Cost-Effectiveness of Radar Localisation Versus Wire Localisation for Wide Local Excision of Non-palpable Breast Cancer

BACKGROUND

Wire localisation (WL) is the "gold standard" localisation technique for wide local excision (WLE) of non-palpable breast lesions but has disadvantages that have led to the development of wireless techniques. This study compared the cost-effectiveness of radar localisation (RL) to WL.

METHODS

This was a single-institution study of 110 prospective patients with early-stage breast cancer undergoing WLE using RL with the SCOUT® Surgical Guidance System (2021-2023) compared with a cohort of 110 patients using WL. Margin status, re-excision rates, and surgery delays associated with preoperative localisation were compared. Costs from a third-party payer perspective in Australian dollars (AUD$) calculated by using microcosting, break-even point, and cost-utility analyses.

RESULTS

A total of 110 WLEs using RL cost a total of AUD$402,281, in addition to the device cost of AUD$77,150. The average additional cost of a surgery delay was AUD$2318. Use of RL reduced the surgery delay rate by 10% (p = 0.029), preventing 11 delays with cost savings of AUD$25,496. No differences were identified in positive margin rates (RL: 11.8% vs. WL: 17.3%, p = 0.25) or re-excision rates (RL: 14.5% vs. WL: 21.8%, p = 0.221). In total, 290 RL cases are needed to break even. The cost of WLE using RL was greater than WL by AUD$567. There was a greater clinical benefit of 1.15 quality-adjusted life-years (QALYs) and an incremental cost-utility ratio of AUD$493 per QALY favouring RL.

CONCLUSIONS

Routine use of RL was a more cost-effective intervention than WL. Close to 300 RL cases are likely needed to be performed to recover costs of the medical device.

CLINICAL TRIAL REGISTRATION

ACTRN12624000068561.

A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

Introduction

Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.

Methods

ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.

Results

The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.

Conclusion

Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

Radar localization of breast and axillary lesions with SCOUT: a prospective single institution pilot study

BACKGROUND

Wire-guided localization has been the mainstay of localization techniques for non-palpable breast and axillary lesions prior to excision. Evidence is still growing for relatively newer localization technologies. This study evaluated the efficacy of the wireless localization technology, SCOUT®, for both breast and axillary surgery.

METHODS

Data were extracted from a prospective database (2021-2023) of consecutive patients undergoing wide local excision, excisional biopsy, targeted axillary dissection, or axillary lymph node dissection with SCOUT at a high-volume tertiary centre. Rates of successful reflector placement, intraoperative lesion localization, and reflector retrieval were evaluated. A survey of surgeon-reported ease of lesion localization and reflector retrieval was also evaluated.

CLINICAL TRIAL REGISTRATION

ACTRN386751.

RESULTS

One-hundred-ninety-five reflectors were deployed in 172 patients. Median interval between deployment and surgery was 3 days (range 1-20) and mean distance from reflector to lesion was 3.2 mm (standard deviation, SD 3.1). Rate of successful localization and reflector retrieval was 100% for both breast and axillary procedures. Mean operating time was 65.8 min (SD 33). None of the reflectors migrated. No reflector deployment or localization-related complications occurred. Ninety-eight percent of surgeons were satisfied with ease of localization for the first half of cases.

CONCLUSION

SCOUT is an accurate and reliable method to localize and excise both breast and axillary lesions, and it may overcome some of the limitations of wire-guided localization.

Detailed DNA methylation characterisation of phyllodes tumours identifies a signature of malignancy and distinguishes phyllodes from metaplastic breast carcinoma

Phyllodes tumours (PTs) are rare fibroepithelial lesions of the breast that are classified as benign, borderline, or malignant. As little is known about the molecular underpinnings of PTs, current diagnosis relies on histological examination. However, accurate classification is often difficult, particularly for distinguishing borderline from malignant PTs. Furthermore, PTs can be misdiagnosed as other tumour types with shared histological features, such as fibroadenoma and metaplastic breast cancers. As DNA methylation is a recognised hallmark of many cancers, we hypothesised that DNA methylation could provide novel biomarkers for diagnosis and tumour stratification in PTs, whilst also allowing insight into the molecular aetiology of this otherwise understudied tumour. We generated whole-genome methylation data using the Illumina EPIC microarray in a novel PT cohort (n = 33) and curated methylation microarray data from published datasets including PTs and other potentially histopathologically similar tumours (total n = 817 samples). Analyses revealed that PTs have a unique methylome compared to normal breast tissue and to potentially histopathologically similar tumours (metaplastic breast cancer, fibroadenoma and sarcomas), with PT-specific methylation changes enriched in gene sets involved in KRAS signalling and epithelial-mesenchymal transition. Next, we identified 53 differentially methylated regions (DMRs) (false discovery rate < 0.05) that specifically delineated malignant from non-malignant PTs. The top DMR in both discovery and validation cohorts was hypermethylation at the HSD17B8 CpG island promoter. Matched PT single-cell expression data showed that HSD17B8 had minimal expression in fibroblast (putative tumour) cells. Finally, we created a methylation classifier to distinguish PTs from metaplastic breast cancer samples, where we revealed a likely misdiagnosis for two TCGA metaplastic breast cancer samples. In conclusion, DNA methylation alterations are associated with PT histopathology and hold the potential to improve our understanding of PT molecular aetiology, diagnostics, and risk stratification. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Avoiding unnecessary sentinel lymph node biopsy with the use of superparamagnetic iron oxide mapping agents (Magtrace®) in breast surgery

