Systematic Review and Critical Appraisal of Urticaria Clinical Practice Guidelines: A Global Guidelines in Dermatology Mapping Project (GUIDEMAP)

BACKGROUND

Management of urticaria can be optimized with clinical practice guidelines (CPGs). However, the quality of recent urticaria CPGs remains unclear.

OBJECTIVE

To identify and appraise urticaria CPGs worldwide published in the last 5 years.

METHODS

A search for relevant urticaria CPGs was conducted between January 1, 2017, and May 31, 2022, using the following databases: MEDLINE, Embase, National Institute for Health and Care Excellence (NICE) Evidence Search, Guidelines International Network, ECRI Guidelines Trust, Australian Clinical Practice Guidelines, Trip Medical Database, and DynaMed. The included CPGs were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, Lenzer et al's red flags, and the Institute of Medicine (IOM) criteria of trustworthiness.

RESULTS

We included 21 urticaria CPGs. Most guidelines reviewed treatment recommendations of chronic spontaneous urticaria. The majority of guidelines were from European and Asian countries with high and high-middle sociodemographic index, written in English, and openly accessible. Seventeen guidelines (81%) had at least 1 AGREE II domain rated poor quality. Applicability, rigor of development, and stakeholder involvement were the 3 AGREE II domains that scored the lowest across guidelines. Appraisal with Lenzer et al's red flags showed that 18 guidelines (86%) raised at least 1 red flag indicating potential bias. The top 3 domains raising red flags were: no inclusion of nonphysician experts/patient representative/community stakeholders, no or limited involvement of a methodologist in the evaluation of evidence, and lack of external review. Based on IOM's criteria of trustworthiness, 20 guidelines (95%) had 1 or more criteria that did not meet best practice standards. The 3 domains with the highest number of best practice standards not met were updating procedures, rating strength of recommendations, and external review. Guidelines scored highest for the AGREE II domains of defining scope and purpose and clarity of presentation, and had the most fully met IOM's best practice standard for articulation of recommendations. However, only 1 urticaria CPG by NICE was identified as rigorously developed across all 3 appraisal tools.

CONCLUSIONS

The quality of urticaria CPGs in the last 5 years varied widely. Only the NICE urticaria guideline consistently demonstrated excellent quality, high trustworthiness, and low risk of bias. Use of a rigorous framework to rate certainty of evidence and grade strength of recommendation, involvement of methodologists, stakeholder engagement with external review, and clear guidance for updating can help improve the quality of future CPGs.

Effects of Preoperative Chronic Steroid Use on Postoperative Outcomes in Orthopedic Surgery: A Systematic Review and Meta-Analysis

Higher rates of postoperative complications have been found in preoperative chronic steroid users. However, the effects of preoperative chronic steroid use on outcomes in orthopedic surgery were unclear. We performed a systematic review of cohort studies examining the effects of chronic steroid use on postoperative outcomes following orthopedic surgery and searched PubMed, Embase, and CENTRAL through 29 April 2023. We included 17 studies with 1,546,562 patients. No increase in 30-day mortality (adjusted odds ratio (aOR) 1.40, 95% confidence interval (CI) 0.64-3.09) and composite thromboembolic events (aOR 1.61, 95% CI 0.99-2.63) but increases in 30-day overall complications (aOR 1.42, 95% CI 1.16-1.75), wound dehiscence (aOR 2.91, 95% CI 1.49-5.66), infectious complications (any infection (aOR 1.61, 95% CI 1.44-1.80), sepsis (aOR 2.07, 95% CI 1.34-3.21), superficial surgical site infection (SSI) (aOR 1.73, 95% CI 1.03-2.89) and deep SSI (aOR 1.96, 95% CI 1.26-3.05)), re-admission (aOR 1.62, 95% CI 1.48-1.77), both 30-day (aOR 1.28, 95% CI 1.03-1.59) and 1-year re-operation (aOR 1.78, 95% CI 1.09-2.92), pulmonary embolism (aOR 5.94, 95% CI 1.52-23.29), and deep vein thrombosis (aOR 2.07, 95% CI 1.24-3.46) were detected in preoperative steroid users. An increased risk of adverse outcomes following orthopedic surgery in chronic steroid users was found.

