reports and ex vivo experiments. A systematic review of 12 studies concluded that air travel is not associated with upper limb lymphedema after breast cancer surgery. Deep-vein thrombosis (DVT) is a known complication after air travel; in addition, malignancy itself is a known risk factor for DVT. Evidence of safety to continue tamoxifen during the period of air travel is lacking in the literature. Evidence to support the use of systemic DVT prophylaxis in general postoperative breast cancer patients is also limited. Best evidence from a large retrospective study suggested that mechanical antiembolism devices and early mobilization are the only measures required. Air travel is generally safe in patients after breast cancer surgery.

Air Travel and Postoperative Lymphedema-A Systematic Review

Lymphedema is not uncommon after axillary dissection for breast cancer. Improved survival of patients with breast cancer from advances in adjuvant therapy has resulted in increased awareness of the quality of life for long-term survivors. Air travel has been postulated as 1 of the risk factors of lymphedema exacerbation. In the present systematic review, we sought to critically evaluate the current data on this topic. The present study was registered in the Research Registry. A systematic review of lymphedema and air travel was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The Medline, EMBASE, CINAHL, and Cochrane databases were searched for English-language studies up to June 2017 with a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted by 2 of us. A total of 55 studies were identified using predefined keywords; 12 studies were included using the criteria stated in the study protocol. A pooled analysis of 2051 patients with a history of air travel revealed that ≤ 14.5% developed lymphedema after air flight. However, a subsequent analysis of 4 studies with a control arm showed that 107 of 1189 patients (9%) with a documented history of air travel developed lymphedema compared with 204 of 2356 patients (8.7%) who had not flown (χ² test; P = .80). Two studies (1030 patients) evaluated the effect of lymphedema on patients' air travel patterns. Of the 1030 patients, 141 (13.7%) had totally avoided air travel after the development of lymphedema. However, air travel was not adversely associated with the development of lymphedema.

Mammary phyllodes tumour: a 15-year multicentre clinical review

Aims

Phyllodes tumour (PT) is an uncommon fibroepithelial tumour of the breast. It has a spectrum of aggressiveness in biological behaviour with chance of local recurrence and, occasionally, metastasis.

Methods

A 15-year retrospective review from a multicentre database in Hong Kong was performed.

Results

Clinical and pathological records of 465 patients with 469 PTs between 1998 and 2014 were reviewed. Median age of occurrence was 44 years (range 12–86 years). 281 (59.9%) PTs were benign, 124 (26.4%) were borderline and 64 (13.6%) were malignant. About half of all PTs (239, 51.5%) were between 2 and 5 cm while another 186 (40.1%) were >5 cm in size. Most PT (84.6%) were radiologically benign. Breast-conserving surgery (BCS) was feasible in 384 (82%) patients, whereas 84 (18%) patients had mastectomy. Multivariate analysis found that positive surgical margin (P<0.001) and BCS (P<0.001) were the only significant risk factors for local recurrence, while large tumour size (P=0.008) and malignant PT histotype (P<0.001) were the only significant risk factors for metastasis. Long-term prognosis of benign and borderline PT was excellent. After median follow-up interval of 85 months (range 12–180 months), the disease-specific survival of benign, borderline and malignant PT were 99.6%, 100% and 90.6%, respectively.

Conclusions

Local recurrence of PTs occurs irrespective of the tumour grade. Surgical margin is the only amendable factor to reduce the chance of recurrence.

Ductal carcinoma in situ of the breast - Long term results from a twenty-year cohort

INTRODUCTION

Long-term survival is excellent in ductal Carcinoma in situ (DCIS); whether or not we are over-treating DCIS has been a major public concern. This study aims at reviewing the long-term survival outcome of DCIS and identifying adverse prognosticators for DCIS.

PATIENTS AND METHODS

Patients treated for DCIS between 1st January 1997 and 31st December 2016 were identified from a prospectively maintained database. Multivariate analysis was performed to evaluate the adverse factors for surgical margin involvement and local recurrence RESULTS: 3042 female patients were treated for breast cancer over the 20-year study period, of which 203 (6.7%) had DCIS in final pathology. The median age of diagnosis was 53 year-old (Range 30-85). 57 (28.1%) were detected by screening mammogram, 101 had breast mass on presentation. 132 (65%) patients received mastectomy and the remaining received breast conserving surgery (BCS); Sentinel lymph node biopsy was performed in 86 (42.4%) patients. 19 (9.4%) patients had positive resection margin, 18 were re-operated for clear resection margin. Multivariate analysis found that high grade DCIS is the only independent risk factors for margin involvement (HR 2.55, 95% CI 1.02-6.42). After median follow-up of 106 months (6-223 months), the overall survival was 97%. 4 (2%) patients developed local recurrence. Multivariate analysis found that positive surgical margin is the only independent factor of local recurrence (HR 9.58, 95% CI 1.43-64.18).