BACKGROUND

Superparamagnetic iron oxide (SPIO) (Magtrace®) is a non-radioactive liquid tracer that can stay in the sentinel lymph nodes for 30 days. Injection of SPIO at time of primary breast surgery where upfront sentinel lymph node biopsy (SLNB) is not immediately indicated allows for a return to theatre if pathology then identifies invasive disease. SLNB is associated with paraesthesia, pain, seroma formation and lymphoedema risk. Hence, our study aims to assess the use of SPIO to avoid upfront SLNB in breast surgery for ductal carcinoma in situ (DCIS) and prophylaxis.

METHODS

Retrospective single-centre study of consecutive patients who underwent injection of SPIO tracer at time of primary breast surgery to avoid upfront SLNB at Chris O'Brien Lifehouse, Sydney, NSW, Australia over a 10-month period.

RESULTS

SPIO was injected 38 times, with 34 at time of mastectomy and four cases at time of wide local excision. The indication for surgery was DCIS in 18 cases, risk reduction in 17 cases and other indications in three patients. Six cases (15.8%) required delayed SLNB (D-SLNB) due to the finding of invasive disease on post-operative histopathology. All patients who underwent D-SLNB had nodes successfully localized with SPIO.

CONCLUSION

In our cohort, 84.2% of cases were able to avoid upfront SLNB, and hence avoid the associated complications of SLNB. SPIO injection was successful in localizing the SLN in all cases at time of surgery for D-SLNB. This technique was safe with few associated complications.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience

The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.

Dermatofibrosarcoma protuberans of the breast in pregnancy

Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive fibroblastic mesenchymal neoplasm, typically derived from the dermis, with the intramammary subtype being seen infrequently. We present a case of a 40-year-old woman whom was diagnosed with an intramammary DFSP during pregnancy, whom underwent successful surgical management during her second trimester. Our case demonstrates the importance of increased clinical awareness in the diagnosis and treatment of breast DFSP with careful multidisciplinary consideration.

Neoadjuvant chemotherapy in non-metastatic breast cancer: The surgeon's perspective

Breast cancer is the most common non-skin cancer in Australia, affecting 1 in 7 women by the age of 85 years. Current management of early breast cancer is becoming increasingly variable and complex. The typical range of treatments include some combination of surgery, chemotherapy and targeted therapy, immunotherapy, radiotherapy, and endocrine therapy. Neoadjuvant chemotherapy (NACT) in carefully selected patients can facilitate increased rates of breast conservation therapy, and when successful, offers improved cosmesis due to less extensive resection of tissue. A neoadjuvant approach also provides biological insight into a patient's tumour, prognostication based on a patient's response to therapy, as well as enabling their treating oncologist to personalise adjuvant strategies based on the presence or absence of residual cancer at surgery. Neoadjuvant chemotherapy has become an integral element in the provision of breast conserving surgery to selected early-stage breast cancer patients. Appreciating the indications and understanding the likely outcomes from NACT in select situations, can result in significant improvements in patient tailored care.

An Australian-based nomogram predicting nodal positivity for breast cancer in older patients

INTRODUCTION

Regional nodal status is one of the most powerful prognosticators in breast cancer. The sentinel lymph node biopsy (SLNB) evaluates the first node in the axillary lymphatic basin theorised to drain the anatomical region of breast cancer. Recent literature has appropriately raised the query of the need for SLNB for breast cancer in older patients (BCOP). Though some early-stage older patients may safely have SLNB omitted, we are potentially missing the under-represented aggressive cancers. No sentinel lymph node metastases nomogram has been developed solely from BCOP data to date. This study aimed to identify older patients with breast cancer at risk for nodal involvement using a nomogram developed from their data alone.

METHODS

A retrospective analysis of prospectively collected data on BCOP (aged ≥70 years) was performed using the Breast Surgery Quality Audit (BQA). Inclusion criteria were T1-2 invasive breast cancer patients that underwent a SLNB from 1st January 2001 to 31st December 2019. The primary outcome was nodal involvement. Data obtained from the dataset included: age, tumour type, tumour size in millimeters, histological grade, lymphovascular invasion, oestrogen receptor status, progesterone receptor status, HER2 status and referral source. Binary logistic regression was used to develop a nomogram. The model was internally validated by splitting the data set (80% for training and 20% for testing). A receiver operating characteristic curve was developed, with the area under the curve (AUC) and a calibration plot.

RESULTS

There were 22,313 patients of which 14,856 (66.6%) were symptomatic presentations and 7457 (33.4%) were screen-detected. Invasive tumour type, tumour size, tumour grade, lymphovascular invasion, oestrogen receptors, and referral source indicated a statistically significant effect on predicting a nodal positivity event (Table 1). The AUC was 0.782 (95% CI 0.776-0.789) (Fig. 1a) and demonstrated good calibration (Fig. 1b). The negative predictive value established was 85%.