Advances in understanding of the pathogenesis and therapeutic implications of drug reaction with eosinophilia and systemic symptoms: an updated review

Drug reaction with eosinophilia and systemic symptoms or drug-induced hypersensitivity syndrome (DRESS/DIHS) is one type of severe cutaneous adverse reaction (SCAR). It is featured by fever, widespread skin lesions, protracted clinical course, internal organ involvement, and possibly long-term autoimmune sequelae. The presence of high-risk human leukocyte antigen (HLA) alleles, hypersensitivity reaction after culprit drug ingestion, and human herpesvirus reactivation may all contribute to its complex clinical manifestations. Some recent studies focusing on the roles of involved cytokines/chemokines and T cells co-signaling pathways in DRESS/DIHS were conducted. In addition, some predictors of disease severity and prognosis were also reported. In this review, we provided an update on the current understanding of the pathogenesis, potential biomarkers, and the relevant therapeutic rationales of DRESS/DIHS.

Bidirectional associations between psoriasis and migraine: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

To evaluate the association between psoriasis and migraine.

PATIENTS AND METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant observational studies from their respective inception to May 1, 2022. A random-effects model meta-analysis was performed to calculate the risk estimates quantifying the associations between psoriasis and migraine. We also performed a sensitivity analysis by including only studies with adjusted risk estimates and a subgroup analysis according to the severity of psoriasis.

RESULTS

We included 9 studies with 6,742,075 participants. The meta-analysis illustrated increased odds for prevalent migraine among patients with psoriasis (pooled OR: 1.69, 95% CI: 1.26-2.28) and increased odds for prevalent psoriasis among those with migraine (OR: 1.88, 95% CI: 1.32-3.67). A subgroup analysis of cohort studies demonstrated an increasingly higher risk of incident migraine in patients with mild psoriasis and severe psoriasis (IRR being 1.37 (95% CI 1.30-1.44) and 1.55 (95% CI 1.29-1.86), respectively).

CONCLUSIONS

This meta-analysis revealed significant bidirectional associations between migraine and psoriasis. Greater severity of psoriasis appears to be associated with a higher risk of developing migraine. Clinicians should evaluate symptoms of migraine in patients with psoriasis and provide proper treatments.

Risk for incident suicidality among psoriasis patients: a systematic review and meta-analysis

Previous meta-analyses have produced conflicting conclusions about suicidality risk among psoriasis patients. We aimed to update the evidence on the risk for the whole continuum of incident suicidality in psoriasis patients. We performed an update systematic review and meta-analysis and searched CENTRAL, PubMed, and Embase from January 1, 2017 to August 14, 2021 for relevant new cohort studies and incorporated new studies into our previous systematic review. Random-effects model meta-analysis was used to obtain pooled hazard ratio (HR) with 95% confidence interval (CI). Subgroup analysis was conducted according to age and disease severity. A total of 12 studies were included in this meta-analysis. We detected no significant differences in the risk for incident completed suicide (HR 1.33, 95% CI 0.91-1.95), suicide attempt (HR 1.22, 95% CI 0.96-1.56), suicidal behavior (HR 1.08, 95% CI 0.98-1.19), and suicide ideation (HR 1.74, 95% CI 0.99-3.06) between psoriasis patients and non-psoriatic controls. In the subgroup analysis based on age, an increased risk for incident suicide ideation was observed in pediatric subgroup (HR 1.50, 95% CI 1.12-2.03). The updated evidence suggests no increased risk for whole continuum of incident suicidality spectrum in psoriasis patients but an increased risk for incident suicide ideation among pediatric psoriasis patients. Involving mental health professionals may be crucial in psoriasis management especially in young patients.