CONCLUSION

High grade DCIS is associated with increased risk of surgical margin involvement which is in turn an independent factor of local recurrence.

Preoperative Sentinel Node Mapping in Sentinel Node Biopsy in Early Breast Cancers - Is It Cost-Effective?

INTRODUCTION

Sentinel lymph node (SLN) biopsy is currently the gold standard of treatment in early breast cancers. Identification of SLNs by preoperative scintigraphy has been carried out to improve the detection of SLNs intraoperatively, but the evidence of its cost-effectiveness is lacking. Here, we analyze the cost-effectiveness of the utilization of scintigraphy in detection of SLNs.

PATIENTS AND METHODS

Clinical and operative details were retrieved from a prospectively maintained database. The resources and cost data from each patient who had undergone SLN biopsy with preoperative scintigraphy were retrieved.

RESULTS

From January 2008 to December 2012, 400 patients underwent SLN biopsy for breast cancer. A total of 329 had preoperative SLN mapping with scintigraphy, Baseline patient demographic data for both arms were comparable. The relapse and recurrence rate of both arms were not statistically different. The detection rate of SLNs of both arms was the same (100%), and there were no grade 2 or above lymphedema in both groups of patients. However, the cost of each patient undergoing SLN mapping was USD $345.8.

CONCLUSION

Preoperative SLN mapping does not improve the SLN detection rate. In addition, it does not affect the surgical outcomes in terms of complication, local relapse, and recurrence. The use of preoperative SLN mapping is no longer cost-effective.

Mastectomy technique using a self-designed self-retaining retractor system

Mastectomy is one of the most common procedures for treating breast cancer. It is often performed by a breast surgeon with an assistant holding the retractor to provide adequate tension for dissection of the skin flap. However, the technique is highly dependent on the retraction from the assistant. We herein describe a novel technique using a self-retained retractor system with a specially designed retractor ring and elastic stay hooks to allow adequate and constant tension of retraction throughout the entire mastectomy procedure. This new technique was introduced at our breast center in 2008, and the skin flap necrosis rate and time required for skin flap dissection remain comparable to those in other regions. The retractor ring costs less than $200 USD, and the disposable elastic hooks cost around $50 USD. In conclusion, this new technique is simple, versatile, and effective.

Abstract P2-12-22: Atypical ductal hyperplasia and breast cancers - A ten year clinical and pathological review on core biopsy, lumpectomy and mastectomy specimens

Introduction

Atypical ductal hyperplasia (ADH) is known to be associated with underlying pre-malignant or malignant breast conditions. Here we report our 10-year data on ADH found in core biopsy, lumpectomy and mastectomy specimens

Methods

From 1st January 2005 to 31st December 2014, a total of 104 core needle biopsy specimens and 218 lumpectomy / mastectomy specimens were found to contain ADH. Clinical, radiological and pathology data were retrieved and analysed from a prospectively-maintained database.

Results

Out of the 104 patients with core biopsy showing ADH, 101 patients received excision and 3 refused operation. 34 patients turned out to have ductal carcinoma in-situ (DCIS) on excision, while 6 had invasive ductal carcinoma (IDC), 1 had lobular carcinoma in-situ (LCIS) and 1 had angiosarcoma resulting in an upstaging rate of 40.4% (42/104). The remaining patients had benign lesions including papillary lesions, fibrocystic disease, or ADH alone. Multivariate analysis found that the only correlating factor for the presence of DCIS or IDC was suspicious mammographic features (BIRADS 4 or above) (P = 0.008 and 0.02 respectively) but not other parameters such as extent of micro-calcifications (P = 0.12) or age (P = 0.11).

Histopathological diagnosis after excision of lesions containing ADH on core biopsyExcisional Biopsy ResultNumber (%)DCIS34 (32.7%)ADH32 (30.8%)Benign27 (26%)IDC6 (5.8%)LCIS1 (0.9%)Angiosarcoma1 (0.9%)Refuse operation3 (2.9%)

218 lumpectomy or mastectomy specimens were found to harbor ADH. 62 (28.4%) had co-existing pre-malignant or malignant breast diseases. The only determining factor for the presence of malignant or pre-malignant condition was suspicious breast imaging features (BIRADS 4 or above) after multivariate analysis (P = 0.0003).