CONCLUSION

We have developed an Australian sentinel lymph node metastasis nomogram for BCOP using routine histopathological data obtained pre-operatively (Fig. 2). This is the first Australian nomogram, as well as the first nomogram developed solely for BCOP - and maintains a superior AUC compared to other well-established nomograms.

Novel Dual Tracer Indocyanine Green and Radioisotope Versus Gold Standard Sentinel Lymph Node Biopsy in Breast Cancer: The GREENORBLUE Trial

BACKGROUND

The methods for sentinel lymph node (SLN) biopsy in breast cancer have been variable in type and number of tracers. Some units have abandoned the use of blue dye (BD) due to adverse reactions. Fluorescence-guided biopsy with indocyanine green (ICG) is a relatively novel technique. This study compared the clinical efficacy and costs between novel dual tracer ICG and radioisotope (ICG-RI) with "gold standard" BD and radioisotope (BD-RI).

METHODS

Single-surgeon study of 150 prospective patients with early breast cancer undergoing SLN biopsy (2021-2022) using ICG-RI compared with a retrospective cohort of 150 consecutive previous patients using BD-RI. Number of SLNs identified, rate of failed mapping, identification of metastatic SLNs, and adverse reactions were compared between techniques. Cost-minimisation analysis performed by using Medicare item numbers and micro-costing analysis.

RESULTS

Total number of SLNs identified with ICG-RI and BD-RI was 351 and 315, respectively. Mean number of SLNs identified with ICG-RI and BD-RI was 2.3 (standard deviation [SD] 1.4) and 2.1 (SD 1.1), respectively (p = 0.156). There were no cases of failed mapping with either dual technique. Metastatic SLNs were identified in 38 (25.3%) ICG-RI patients compared with 30 (20%) BD-RI patients (p = 0.641). There were no adverse reactions to ICG, whereas four cases of skin tattooing and anaphylaxis were associated with BD (p = 0.131). ICG-RI cost an additional AU$197.38 per case in addition to the initial cost for the imaging system.

CLINICAL TRIAL REGISTRATION

 ACTRN12621001033831.

CONCLUSIONS

Novel tracer combination, ICG-RI, provided an effective and safe alternative to "gold standard" dual tracer. The caveat was the significantly greater costs associated with ICG.

Xanthogranulomatous inflammation and spindle cell proliferation in response to silicone breast implant leakage

This case study highlights the rare complications of silicone breast implants, as well as the diagnostic limitations of imaging. The patient initially presented with leakage of bilateral breast implants as discovered by a positron emission tomography (PET)-computerized tomography (CT) scan performed as part of a workup for small bowel Langerhans cell sarcoma metastases. The imaging results of the PET-CT scan revealed increased activity bilaterally with an enhancing, irregular, heterogeneously enhancing mass in the right breast. Given the clinical suspicion for breast implant-associated anaplastic large cell lymphoma, further investigation including surgical excision was undertaken. What initially was a concern for a serious complication of long-standing breast implants, fortuitously turned out to be a benign but exuberant xanthogranulomatous inflammatory reactive process. We hope that our report will add to the literature of this rare phenomenon and highlight it as a differential diagnosis of a mass in association with breast implants.

Diagnosis and management of phyllodes tumours for the surgeon: An algorithm

A Phyllodes Tumour (PT) is an uncommon fibroepithelial lesion, with three histological grades - benign, borderline and malignant. PTs cause significant challenges in diagnosis, management and prognostication. Recent publications have clarified the definitions and prognostication of PTs. Contemporary data currently challenge international guidelines on PT management. We performed an in-depth literature review to develop a best-practice management algorithm for PTs. Diagnostic recommendations are that neither current imaging techniques, nor fine-needle biopsies, can reliably diagnose a PT. Core needle biopsy is the optimal diagnostic technique. Indeterminate or suspicious lesions are recommended to undergo an excisional biopsy due to the inherently heterogeneous nature of PTs. Management guidelines are that benign PTs should be completely excised, although an involved margin is acceptable in select situations. Borderline PTs should have a clear margin on excision due to their higher risk of recurrence, as well as the potential for a recurrence to progress to a malignant PT. In malignant PTs, a margin of 3 mm is acceptable as there is no reduction in recurrence risk if margins are >3 mm. Routine axillary surgery is not indicated in PTs, with axillary surgery only indicated in a histologically-confirmed positive axilla. Adjuvant treatment recommendations are that borderline and malignant PTs should be discussed at MDT, with radiotherapy considered in both. Chemotherapy should be discussed in malignant PT patients. In summary, we have developed an up-to-date simple algorithm to guide the surgeon's management of patients diagnosed with PTs and reduce excessive surgery.

Cryopreservation of human cancers conserves tumour heterogeneity for single-cell multi-omics analysis

BACKGROUND

High throughput single-cell RNA sequencing (scRNA-Seq) has emerged as a powerful tool for exploring cellular heterogeneity among complex human cancers. scRNA-Seq studies using fresh human surgical tissue are logistically difficult, preclude histopathological triage of samples, and limit the ability to perform batch processing. This hindrance can often introduce technical biases when integrating patient datasets and increase experimental costs. Although tissue preservation methods have been previously explored to address such issues, it is yet to be examined on complex human tissues, such as solid cancers and on high throughput scRNA-Seq platforms.