Buschke-Ollendorff syndrome presenting with asymptomatic yellowish papules and leg length discrepancy: A case report

Buschke-Ollendorff syndrome (BOS) is a rare, usually benign, autosomal dominant genetic disease affecting about 0.005% globally. BOS commonly manifests with asymptomatic connective tissue nevi, sometimes with sclerotic bone lesions like osteopoikilosis or melorheostosis. However, BOS may develop severe, symptomatic complications that require surgical intervention. Here we report a 9-year-8-month girl presenting with multiple nonpruritic, nonpainful skin plaques scattered around the trunk, buttocks, and bilateral legs. She had a history of right varus foot with inadequate plantar flexion. Upon visiting, obvious leg length discrepancy (LLD) was noted. Lesional biopsy revealed increased fibroblasts within dermal collagen bundles. Verhoeff-van Gieson stain revealed scattered foci of thickened elastic fibers between collagen fibers, especially in the mid-dermis. Radiographic examination of the lower extremities showed multiple small, round-to-oval shaped, radiopaque spots on the pelvic bones, femurs, tibiae, and both feet. Hyperostosis along the long axis with "dripping candle wax" appearance was characteristic of osteopoikilosis and melorheostosis. Genetic analysis showed heterozygous point mutation in exon 1 of LEMD3 gene (c.1323C>A, p.Y441X), confirming diagnosis of BOS. Sequential and epiphyseodesis were performed to correct LLD with a favorable outcome at 2-year follow-up. BOS associated with severe bone abnormalities is rare, but orthopedic surgical intervention can provide satisfactory outcome.

One-Year Mortality Risk Stratification in Patients Hospitalized for Acute Decompensated Heart Failure: Construction of TSOC-HFrEF Risk Scoring Model

Background

Most previous risk prediction models in patients hospitalized for heart failure (HF) are derived from populations in Western countries, and it is unclear whether these models are applicable to Asian populations. This study aimed to construct a risk score system for predicting one-year mortality risk in Asian patients and to compare the applicability of this risk score system with the 3C-HF score system.

Methods

We used the population in the Taiwan Society of Cardiology-Heart Failure with Reduced Ejection Fraction (TSOC-HFrEF) registry, which is a prospective cohort of patients admitted for acute decompensated heart failure (ADHF) in Taiwan. The risk score system was constructed using multivariate Cox-model derived coefficients. A bootstrapping procedure was also used for bias-corrected evaluations. Comparisons between this constructed model and the 3C-HF score prediction model were evaluated using calibration plots and area under curve (AUC)/receiver operating characteristic (ROC) curve.

Results

Patients with complete data (n = 1127) in the TSOC-HFrEF registry were analyzed. During one year of follow-up, 14.5% (n = 163) of the patients died. A risk score system was constructed with the following predictors: body mass index, diastolic blood pressure, dyslipidemia, diabetes, aortic regurgitation, QRS duration, hemoglobin concentration, and digoxin usage. Compared to the 3C-HF score system, this risk score system had a similar discriminatory ability (AUC/ROC values of 0.675 and 0.636, p = 0.127) and both were well-calibrated in the Taiwan population.

Conclusions

The proposed risk score system for predicting one-year all-cause mortality in Taiwanese patients with ADHF may facilitate risk stratification in Asian patients with HF.

Abstract P1-01-21: Is it safe to skip intra-operative frozen section examination of sentinel lymph node for core biopsy-diagnosed DCIS?

Background

Our initial experience on sentinel lymph node (SLN) biopsy with on-table frozen section examination has shown to be an accurate alternative to axillary dissection in the staging of invasive breast cancer. Patients with a preoperative diagnosis of ductal carcinoma in-situ (DCIS) by core biopsy follow a similar treatment pathway because the risk of axillary metastasis and histological upstaging in the final excisional specimen is not negligible. Intra-operative frozen section reporting facilitates axillary clearance in a single operation when necessary. However, with the declining role of completion axillary dissection for those with minimal SLN involvement, its significance in DCIS is questioned.

Methods

A retrospective analysis was performed for patients with core biopsy-diagnosed DCIS undergoing SLN biopsy at the time of definitive surgery. Those with evidence of microinvasion in the core biopsy specimen were excluded. SLN were identified by blue dye, radioactive isotope, or combined mapping technique, and examined by intra-operative frozen section. Full axillary dissection was performed if frozen section was positive for metastasis, whereas patients with failed SLN localization were spared from the procedure. All lymph nodes harvested would undergo further paraffin section with immuno-histochemical staining. The results of SLN biopsy in relation to the final pathology of the primary tumour and the axillary disease status were analysed.