Co-existing conditions in the lumpectomy / mastectomy specimens with ADHCo-existing Patholog(ies)Number (%)Atypical Ductal Hyperplasia alone97 (44.4%)Fibroadenoma / Fibrocystic disease31 (14.2%)Intraductal papilloma22 (10%)Phyllodes tumor6 (2.8%)Ductal carcinoma in-situ36 (16.5%)Invasive ductal carcinoma23 (10.6%)Lobular carcinoma in-situ1 (0.5%)Invasive lobular carcinoma1 (0.5%)Malignant phyllodes tumor1 (0.5%)

Conclusion

ADH is closely related to the presence of invasive cancer or DCIS especially when suspicious breast imaging features are present. The upstaging rate is still high in patients where initial biopsy was ADH.

Citation Format: Co M, Kwong A. Atypical ductal hyperplasia and breast cancers - A ten year clinical and pathological review on core biopsy, lumpectomy and mastectomy specimens. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-22.

Macrometastasis, micrometastasis, and isolated tumor cells in sentinel lymph nodes of early breast cancers: a 10-year histopathological and survival analysis of 537 Asian patients

BACKGROUND

In patients with negative sentinel lymph node biopsy (SLNB), axillary dissection (AD) can be avoided to reduce morbidities. However, there is only limited data on the rate of positive non-SLN (NSLN) in those who have micrometastasis and isolated tumor cells (ITC) in the literature.

METHODS

We did a retrospective review of all clinically node-negative breast cancer patients with SLNB done at our unit from January 2001 to June 2011. Multivariate analysis was adopted to evaluate the risk factors for NSLN metastasis. Difference in 5-year disease-free survival (DFS) was evaluated with log-rank test.

RESULTS

Five-hundred and thirty-seven patients underwent SLNB; 161 (30%) had positive SLN on frozen section (FS), 50 of these patients (31%) had NSLN metastasis, 25 patients had negative SLN on FS but were found to have micrometastasis on histopathology, and only 1 (4%) of them had NSLN metastasis, while 14 patients were found to have ITC in SLN; none of them had NSLN metastasis. Multivariate analysis found that the number of SLN harboring micrometastasis is the only independent risk factor for NSLN metastasis in patients with micrometastasis (p value = 0.008). On the contrary; tumor size, grade, and biology were not associated with NSLN metastasis. 5-year DFS in patients with macrometastasis in SLN was 94.2%, while that in patients with micrometastasis and ITC was 100% (p value <0.001).

CONCLUSION

NSLN metastasis in those who only have micrometastasis and ITC is rare, and 5-year DFS is significantly better in this group of patients as well. It is therefore a routine practice in our unit to omit AD in patients with micrometastasis and ITC on SLN.

Interaction of a dengue virus NS1-derived peptide with the inhibitory receptor KIR3DL1 on natural killer cells

Killer immunoglobulin-like receptors (KIRs) interact with human leucocyte antigen (HLA) class I ligands and play a key role in the regulation and activation of NK cells. The functional importance of KIR-HLA interactions has been demonstrated for a number of chronic viral infections, but to date only a few studies have been performed in the context of acute self-limited viral infections. During our investigation of CD8(+) T cell responses to a conserved HLA-B57-restricted epitope derived from dengue virus (DENV) non-structural protein-1 (NS1), we observed substantial binding of the tetrameric complex to non-T/non-B lymphocytes in peripheral blood mononuclear cells (PBMC) from a long-standing clinical cohort in Thailand. We confirmed binding of the NS1 tetramer to CD56(dim) NK cells, which are known to express KIRs. Using depletion studies and KIR-transfected cell lines, we demonstrated further that the NS1 tetramer bound the inhibitory receptor KIR3DL1. Phenotypical analysis of PBMC from HLA-B57(+) subjects with acute DENV infection revealed marked activation of NS1 tetramer-binding natural killer (NK) cells around the time of defervescence in subjects with severe dengue disease. Collectively, our findings indicate that subsets of NK cells are activated relatively late in the course of acute DENV illness and reveal a possible role for specific KIR-HLA interactions in the modulation of disease outcomes.