METHODS

Using the Chromium 10X platform, we sequenced a total of ~ 120,000 cells from fresh and cryopreserved replicates across three primary breast cancers, two primary prostate cancers and a cutaneous melanoma. We performed detailed analyses between cells from each condition to assess the effects of cryopreservation on cellular heterogeneity, cell quality, clustering and the identification of gene ontologies. In addition, we performed single-cell immunophenotyping using CITE-Seq on a single breast cancer sample cryopreserved as solid tissue fragments.

RESULTS

Tumour heterogeneity identified from fresh tissues was largely conserved in cryopreserved replicates. We show that sequencing of single cells prepared from cryopreserved tissue fragments or from cryopreserved cell suspensions is comparable to sequenced cells prepared from fresh tissue, with cryopreserved cell suspensions displaying higher correlations with fresh tissue in gene expression. We showed that cryopreservation had minimal impacts on the results of downstream analyses such as biological pathway enrichment. For some tumours, cryopreservation modestly increased cell stress signatures compared to freshly analysed tissue. Further, we demonstrate the advantage of cryopreserving whole-cells for detecting cell-surface proteins using CITE-Seq, which is impossible using other preservation methods such as single nuclei-sequencing.

CONCLUSIONS

We show that the viable cryopreservation of human cancers provides high-quality single-cells for multi-omics analysis. Our study guides new experimental designs for tissue biobanking for future clinical single-cell RNA sequencing studies.

Transanal mesorectal excision: early outcomes in Australia and New Zealand

BACKGROUND

Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand.

METHODS

Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed.

RESULTS

A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months.

CONCLUSION

This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.

Complete pathological response in rectal cancer utilising novel treatment strategies for neo-adjuvant therapy: A systematic review

BACKGROUND

Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates.

METHODS

A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded.

RESULTS

Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%.

CONCLUSION

A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.

Abstract OT-09-07: Winpro: A window of opportunity study of endocrine therapy with and without prometrium in postmenopausal women with early stage hormone receptor-positive breast cancer

Background: There is bidirectional interplay between PR and ER in human breast cancers (Lim, Endo Rel Can 2016). Evidence in breast cancer cell lines suggests that dual treatment with estrogen and progesterone compared to estrogen alone leads to reprogramming of ER chromatin binding sites via regulation of 470 genes (Mohammed, Nature 2015). Importantly, there was an additive anticancer effect in preclinical breast cancer models when natural progesterone was combined with standard endocrine therapy; we hypothesize that this combination has activity in women with breast cancer.Trial design: We are conducting a phase II multi-center, randomised, open-label, three-arm study in which 200 postmenopausal women with early-stage ER-positive (ER ≥10%), PR-positive (PR ≥10%), HER2-negative breast cancer will be randomised 1:1:1 to letrozole 2.5mg daily (arm 1); letrozole 2.5mg and prometrium 300mg PO daily (arm 2); or tamoxifen 20mg and prometrium 300mg PO daily (arm 3). Surgery will occur on day 14 after treatment initiation. Eligible subjects must have tumor size ≥10mm on imaging, no history of uterine cancer or venous thromboembolism, and no receipt of other preoperative therapies. The primary objective is to assess the reduction in proliferative marker Ki67 following treatment in either combination arm compared to letrozole alone.Methods: Blood will be collected at baseline and at end of treatment. Tissue samples will be collected from the diagnostic biopsy and at the time of surgery. The primary endpoint is geometric mean reduction of centrally assessed Ki67 expression after two weeks of treatment compared with baseline. Given the expected geometric mean reduction of 76% for aromatase inhibitor alone (Dowsett, J Natl Can Inst 2007) and allowing 4% dropouts, 200 patients provides 80% power to detect an improvement in Ki67 suppression to 92% in either experimental arm with p-value 0.025 for each comparison.The secondary endpoint of safety and tolerability will be assessed (NCI-CTCAE v4.0). Translational endpoints include definition of a predictive gene set biomarker for Ki67 reduction; tumor biomarkers after treatment, including apoptotic markers Bcl-2 and cleaved-caspase3, as well as protein and mRNA expression of ER, PR, AR, FoxA1, and CyclinD1; and levels of estrone, estradiol, E2, progesterone, testosterone, DHT, and DHEAS in serum and finger prick dried blood spot after treatment.Accrual: Enrolment commenced in February 2018 and 70 patients have been randomized from 7 sites to date (1 July 2020). Target accrual is 200 patients enrolled from 8 sites.Contact information: This study is led at The Kinghorn Cancer Centre, St Vincent’s Sydney Hospital Sydney, Australia, and funded by the Cancer Council of NSW and the NHMRC Translational Breast Cancer Project grant. Contact Elgene Lim MBBS FRACP PhD at e.lim@garvan.org.au.

Citation Format: Brandon Lau, Davendra Segara, Andrew Ong, Janne Bingham, Belinda Kiely, Emma-Kate Carson, Julia Chen, Cindy Mak, Sanjay Warrier, Mun Hui, Kate Middleton, Andrew Parker, Bruce Mann, Geoffrey Lindeman, Wayne Tilley, Elgene Lim. Winpro: A window of opportunity study of endocrine therapy with and without prometrium in postmenopausal women with early stage hormone receptor-positive breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-09-07.