Results

From March 2002 to March 2013, 297 patients who had a core biopsy diagnosis of DCIS underwent simultaneous SLN biopsy with their definitive excisional operation. SLN localization was successful in 283 patients (95.3%). Metastases in SLN were found in 19 (6.4%) of them. Axillary dissection, either in the same or second operative setting, was completed in 12 (4%) patients. Only four (1.3%) showed additional positive lymph nodes in the rest of axilla. All of these four patients had invasive disease revealed in their primary lesions upon final pathological assessment. Overall, 83 patients (27.9%) had histological upstaging from DCIS to microinvasive or invasive carcinoma. It was more commonly associated with the presence of a palpable (48.5% versus 21.6%, p = 0.0067) or radiological (46.3% versus 19.7%, p = 0.0047) mass lesion. Out of the 214 patients who remained in the category of “pure DCIS”, six (2.8%) had SLN metastases. Three proceeded to axillary dissection and their SLN were confirmed to be the only positive ones in the axilla.

Conclusion

Although SLN metastases were rare in patients with “pure DCIS”, underestimation of invasive disease was frequent on core biopsy. Performing SLN biopsy during definitive surgery for DCIS allowed correct nodal staging in a single operation. Nevertheless, in contrast to invasive carcinoma, frozen section examination could safely be foregone since the additional yield of completion axillary dissection was shown to be slim in “pure DCIS” even if SLN shows positive results. However, management of SLN in DCIS with high risk features should follow that of invasive breast cancer in view of the considerable chance of histological upstaging.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-21.

Localisation of occult breast lesion: a comparative analysis of hookwire and radioguided procedures

OBJECTIVES

For occult breast lesions, to retrospectively compare the performance of radioguided and hookwire methods in terms of ease of localisation and surgical procedures, and the ability to obtain a specimen with a clear margin.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients who underwent occult breast lesion localisation by either ultrasonography- or stereotactic-guided radioguided occult lesion localisation or hookwire localisation from August 2003 to December 2007 were included.

MAIN OUTCOME MEASURES

Demographic data, localisation and operation procedure time, size of specimens and margin clearance.

RESULTS

In all, 165 patients (mean age, 52 years) having these procedures were assessed. In 98 instances, the procedure (hookwire=53, radioguided=45) was for diagnostic purposes and in 67 (hookwire=23, radioguided=44) for therapy. Both techniques attained a very high success rate (>95%). For radioguided occult lesion localisation, there was a significantly shorter mean localisation time than for hookwire localisation (18 min versus 31 min; P<0.001), while the mean operating time was similar. Radioguided occult lesion localisation entailed larger specimens and fewer cases with close or involved margins, or recourse to intra-operative re-excision or a second operation, but these differences were not statistically significant. Within the radioguided occult lesion localisation group, there were 42 patients who had a simultaneous sentinel lymph node biopsy (sentinel node and occult lesion localisation), with a 98% success rate although no lymph node metastasis was revealed.

CONCLUSION

Radioguided occult lesion localisation excels in yielding a much shorter localisation time and is as good as hookwire localisation in terms of specimen margin clearance and need for re-excision. It also offers the advantage of enabling simultaneous sentinel lymph node biopsy for invasive cancers. Therefore it is a recommended procedure that should be used more widely.

Randomized clinical trial comparing blue dye with combined dye and isotope for sentinel lymph node biopsy in breast cancer

Background

Use of blue dye alone as a marker for sentinel lymph node (SLN) biopsy is effective, but combining it with isotope marking can improve the success rate. Use of the isotope adds extra cost and there are potential radiation hazards. The two techniques were compared in a randomized trial.

Methods

Women with early breast cancer (less than 3 cm) and no palpable axillary nodes were recruited. Women older than 70 years with multicentric cancers or previous surgery to the breast or axilla were excluded. Patients were randomized to either blue dye alone or combined mapping for SLN biopsy. All women had a level I and II axillary dissection after the SLN biopsy.

Results

A total of 123 patients were recruited, of whom five were excluded from analysis. Blue dye alone was used in 57 women and 61 had combined mapping. Baseline demographic data were similar in the two cohorts. The success rate of SLN biopsy was higher with combined mapping than with blue dye alone (100 versus 86 per cent; P = 0·002). The accuracy and false-negative rate were similar (accuracy 100 per cent for combined mapping versus 98 per cent for blue dye; false-negative rate 0 versus 5 per cent).

