Quality of life and satisfaction of patients after oncoplastic or traditional breast-conserving surgery using the BREAST-Q (BCT module): a prospective study

INTRODUCTION

The oncoplastic conservative surgery was developed as a natural evolution of traditional surgery, attempting to improve the therapeutic and aesthetic outcomes where tumor resection could be followed by not-adequate results. Our primary aim is to evaluate how patient satisfaction and quality-of-life after conservative oncoplastic surgery, using BREAST-Q (BCT Module), change pre- and post-operatively. The secondary aim is to compare patient-reported outcome after oncoplastic or traditional conservative surgery.

PATIENTS AND METHODS

We enrolled 647 patients who underwent traditional conservative surgery or oncoplastic surgery from January 2020 to December 2022. Only 232 women (35.9%) completed the BREAST-Q questionnaire on a web-based platform, at the preoperative phase and 3 months after treatment.

RESULTS

The average score of "Psychosocial well-being" and "Satisfaction with Breasts" 3 months after surgery showed a statistically significant improvement, while the average score for "Physical well-being: Chest" at 3 months showed a worsening compared to the baseline. "Sexual well-being" did not show statistically significant change. A significant difference between the post-operative outcome of oncoplastic surgery and traditional surgery was observed only for Physical well-being (better for traditional surgery).

CONCLUSIONS

The study showed significant improvement in patient-reported outcomes 3 months after the surgery, except for physical discomfort that increases especially after oncoplastic surgery. Furthermore, our data, as well as many others, point to the appropriateness of using OCS where there is an effective indication, while the perspective of patients cannot find significant superiority over TCS in any of the areas analyzed.

Germline investigation in male breast cancer of DNA repair genes by next-generation sequencing

PURPOSE

In order to better define the breast cancer (BC) genetic risk factors in men, a germline investigation was carried out on 81 Male BC cases by screening the 24 genes involved in BC predisposition, genome stability maintenance and DNA repair mechanisms by next-generation sequencing.

METHODS

Germline DNAs were tested in a custom multi-gene panel focused on all coding exons and exon-intron boundaries of 24 selected genes using two amplicon-based assays on PGM-Ion Torrent (ThermoFisher Scientific) and MiSeq (Illumina) platforms. All variants were recorded and classified by using a custom pipeline.

RESULTS

Clinical pathological data and the family history of 81 Male BC cases were gathered and analysed, revealing the average age of onset to be 61.3 years old and that in 35 cases there was a family history of BC. Our genetic screening allowed us to identify a germline mutation in 22 patients (23%) in 4 genes: BRCA2, BRIP1, MUTYH and PMS2. Moreover, 12 variants of unknown clinical significance (VUS) in 9 genes (BARD1, BRCA1, BRIP1, CHEK2, ERCC1, NBN, PALB2, PMS1, RAD50) were predicted as potentially pathogenic by in silico analysis bringing the mutation detection rate up to 40%.

CONCLUSION

As expected, a positive family history is a strong predictor of germline BRCA2 mutations in male BC. Understanding the potential pathogenicity of VUS represents an extremely urgent need for the management of BC risk in Male BC cases and their own families.

An integrated approach with homeopathic medicine and electro-acupuncture in anaesthesiology during breast cancer surgery: Case reports

This study investigates the effect of a combination of homeopathic medicine and electro-acupuncture in two patients with breast cancer and severe liver disease who could not receive standard anaesthesia therapy due to liver problems. Specifically, measurable and quantifiable parameters were used to evaluate whether an integrated approach-consisting of electro-acupuncture and a homeopathic medicine diluted above Avogadro's limit (that is, above a potency of 12CH) during the pre-surgical, surgical and post-surgical phases--can improve general well-being of a patient undergoing breast cancer surgery. In breast cancer surgery, we employed an integrated approach consisting of induction with hypnotics and muscle relaxants, followed by maintenance with anaesthetic gas, combined with a homeopathic treatment (Arnica montana 15CH and Apis mellifica 15CH) before and after surgery and an electro-acupuncture treatment performed in the pre- and post-surgical phases without any analgesic/pain relieving medications. Both of the patients treated with the integrated approach improved their overall condition without need for other common pain relieving medicines. Additionally, thanks to their rapid awakening, the patients were not relocated to a protected area and the hospitalization was shorter. A multidisciplinary approach incorporating homeopathic medicine and electro-acupuncture can be a solution for patients who need or ask about a different and/or safer alternative to the standard treatment. This approach can offer a safe, much less expensive, non-invasive and viable alternative for such cases. Moreover it can be useful for an opioids free anesthesia.