Prognostic factors influencing survival in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for isolated colorectal peritoneal metastases: a systematic review and meta-analysis

AIM

Peritoneal metastases from colorectal cancer confer the worst survival among all metastatic sites. The adoption of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) can offer selected patients with isolated colorectal peritoneal metastases (CRPM) a favourable long-term survival. There are numerous factors postulated to influence survival in patients undergoing CRS and HIPEC. The aim of this study was to identify the key perioperative prognostic factors that influence survival in patients undergoing CRS and HIPEC for isolated CRPM.

METHOD

A systematic review and meta-analysis were conducted to evaluate prognostic factors influencing survival in patients undergoing CRS and HIPEC for isolated CRPM.

RESULTS

Thirty-three studies fitted the inclusion criteria for the systematic review, with 25 studies included in the meta-analysis. On pooled analysis, incomplete cytoreduction, increasing peritoneal carcinoma index (PCI) and lymph node involvement were significantly associated with a worse survival. Additionally, a rectal primary [hazard ratio (HR) 1.93, 95% CI 1.10-3.37], adjuvant chemotherapy (HR 0.71, 95% CI 0.54-0.93) and perioperative grade III/IV morbidity (HR 1.59, 95% CI 1.17-2.16) were also found to significantly influence survival. Notably, tumour differentiation and signet ring cell histology did not influence survival on pooled analysis.

CONCLUSION

This meta-analysis confirms that in patients undergoing CRS and HIPEC for isolated CRPM, incomplete cytoreduction, high PCI and lymph node involvement have a negative influence on survival. In addition, a rectal primary, adjuvant chemotherapy use and grade III/IV morbidity are important factors that also significantly influence survival.

Value of Indocyanine Green Angiography to Guide Wound Management and Prevent Necrosis in a Robotic Surgical Procedure

Background: Inguinal lymph node dissection is performed in penile cancers and has a high complication rate with mostly wound-related complications. This case study demonstrates the use of robotic technique, tissue perfusion assessment, and negative pressure wound dressing to minimize wound-related complications. Case Presentation: A 67-year-old Maltese man was diagnosed with squamous cell carcinoma (SCC) in situ on biopsy of a self-detected penile lump. The patient underwent a partial penectomy and histopathology report confirmed moderately differentiated SCC with clear surgical margins. A positron emission tomography/CT scan was performed preoperatively, which showed several nodes in the right inguinal region with increased metabolic activity and nonspecific findings in the left inguinal region. The patient had a robotic right inguinal node dissection the following month. Assessment of the skin flap was performed using indocyanine green (ICG) angiography with the SPY system and there was excellent vascularity. Further treatment was performed 3 months later with a robotic left inguinal node dissection. Again, assessment of the skin flap was performed using the SPY system but showed an area of poor perfusion in the left femoral triangle, which suggested a high risk of inadequate wound healing and tissue necrosis. The clinical decision to use the negative pressure PICO dressing was made intraoperatively to enhance perfusion of the skin. When the PICO dressing was removed it revealed excellent tissue viability and vascularity of the skin flap. Histopathology analysis showed no evidence of malignancy in the nodes removed and patient was discharged to the outpatient care of their urologist. Conclusion: This case study demonstrates that the use of a tissue perfusion assessment tool avoided a potentially poor clinical outcome for the patient. Robotic inguinal lymph node dissection was performed in coordination with ICG angiography to guide the use of negative pressure wound therapy and facilitate good wound healing.

Robotic transanal minimally invasive surgery - technical, oncological and patient outcomes from a single institution

AIM

Robotic transanal minimally invasive surgery (R-TAMIS) is gaining traction around the globe as an alternative to laparoscopic conventional TAMIS for local excision of benign and early malignant rectal lesions. The aim was to analyse patient and oncological outcomes of R-TAMIS for consecutive cases in a single centre.

METHODS

A prospective analysis of consecutive R-TAMIS procedures over a 12-month period was performed. Data were collated from hospital databases and theatre registers.

RESULTS

Eleven patients (six men, five women), mean age 69.81 years (51-92 years), underwent R-TAMIS over 12 months utilizing a da Vinci Xi platform. The mean lesion size was 36 mm (20-60 mm) with a mean distance from the anal verge of 7.5 cm (3-14 cm). Five lesions were posterior in anatomical location, four anterior, one right lateral and one left lateral. All procedures were performed in the lithotomy position using a GelPOINT Path Platform. Mean operative time was 64 min (40-100 min). Complete resection was achieved in 10/11 patients with two patients being upgraded to a diagnosis of adenocarcinoma. Nine patients were diagnosed with dysplastic lesions. Four patients had a false positive diagnosis of an invasive tumour on MRI. Six patients required suturing for full-thickness resections. One patient had a postoperative bleed requiring repeat endoscopy and clipping. One patient (full-thickness resection of T3 tumour) proceeded to a formal resection without difficulty with no residual disease (T0N0, 0/22). One patient with a fully resected T2 tumour is undergoing a surveillance protocol. The mean length of stay was 1 day with two patients having a length of stay of 2 days and one patient of 4 days.

