Oncologic outcomes after breast-conserving surgery with radiotherapy versus mastectomy in patients with Paget's disease of the breast: systematic review and meta-analysis

BACKGROUND

The conventional approach to treatment for Paget's disease of the breast has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) followed by radiotherapy (RT) in these patients. This study aimed to provide an updated systematic review and meta-analysis comparing outcomes after BCS with RT versus mastectomy in the treatment of Paget's disease of the breast.

METHODS

Studies before May 2021 were included. Primary outcomes were overall survival and local recurrence. Separate analyses of Paget's disease associated with ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) were undertaken. Meta-regression was used to adjust for imbalance in the proportion of IDC among patients selected to undergo BCS versus mastectomy.

RESULTS

Overall survival in patients with Paget's disease who underwent BCS with RT was higher than for those who underwent mastectomy with pooled mortality hazard ratio (HR) of 0.68, (95% per cent c.i. 0.45 to 1.01). Patients with Paget's disease with DCIS had higher overall survival after BCS with or without RT versus mastectomy, with adjusted HR of 0.14 (0.10 to 0.20) and 0.28 (0.22 to 0.36), respectively. For patients with Paget's disease and IDC, overall survival was lower for BCS with or without RT versus mastectomy, with adjusted HR of 0.84 (0.57 to 1.25) and 1.64 (1.04 to 2.58), respectively. In Paget's disease and IDC, local recurrence risk was much higher for BCS with RT, RR 26.8 (1.60 to 456) versus without RT, RR 51.8 (6.80 to 391). In patients with Paget's disease and DCIS, risk of local recurrence versus mastectomy was lower for BCS with RT 0.72 (0.11 to 4.50) but slightly higher for BCS alone 1.38 (0.09 to 21.20).

CONCLUSION

BCS with RT may be a comparable treatment alternative to mastectomy for patients with Paget's disease with DCIS, and for selected patients with Paget's disease and IDC.

Effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors on serum urate levels in patients with and without diabetes: a systematic review and meta-regression of 43 randomized controlled trials

Objectives

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been found to reduce serum urate in patients with type 2 diabetes mellitus. To evaluate if this effect applies to both patients with and without diabetes, we conducted a systematic review and meta-analysis of SGLT2 inhibitors on serum urate levels in this population.

Methods

Four electronic databases (PubMed, Embase, Cochrane and SCOPUS) were searched on 25 September 2021 for articles published from 1 January 2000 up to 25 September 2021, for studies that examined the effect of SGLT2 inhibitors on serum urate in study subjects. Random-effects meta-analysis was performed, with subgroup analyses on the type of SGLT2 inhibitor agent administered, presence of type 2 diabetes mellitus, presence of chronic kidney disease and drug dose.

Results

A total of 43 randomized controlled trials, with a combined cohort of 31,921 patients, were included. Both patients with [-31.48 μmol/L; 95% confidence interval (CI): -37.35 to -25.60] and without diabetes (-91.38 μmol/L; 95% CI: -126.53 to -56.24) on SGLT2 inhibitors had significantly lower urate levels when compared with placebo. This treatment effect was similarly observed across different types of SGLT2 inhibitors. However, in type 2 diabetes mellitus (T2DM) patients with chronic kidney disease, the reduction in serum urate with SGLT2 inhibitors became insignificant (95% CI: -22.17 to 5.94, p < 0.01).

Conclusion

This study demonstrated that SGLT2 inhibitors are beneficial in reducing serum urate in patients with and without diabetes. SGLT2 inhibitors could therefore contribute to the general treatment of hyperuricaemia.

Impact of First Assistant Surgeon Experience on the Perioperative Outcomes of Laparoscopic Hepatectomies

Introduction: This study aims to evaluate the impact of first assistant surgeon experience on the outcomes of laparoscopic hepatectomies in a university-affiliated teaching hospital. Methods: This is a retrospective study comparing outcomes of laparoscopic hepatectomies with first assistant surgeons of varying experience levels. Three hundred and eighty-five consecutive laparoscopic hepatectomies performed in a tertiary university-affiliated teaching hospital from 2012 to 2018 were included and stratified into three cohorts-Group 1 in which assistants were residents, Group 2 for fellows, and Group 3 for attendings. Baseline clinicopathologic variables and outcome measures were analyzed using the augmented inverse probability of treatment weighting approach, which is a propensity score-based method that combines aspects of covariate adjustment and inverse probability weighting. Results: Group 3 comprised a greater proportion of advanced- and expert-level surgeries based on the Iwate criteria; 33.8%, 32.2%, and 46.0% of patients underwent advanced- and expert-level surgeries in Groups 1, 2, and 3, respectively. Group 3 had consistently higher operative times as well as more frequent use and longer duration of Pringle's maneuver (P < .05). The median operative times for Groups 1, 2, and 3 were 195, 195, and 290 minutes, respectively. Pringle's maneuver was applied in 26.9%, 33.9%, and 60.2% of patients with a corresponding median duration of 35, 36, and 45 minutes, respectively. None of the other perioperative and postoperative outcomes demonstrated statistically significant differences. Conclusion: With an appropriate selection of cases, participation of residents as first assistants in laparoscopic hepatectomies can be encouraged without compromise in perioperative outcomes.