The role of clinicopathologic and molecular prognostic factors in the post-mastectomy radiotherapy (PMRT): a retrospective analysis of 912 patients

OBJECTIVE

To assess the association of clinicopathologic and molecular features with loco-regional recurrence (LRR) in post-mastectomy breast cancer patients with or without adjuvant radiotherapy (PMRT).

PATIENTS AND METHODS

We retrospectively reviewed data of patients undergone to mastectomy followed or not by PMRT between January 2004 and June 2013. The patients were divided according to clinicopathologic and molecular sub-classification features. LRR and Cancer Specific Survival (CSS) were calculated using the Kaplan-Meier method; the prognostic factors were compared using long-rank tests and Cox regression model.

RESULTS

A total of 912 patients underwent to mastectomy of whom 269 (29.5%) followed by PMRT and 643 (70.5%) not; among the PMRT group, 77 underwent to the chest wall (CW) and 202 to the chest wall and lymphatic drainage (CWLD) irradiation. The median follow-up was 54 months (range, 3-118). No significant difference in terms of LRR and CSS was found between non-PMRT and PMRT group (p=0.175; and p=0.628). The multivariate analysis of LRR for patients who did not undergo PMRT showed a significant correlation with the presence of extracapsular extension (ECE) (p=0.049), Ki-67>30% (p=0.048) and triple negative status (p=0.001). In the PMRT group, triple negative status resulted as the only variable significantly correlated to LRR (p=0.006) at the multivariate analysis and T-stage also showed a trend to significance (p=0.073). Finally, no difference in LRR control was shown between CW and CWLD-PMRT (p=0.078).

CONCLUSIONS

After mastectomy ECE, a cut off of Ki-67>30% and triple negative status were strictly correlated with LRR regardless of clinicopathologic stage. PMRT has a positive impact in decreasing LRR in patients with this molecular profile. Besides, CW might represent a valid option for patients with one to three positive nodes.

The superparamagnetic iron oxide tracer: a valid alternative in sentinel node biopsy for breast cancer treatment

The European Union has determined that from 2016 breast cancer patients should be treated in Specialist Breast Units that achieve the minimum standards for the mandatory quality indicators as defined by Eusoma. The existing standard for axillary lymph node staging in breast cancer is sentinel node biopsy (SNB), performed using Technetium-sulphur colloid (^99m Tc) alone or with blue dye. The major limits of radioisotope consist in the problems linked to radioactivity, in the shortage of tracer and nuclear medicine units. Among existing alternative tracers, SentiMag^® , which uses superparamagnetic iron oxide particles, can represent a valid option for SNB. We conducted a paired, prospective, multicentre study to evaluate the non-inferiority of SentiMag^® vs. ^99m Tc. The primary end point was the detection rate (DR) per patient. The study sample consists of 193 women affected by breast carcinoma with negative axillary assessment. The concordance rate per patients between ^99m Tc and SentiMag^® was 97.9%. The DR per patient was 99.0% for ^99m Tc and 97.9% for SentiMag^® . SentiMag^® appears to be non-inferior to the radiotracer and safe. While ^99m Tc remains the standard, SentiMag^® DR appears adequate after a minimum learning curve. In health care settings where nuclear medicine units are not available, SentiMag/Sienna+^® allows effective treatment of breast cancer patients.

Does thyroid peroxidase provide an antigenic link between thyroid autoimmunity and breast cancer?

Women with breast cancer (BC) and antithyroid peroxidase (TPO) autoantibodies (TPOAb) have a better prognosis than women lacking TPOAb. Sera from women with TPOAb displayed immunoreactivity to BC tissue by immunofluorescence that was not apparent in women without TPOAb. We hypothesize a BC/thyroid shared antigen that provides a target for humoral or cell-mediated immune activity; candidates include the sodium/iodide symporter (expressed in thyroid and BC), cross-reacting epitopes in TPO and lactoperoxidase (LPO) or TPO itself. As the association is with TPOAb, we investigated TPO expression in BC, breast peritumoral tissue (PT), other tissues (tumoral and not) and thyroid as positive control. Transcripts for known and novel TPO isoforms were detected in BC (n = 8) and PT (n = 8) but at approximately 10(4) -fold lower than in thyroid while in non-BC tumors (n = 5) they were at the limit of detection. TPO was expressed also in adipose tissue (n = 17), 10(3) -fold lower than in thyroid. Full length TPO (Mr 105-110 kDa) was detected in Western blots in the majority of examined tissues; preabsorption of the TPO antibody with recombinant TPO (but not LPO) reduced the signal, indicating specificity. The same occurred with some lower molecular weight bands, which could correspond to smaller TPO transcript isoforms, present in all samples. In conclusion, TPO is weakly expressed in BC and other tissues; this could partly explain the high frequency and protective role of TPOAb in BC patients. Further studies will investigate tissue specificity, function and immunogenicity of the novel TPO variants (some BC-specific) identified.