CONCLUSION

R-TAMIS could potentially represent a safe novel approach for local resection of rectal lesions.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Stromal cell diversity associated with immune evasion in human triple-negative breast cancer

The tumour stroma regulates nearly all stages of carcinogenesis. Stromal heterogeneity in human triple-negative breast cancers (TNBCs) remains poorly understood, limiting the development of stromal-targeted therapies. Single-cell RNA sequencing of five TNBCs revealed two cancer-associated fibroblast (CAF) and two perivascular-like (PVL) subpopulations. CAFs clustered into two states: the first with features of myofibroblasts and the second characterised by high expression of growth factors and immunomodulatory molecules. PVL cells clustered into two states consistent with a differentiated and immature phenotype. We showed that these stromal states have distinct morphologies, spatial relationships and functional properties in regulating the extracellular matrix. Using cell signalling predictions, we provide evidence that stromal-immune crosstalk acts via a diverse array of immunoregulatory molecules. Importantly, the investigation of gene signatures from inflammatory-CAFs and differentiated-PVL cells in independent TNBC patient cohorts revealed strong associations with cytotoxic T-cell dysfunction and exclusion, respectively. Such insights present promising candidates to further investigate for new therapeutic strategies in the treatment of TNBCs.

Robotic-assisted complete mesocolic excision, central vascular ligation and para-aortic lymph node dissection in multifocal carcinoid: A case report and technical description

•

Neuroendocrine tumours are the most common type of small bowel neoplasm.

•

Robotic technique may be superior to open technique for lymph node dissection.

•

Robotic-assisted complete mesocolic excision is a safe and effective technique.

Introduction

Neuroendocrine tumours are the most common type of primary small bowel neoplasm. Consensus guidelines recommend a multimodal approach to treatment of such tumours, with aggressive surgical resection remaining the mainstay of management. There is evidence that complete mesocolic excision (CME) of lymph nodes is associated with superior oncological outcomes including longer disease-free survival in patients with colorectal cancer than standard lymph node dissection and there is increasing evidence to suggest that the robotic approach may be superior to laparoscopic or open CME. This report discusses a robotic-assisted approach to CME with central vessel ligation (CVL) and para-aortic lymph node dissection in a case of multifocal neuroendocrine tumour of the small bowel.

Presentation of case and technical approach

This report details the case of a 73-year-old male with multifocal small bowel neuroendocrine tumour. He underwent a robotic-assisted right hemicolectomy, small bowel resection, CME, CVL and para-aortic lymph node dissection. The approach described involved undertaking CME, CVL and bowel resection with a standard right hemicolectomy robotic set-up before re-docking the robot to perform the retroperitoneal para-aortic lymph node dissection.

Discussion

This case highlights the management of multifocal small bowel neuroendocrine tumour using a robotic approach for surgical resection and lymph node clearance.

Conclusion

The robotic approach provides a safe and effective technique for undertaking surgical resection of small bowel neuroendocrine tumour as well as complete mesocolic excision of lymph nodes. With a change in port positions, a robotic approach can be utilised for CME/CVL as well as retroperitoneal node dissection.

Window of opportunity treatment in breast cancer

Window of opportunity therapies, which involve short-term administration of systemic therapy between cancer diagnosis and surgery, have raised significant interest in recent years as a mean of assessing the sensitivity of a patient's cancer to therapy prior to surgery. There is now compelling evidence that in patients with early stage hormone-receptor positive breast cancer, a 2-week preoperative treatment with standard hormone therapies in a preoperative window period provides important prognostic information, which in turn helps to aid decision-making regarding treatment options. Changes in short-term biomarker endpoints such as cell proliferation measured by Ki-67 can act as surrogate markers of long-term outcomes. Paired tissues obtained pre- and post-investigational treatment, without having to subject the patient to additional biopsies, can then be used to conduct translational research to investigate predictive biomarkers and pharmacodynamics. In this review, we will examine the utility and challenges of window of opportunities therapies in breast cancer in the current literature, and the current Australian and international trial landscape in this clinical space.

Correction to: Pelvic fat volume reduction with preoperative very low energy diet (VLED): implications for rectal cancer surgery in the obese

Due to substantial contributions by Dr. Phillip Malouf and Dr. Stephen Bell.

Pelvic fat volume reduction with preoperative very low energy diet (VLED): implications for rectal cancer surgery in the obese

BACKGROUND

Obese patients have higher complication rates after pelvic surgery. Laparoscopic rectal surgery may not be possible in the obese individual due to mesorectal, total pelvic and general visceral fat volumes. Very low energy diets reduce visceral fat but the changes within the pelvis and mesorectum are unknown. The aim of the present study was to quantify the proportion of fat lost from total pelvic and mesorectal fat with a very low energy diet (VLED) and define simple, accessible measurements that correlate with expected volume reduction.

METHODS

A study was conducted on proportion change in mesorectal and intrapelvic fat volumes in patients on a VLED prior to bariatric surgery at the Alfred Hospital in Melbourne. The VLED was a standardized 4-week meal replacement. Proportion change in mesorectal and intrapelvic fat volumes were measured. Patients had standardized pre-diet and post-diet magnetic resonance imaging (MRI) of the pelvis. Body mass index, weight and girth measures were obtained. Adipose quantification analysis was performed using Q-Fat.