Conclusion

Combined mapping was superior to blue dye alone in identification of the SLN, but accuracy and false-negative rates were similar.

Wire-guided excision of mammographic abnormalities

OBJECTIVE

A review of wire-guided excision of abnormal lesions viewed on screening mammography. DESIGN. Retrospective review.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients who underwent wire-guided excision of abnormalities visualised on screening mammography between 1999 and 2002.

INTERVENTION

Wire-guided excision.

MAIN OUTCOME MEASURES

Biopsy rate and positive biopsy rate.

RESULTS

A total of 65 patients underwent wire-guided excision of an abnormal lesion previously identified by screening mammography. Twenty-one were benign, two were lobular carcinoma in situ, and 42 were malignant. Of the latter, 30 were identified as ductal carcinoma in situ, and 12 as invasive breast cancer. Thirty-eight of the 42 malignant cases required further treatment, and 24 of them underwent further operation. Radiological assessment of the 65 patients suggested that nine lesions were probably benign, 31 indeterminate, 20 suspicious, and five malignant. Malignancy was subsequently confirmed by histological examination in 6, 20, 13, and 3 cases of the respective group of radiological assessment.

CONCLUSION

The biopsy rate was approximately 3.7 per 1000 screened women, with results benign in 1.19 per 1000. The positive biopsy rate was 64.6%, and invasion was evident in 28.6%.

One-week ranitidine bismuth citrate, amoxicillin and metronidazole triple therapy for the treatment of Helicobacter pylori infection in Chinese

BACKGROUND

We have previously shown that ranitidine bismuth citrate-based, clarithromycin-containing triple therapy achieves a higher eradication rate than proton pump inhibitor-based regimens in areas with a high prevalence of metronidazole resistance.

AIM

To evaluate whether this higher efficacy of ranitidine bismuth citrate over proton pump inhibitor can be extended to non-clarithromycin-containing regimens.

METHODS

Helicobacter pylori-positive dyspeptic patients were randomized to receive either ranitidine bismuth citrate, 400 mg, amoxicillin, 1000 mg, and metronidazole, 400 mg, or omeprazole, 20 mg, amoxicillin, 1000 mg, and metronidazole, 400 mg, each given twice daily for 1 week. H. pylori eradication was confirmed by 13C-urea breath test 5 weeks later. The side-effects of the treatments were documented.

RESULTS

Two hundred and twenty-nine patients were eligible for analysis. By intention-to-treat and per protocol analysis, the eradication rates were 77% and 79%, respectively, in the ranitidine bismuth citrate-amoxicillin-metronidazole group and 77% and 82%, respectively, in the omeprazole-amoxicillin-metronidazole group (P = 0.58 and P = 0.65). However, patients in the omeprazole-amoxicillin-metronidazole group reported a significantly higher incidence of minor side-effects when compared to those in the ranitidine bismuth citrate-amoxicillin-metronidazole group (P = 0.001).

CONCLUSIONS

Ranitidine bismuth citrate-amoxicillin-metronidazole was equally as effective as omeprazole-amoxicillin-metronidazole triple therapy, and may be considered as an alternative non-clarithromycin-based regimen in the Chinese population.

Double blind, randomised, placebo controlled study of four weeks of lansoprazole for the treatment of functional dyspepsia in Chinese patients

BACKGROUND

The use of proton pump inhibitors for the treatment of functional dyspepsia is controversial and the role of Helicobacter pylori infection in functional dyspepsia is uncertain.

AIM

To evaluate the efficacy of different doses of lansoprazole for the treatment of functional dyspepsia in Chinese patients.

METHOD

Patients with a clinical diagnosis of functional dyspepsia according to the Rome II criteria and normal upper gastrointestinal endoscopy were recruited and randomised to receive: (1) lansoprazole 30 mg, (2) lansoprazole 15 mg, or (3) placebo, all given daily for four weeks. Dyspepsia symptom scores and quality of life (SF-36 score) were evaluated before and four weeks after treatment.