Identification of a Prognostic Signature Based on the Expression of Insulin-Related Genes in Early Breast Cancer

Background: A substantial body of evidence indicate that the insulin pathway plays a key role in breast cancer development and progression and may represent a therapeutic target, especially in those patients exposed to high plasmatic level of insulin. However, the potential prognostic role of genes related to the insulin-pathway in breast cancer cells has not been explored. With these premises, we evaluated the prognostic role of the expression of genes related to the insulin pathway in early breast cancer. Methods: Candidate genes were selected from published literature, genomic databases, and gene expression profiling experiments performed in insulin resistant subjects, yielding 143 genes that were used to develop a molecular classifier. We used three publicly available breast cancer datasets, GSE1456, GSE3494 and GSE2990 that include gene expression data on a total of 502 cases with clinical follow up. The insulin gene signature was developed on GSE1456, containing microarray data from 159 early breast cancer patients. This dataset was split by a random procedure into a training set and a validation set. Univariate non-parametric Mann-Whitney U test was used to identify genes differentially expressed. Expression of genes significantly correlated with relapse was combined in a linear score. Patients were classified as low or high risk with respect to the median score. External validation was performed on GSE3494 and GSE2990. Results: On the training set, 15 genes resulted differentially expressed in relapsed and non relapsed patients: the 8-year disease free survival (DFS) was 91% (SE =4%) and 51% (SE = 8%) in the high and low risk group (p< 0.001); HR = 10.6 (95% CI 3.2-35.5, p<0.00001). In the validation set, the 8-year RFS was 97% (SE = 3%) and 54% (SE = 10%), respectively (p = 0.009); HR = 4.6 (95% CI 1.01 to 20.7, p 0.04). External validation was performed on two independent datasets, GSE3494 and GSE 2990 including 350 early breast cancer patients. In GSE3494 the 8-year DFS was 72% (SE = 5%) and 61% (SE = 4%) in the high and low risk group (p = 0.03), respectively. In GSE 2990 the 8-year DFS was 74% (SE = 7%) and 55% (SE = 8%), respectively, (p = 0.03). By multivariate analysis, the insulin signature resulted significantly associated with DFS, independently of age, tumor size, ER status, nodal status and grade. Conclusions: Our findings indicate that the insulin pathway is involved in breast cancer prognosis at a genomic level and might provide a better way to individualize therapeutic interventions targeting insulin signaling.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 108.

Association between expression of insulin resistance (IR) related genes and breast cancer outcome

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Background: IR is associated with adverse outcome in breast cancer. IR may affect patient outcome via the insulin and the IGF axis, acting through the tyrosine kinase signaling in enhancing cell proliferation. To date, no study explored the role of insulin- related gene expression in breast cancer progression. The aim of this study was to evaluate the prognostic value of a set of insulin-related genes using published microarray datasets. Methods: IR genes were sorted according to the “insulin sensitivity gene set” previously defined in peripheral tissues of healthy subjects screened for IR by the euglycaemic insulin clamp technique. One-hundred-forty- three genes were used to develop an outcome predictor on a training set of 102 primary breast tumors, randomly selected from 159 patients in the GEO database ( GSE1456 ). The outcome predictor was validated on the remaining 57 patients. Primary outcome measure was relapse free survival (RFS). Univariate non-parametric Mann-Whitney U test was used to identify genes differentially expressed. Expression of genes significantly correlated with relapse was combined in a linear score. Patients were classified as low or high risk with respect to the median score. Kaplan-Meier curves were used to evaluate the discriminating power of the score. Results: Fourteen genes resulted differentially expressed in the training set: the 8-year RFS was 91% (SE =4%) and 51% (SE = 8%) in the low risk and high risk group, respectively (p < .001). In the validation set, the 8-year RFS was 97% (SE = 3%) and 54% (SE = 10%), respectively (p = .009), supporting the discriminating ability of the score. By multivariate Cox analysis, the prognostic ability of the score was independent of subtype and grade (p < .001). Conclusions: Our data provide the first evidence that expression of insulin related genes can predict outcome, and indicate that the insulin pathway is involved in breast cancer progression. This is particularly important since IR is responsive to lifestyle interventions. We are currently validating the insulin-related score on independent breast cancer microarray datasets.