RESULTS

Nine patients were included in this study, who were preparing for bariatric (not colorectal) surgery (5 females, median age 42 years, range 27-59 years) pre-protocol body mass index was 55.8 (range 39.5-60.6 kg/m²); median weight was 163 kg. Median mesorectal fat reduction was 29.9% (range 11.6-66.6%). Linear regression showed a relationship between the amount of mesorectal fat reduction and two variables: patient height and the distance from S1 to the posterior aspect of the rectum on MRI. The relationship predicted response to the diet (R² 67%, p = 0.040).

CONCLUSIONS

Very low energy diets result in a clinically significant reduction in mesorectal fat with a lesser change in total pelvic fat, suggesting that very low energy diets may be useful for preparation for pelvic surgery in the obese. The distance from S1 to the posterior rectum correlates well with mesorectal reduction, making this a valuable clinical tool when volumetric analysis is not possible. This analysis is limited to the quantification of the effect of the diet and cannot comment on the safety of this approach before pelvic cancer surgery.

Transcriptional landscape changes during human embryonic stem cell derivation

STUDY QUESTION

What are the transcriptional changes occurring during the human embryonic stem cell (hESC) derivation process, from the inner cell mass (ICM) to post-ICM intermediate stage (PICMI) to hESC stage, that have downstream effects on pluripotency states and differentiation?

SUMMARY ANSWER

We reveal that although the PICMI is transcriptionally similar to the hESC profile and distinct from ICM, it exhibits upregulation of primordial germ cell (PGC) markers, dependence on leukemia inhibitory factor (LIF) signaling, upregulation of naïve pluripotency-specific signaling networks and appears to be an intermediate switching point from naïve to primed pluripotency.

WHAT IS KNOWN ALREADY

It is currently known that the PICMI exhibits markers of early and late-epiblast stage. It is suggested that hESCs acquire primed pluripotency features due to the upregulation of post-implantation genes in the PICMI which renders them predisposed towards differentiation cues. Despite this current knowledge, the transcriptional landscape changes during hESC derivation from ICM to hESC and the effect of PICMI on pluripotent state is still not well defined.

STUDY DESIGN, SIZE, DURATION

To gain insight into the signaling mechanisms that may govern the ICM to PICMI to hESC transition, comparative RNA sequencing (RNA-seq) analysis was performed on preimplantation ICMs, PICMIs and hESCs in biological and technical triplicates (n = 3).

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

Primed hESCs (XX) were maintained in feeder-free culture conditions on Matrigel for two passages and approximately 50 cells were collected in biological and technical triplicates (n = 3). For ICM sample collection, Day 3, frozen-thawed human embryos were cultured up to day five blastocyst stage and only good quality blastocysts were subjected to laser-assisted micromanipulation for ICM collection (n = 3). Next, day six expanded blastocysts were cultured on mouse embryonic fibroblasts and manual dissection was performed on the PICMI outgrowths between post-plating Day 6 and Day 10 (n = 3). Sequencing of these samples was performed on NextSeq500 and statistical analysis was performed using edgeR (false discovery rate (FDR) < 0.05).

MAIN RESULTS AND THE ROLE OF CHANCE

Comparative RNA-seq data analysis revealed that 634 and 560 protein-coding genes were significantly up and downregulated in hESCs compared to ICM (FDR < 0.05), respectively. Upon ICM to PICMI transition, 471 genes were expressed significantly higher in the PICMI compared to ICM, while 296 genes were elevated in the ICM alone (FDR < 0.05). Principle component analysis showed that the ICM was completely distinct from the PICMI and hESCs while the latter two clustered in close proximity to each other. Increased expression of E-CADHERIN1 (CDH1) in ICM and intermediate levels in the PICMI was observed, while CDH2 was higher in hESCs, suggesting a role of extracellular matrix components in facilitating pluripotency transition during hESC derivation. The PICMI also showed regulation of naïve-specific LIF and bone morphogenetic protein signaling, differential regulation of primed pluripotency-specific fibroblast growth factor and NODAL signaling pathway components, upregulation of phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) pathway (PI3K/AKT/mTORC), as well as predisposition towards the germ cell lineage, further confirmed by gene ontology analysis. Hence, the data suggest that the PICMI may serve as an intermediate pluripotency stage which, when subjected to an appropriate culture niche, could aid in enhancing naïve hESC derivation and germ cell differentiation efficiency.

LARGE-SCALE DATA

Gene Expression Omnibus (GEO) Accession number GSE119378.

LIMITATIONS, REASONS FOR CAUTION

Owing to the limitation in sample availability, the sex of ICM and PICMI have not been taken into consideration. Obtaining cells from the ICM and maintaining them in culture is not feasible as it will hamper the formation of PICMI and hESC derivation. Single-cell quantitative real-time PCR on low ICM and PICMI cell numbers, although challenging due to limited availability of human embryos, will be advantageous to further corroborate the RNA-seq data on transcriptional changes during hESC derivation process.

WIDER IMPLICATIONS OF THE FINDINGS

We elucidate the dynamics of transcriptional network changes from the naïve ICM to the intermediate PICMI stage and finally the primed hESC lines. We provide an in-depth understanding of the PICMI and its role in conferring the type of pluripotent state which may have important downstream effects on differentiation, specifically towards the PGC lineage. This knowledge contributes to our limited understanding of the true nature of the human pluripotent state in vitro.