RESULTS

A total of 453 patients were randomised. There was no difference in the proportion of patients with complete symptom relief in the lansoprazole 30 mg (23%) and lansoprazole 15 mg (23%) groups compared with the placebo group (30%). The proportion of H pylori positive patients with a complete response was similar with lansoprazole 30 mg (34%) and lansoprazole 15 mg (20%) versus placebo (22%). All symptom subgroups (ulcer-like, dysmotility-like, reflux-like, and unspecified dyspepsia) had similar proportions of patients with complete symptom relief after treatment.

CONCLUSION

Proton pump inhibitor treatment is not superior to placebo for the management of functional dyspepsia in Chinese patients.

Rabeprazole-based 3-day and 7-day triple therapy vs. omeprazole-based 7-day triple therapy for the treatment of Helicobacter pylori infection

BACKGROUND

Rabeprazole is a new proton pump inhibitor with more potent acid suppressive and anti-Helicobacter effects.

AIM

To compare two different regimens of rabeprazole-based triple therapy vs. 7-day omeprazole-based triple therapy for the eradication of Helicobacter pylori infection.

METHOD

Patients with proven H. pylori infection were randomized to receive: (i) 7-day rabeprazole, 10 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; (ii) 3-day rabeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; or (iii) 7-day omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily. Endoscopy (CLO test, histology) was performed before randomization and 6 weeks after drug treatment.

RESULTS

One hundred and seventy-three patients were randomized. H. pylori eradication rates (intention-to-treat, n=173/per protocol, n=167) were 88%/91% for 7-day rabeprazole-based therapy, 72%/72% for 3-day rabeprazole-based therapy and 82%/89% for 7-day omeprazole-based therapy, respectively. The per protocol eradication rate was significantly better in the 7-day rabeprazole-based therapy and 7-day omeprazole-based therapy groups when compared to the 3-day rabeprazole-based therapy group (P=0.01 and P=0.04, respectively). Compliance was excellent and all three regimens were well tolerated.

CONCLUSIONS

The efficacy of seven-day rabeprazole-based triple therapy is similar to 7-day omeprazole-based triple therapy for the eradication of H. pylori infection.

Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions

BACKGROUND

Non-palpable breast lesions present diagnostic difficulties. Ultrasound-guided fine-needle aspiration cytology (FNAC) is a common method used to obtain a diagnosis, but FNAC is frequently inconclusive or insufficiently accurate. Recently a vacuum-assisted biopsy device (Mammotome, Ethicon, Endo-surgery, USA) has been introduced. The diagnostic accuracy of this biopsy device was assessed for lesions that were visible on ultrasound.

METHODS

Fifty ultrasound-guided mammotome biopsies were performed. All were small breast lesions primarily detected by ultrasound. All received FNAC as initial assessment. Mammotome biopsy was performed whenever the breast lesion was considered indeterminate or if it was considered benign and there were associated risk factors such as a family history of breast cancer.

RESULTS

Of 50 mammotome biopsies 45 had benign histology. Three of 45 lesions were excised at the patients' request and were confirmed to be benign. The remaining 42 patients received an ultrasound follow up at 6 months. The lesion size remained static in 39 patients. In three patients the lesion size increased and they were excised and histology was benign. For the four malignancies diagnosed with mammotome biopsy, three patients received definitive treatment and one patient defaulted. There was one failed mammotome biopsy in the present series.

CONCLUSIONS

Mammotome biopsy is an acceptable diagnostic method for small breast lesions seen on ultrasound. It reduces the need for open biopsy without compromising diagnostic accuracy.

Experience of neoadjuvant chemotherapy for breast cancer at a public hospital: retrospective study

OBJECTIVE

To review local experience of neoadjuvant chemotherapy in breast cancer.

DESIGN

Retrospective study.

SETTING

Public hospital, Hong Kong.

PATIENTS

Seventeen patients who presented from August 1988 through April 1997 with locally advanced breast cancer, which was treated with neoadjuvant chemotherapy.

RESULTS

The clinical response rate was 71% and two of the 12 patients who responded to chemotherapy achieved complete remission. Three patients had their tumours downstaged sufficiently to allow them to undergo breast conservation surgery after neoadjuvant chemotherapy. None of these three patients has so far had a local recurrence of disease.

CONCLUSION

Neoadjuvant chemotherapy can achieve a high objective response rate in patients with locally advanced breast cancer and thus enables breast conservation surgery to be performed on patients who are initially not suitable for this procedure.