No significant financial relationships to disclose.

Laparoscopic living donor nephrectomy in Italy: a national profile

BACKGROUND

There are no data concerning the national experience with laparoscopic live donor nephrectomy (LLDN) in Italy. A survey was therefore conducted in May 2003 to establish current practice patterns and to describe the outcome of this procedure.

METHODS

A self-administered questionnaire was mailed to the 37 Italian kidney transplant centers. Items covered each center's attitude toward LLDN, number of cases performed, and the outcome of donors and recipients.

RESULTS

The return rate was 100%. The surveyed centers performed 4818 kidney transplants between January 2000 and May 2003, including 401 (8.3%) from living donors of whom 113 (28.2%) used grafts retrieved by laparoscopy. Despite an absolute increase in the number of living donors, the occurrence of a similar trend in cadaveric donation did not significantly change the overall living donor rate. Sixty-eight percent of LLDNs were done at only two centers. There was no mortality or graft loss and only a minor morbidity related to LLDN. Italian transplant surgeons showed a positive attitude toward LLDN; only a few of those not performing it had no plans to begin an LLDN program.

CONCLUSIONS

Three years after the first national case, LLDN had not yet change the living donor rate, although an increasing number of donor nephrectomies were now performed by laparoscopy. Overall the results with the new technique are encouraging, although the pattern of diffusion of LLDN between different areas is heterogeneous and will demand continuous efforts on training programs in laparoscopic techniques for transplant surgeons.

Plasma exchange for polyradiculoneuropathy following kidney transplantation: a case report

We describe a case of polyradiculoneuropathy (PRN) following living donor kidney transplantation, without clinical evidence of preexisting infection. In this study plasma exchange treatment resulted 6 days later in improvement in extremity weakness and paresthesias in the upper and lower extremities. Total neurological recovery was obtained 3 months after the onset of symptoms.

Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure

BACKGROUND

Laparoscopic low anterior resection for rectal cancer has never gained wide acceptance among general surgeons, mainly due to the technical difficulties encountered during pelvic dissection. It has therefore been stated that these patients should undergo open rather than laparoscopic surgery. Hand-assisted laparoscopic surgery (HALS) is a new technique that has the potential to overcome many of the existing limitations of pure laparoscopy. In the treatment of rectal cancer, HALS could reproduce an operative setting similar to that of the open approach.

METHODS

To assess the technical feasibility of hand-assisted laparoscopic low anterior resection for rectal cancer and evaluate potential benefits and drawbacks of this new procedure, a pilot study was conducted at a university hospital on 16 consecutive patients during a 12-month period. Only patients with extraperitoneal rectal cancer were included in this series. Patients' clinical data, operative time, conversion rate, complications, and early outcome measures were prospectively examined.

RESULTS

There were 9 men and 7 women. The average +/- SD operation time was 238 +/- 38 min. Conversion to open surgery was never required. Ten of 16 patients were off pain medication on the third postoperative day. Eight were able to walk the day after surgery. Three minor postoperative complications were recorded. Mean postoperative stay for patients without complications was 5.6 +/- 1.4 days.

CONCLUSION

From a technical standpoint, the reported hand-assisted procedure makes pelvic dissection during laparoscopic low anterior resection almost equivalent to the laparotomic operation. The incision for hand access that is needed with this technique does not seem to compromise the quick recovery of patients undergoing purely laparoscopic procedures.

Laparoscopic and hand-assisted laparoscopic live donor nephrectomy

Renal grafts from living donors represent an important source of organs, particularly for young patients with chronic renal failure. Laparoscopic donor nephrectomy is a relatively new technique, which has the potential to increase the pool of available kidney grafts by removing some disincentives to live donation. The technique used for left kidney donation at our center, the first to introduce laparoscopic live donor nephrectomy in Italy, is described in this report. To further reduce warm ischemia time, the kidney is preloaded inside the extraction bag and 2 staplers are used to transect the renal artery and vein. The spread of the new technique in our country and in the rest of Europe is likely to raise the issue of training in laparoscopic surgery for transplant surgeons.