STUDY FUNDING/COMPETING INTEREST(S)

This research is supported by the Concerted Research Actions funding from Bijzonder Onderzoeksfonds University Ghent (BOF GOA 01G01112).The authors declare no conflict of interest.

Predicting non-sentinel lymph node metastasis in Australian breast cancer patients: are the nomograms still useful in the post-Z0011 era?

BACKGROUND

Axillary lymph node dissection (ALND) can be avoided in breast cancer patients with low-volume disease in the sentinel lymph nodes (SLNs) according to Z0011 trial. We believe that nomograms developed for predicting non-sentinel lymph node (NSLN) metastases can guide the axillary treatment in patients who do not fully match the criteria of Z0011 study. We identified risk factors and evaluated the performance of three nomograms to predict NSLN status in patients with positive SLNs.

METHODS

Data from 526 breast cancer patients with positive SLNs who underwent ALND at two Australian hospitals from 2002 to 2015 were studied. Univariate and multivariate associations for NSLN metastasis were analysed. Predictive models evaluated were MD Anderson Cancer Centre (MDA), Helsinki University Hospital and Memorial Sloan Kettering Cancer Centre.

RESULTS

Thirty-nine per cent of patients demonstrated NSLN metastasis. The multivariate analysis identified extranodal extension (OR 3.2, 95% CI 2.07-4.80), tumour size >2 cm (OR 2.5, 95% CI 1.66-3.89), macrometastasis (OR 1.9, 95% CI 1.09-3.47), positive SLN ratio >0.5 (OR 1.7, 95% CI 1.16-2.60) and lymphovascular invasion (OR 1.6, 95% CI 1.09-2.44) as independent predictors for NSLN metastasis. MDA nomogram showed the best discrimination (area under the curve of 0.74) and a 9% false negative rate for predicted probability of NSLN metastasis ≤10%.

CONCLUSION

Our results suggest that presence of extranodal extension and tumour size >2 cm may influence the need of further axillary treatment. Conversely, ALND can be safety spared in low risk patients identified by MDA nomogram.

A New Method of Salvaging Breast Reconstruction After Breast Implant Using Negative Pressure Wound Therapy and Instillation

Breast implant infections and their associated inflammatory response can have severe consequences, such as the loss of the prosthesis and cavity, or extensive scarring. Negative pressure wound therapy has been indicated for the management of implant infections. This report describes situations where negative pressure wound therapy was used in conjunction with instillation therapy to treat breast implant infections. The findings showed that the application of these techniques accelerated the treatment of the infections and, most importantly, maintained the breast cavity for future reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Programmed death ligand 1 expression in triple-negative breast cancer is associated with tumour-infiltrating lymphocytes and improved outcome

AIMS

Triple-negative breast cancer (TNBC) patients generally have a poor outcome; there is a pressing need to identify more effective therapeutic strategies. Clinical trials targeting programmed death 1/programmed death ligand 1 (PD1/PDL1) in melanoma and non-small-cell lung cancer have reported high response rates, and tumoral PDL1 expression has been suggested as a potential biomarker to enrich for patient response to these treatments. There are only very limited data to date reporting the expression of PDL1 in TNBC.

METHODS AND RESULTS

PDL1 immunohistochemistry was performed on 161 primary TNBCs and assessed in the tumour as well as immune cells in the stromal compartment. PDL1 expression was very common in TNBC, expressed in the tumour cell membrane (64%), cytoplasm (80%) and stromal (93%) cellular compartments. Cytoplasmic tumoral expression of PDL1 was associated with a lower risk of breast cancer-specific death [hazard ratio (HR) 0.45, P = 0.035] while stromal PDL1 expression was associated with a lower rate of deaths from all causes (HR 0.305, P = 0.0042). Membranous expression of PDL1 was not associated with outcome. While both PDL1 expression and tumour-infiltrating lymphocytes were associated with a better outcome, only lymphovascular invasion and high tumour-infiltrating lymphocytes were independently prognostic for breast cancer-specific death.

CONCLUSION

While PDL1 expression is frequent in TNBC, it was not independently prognostic. There were differences in outcome depending on the cellular compartment of PDL1 expression. These data provide further impetus for investigating the utility of immune checkpoint therapies in TNBC, given the clinical significance of tumour-infiltrating lymphocytes (TILs) and PDL1 expression in this cohort.

An update in breast cancer screening and management

This article provides an overview of the main controversies in a number of key areas of breast cancer management. Relevant studies that have contributed to guide the treatment of this heterogeneous disease in the field of breast screening, surgery, chemotherapy and radiotherapy are highlighted. Mammography and ultrasound are the main methods of breast screening. MRI and tomosynthesis are emerging as new screening tools for a selected group of breast cancer patients. From a surgical perspective, oncoplastic techniques and neoadjuvant chemotherapy are improving cosmetic results in breast-conserving surgery. For high-risk patients, controversies still remain regarding prophylactic mastectomies. Finally, the appropriate management of the axilla continues evolving with the increasing role of radiotherapy as an alternative treatment to axillary dissection.