Does intraductal breast cancer spread in a segmental distribution? An analysis of residual tumour burden following segmental mastectomy using tumour bed biopsies

INTRODUCTION

Breast-conserving surgery for early breast cancer is now routinely used as an alternative to mastectomy. Despite post-operative radiotherapy, early local recurrence of tumour remains a concern. It has been reported that invasive and in-situ ductal carcinoma spread locally through the ductal tree in a segmental distribution, however, there is no consensus as to the best surgical method to maximize tumour clearance whilst leaving a good cosmetic result.

AIM

We aimed to measure the effectiveness of segmental mastectomy (excision of tumour plus associated segmental ductal tissue) in the clearance of different tumour types. Bed biopsy of the excision cavity was employed to assess the rate of incomplete excision or the multifocality of certain breast cancers.

METHODS

One hundred and one patients with breast cancers underwent segmental mastectomy and cavity bed biopsies. Specimens were assessed for tumour type and completeness of excision. An excision of the cancer was considered incomplete if the margins were involved or if any of the bed biopsies showed residual or multifocal tumour.

RESULTS

A total of 24 patients had incomplete tumour excision. Invasive ductal carcinoma was more likely to be completely excised by segmental mastectomy than invasive lobular carcinoma (P<0.05). Incomplete excision was associated with multifocality and the presence of extensive DCIS. The report of clear pathological margins was significantly more likely to be accurate, as measured by negative bed biopsies, in invasive ductal carcinoma when compared to invasive lobular carcinoma (P<0.05).

CONCLUSION

These results support the concept that ductal carcinomas spread locally in a segmental fashion. Patients with invasive ductal carcinomas are more likely to benefit from breast conserving surgery that is tailored to include the associated ductal tissue, in a segmental fashioned excision.

Outcomes of inflammatory bowel disease surgery in obese versus non-obese patients: a meta-analysis

BACKGROUND

Obesity is considered a risk factor for many chronic diseases and obese patients are often considered higher risk surgical candidates. The aim of this meta-analysis was to evaluate the outcomes of obese (body mass index ≥ 30 kg/m²) versus non-obese patients undergoing surgery for inflammatory bowel disease (IBD).

METHODS

PubMed, Scopus, and Embase libraries were searched up to March 2019 for studies comparing outcomes of obese with non-obese patients undergoing surgery for IBD. A meta-analysis was conducted using Review Manager software to create forest plots and calculate odds ratios and mean differences.

RESULTS

Four thousand three hundred and eleven patients from five observational studies were included. Obese patients were older at the time of surgery and more likely to have diabetes. Obese patients had longer operative times (MD 23.28, 95% CI 14.63-31.93, p < 0.001), higher intra-operative blood loss (MD 45.32, 95% CI 5.89-84.76, p = 0.02), longer length of stay (MD 0.90, 95% CI 0.60-1.20, p < 0.001), higher wound infection rates (OR 1.76, 95% CI 1.39-2.23, p < 0.001), and higher total postoperative complication rates (OR 1.33, 95% CI 1.04-1.70, p = 0.02).

CONCLUSIONS

Obesity is associated with significantly worse outcomes following IBD-specific surgery, including longer operative times, greater blood loss, longer length of stay, higher wound infection rates, and higher total postoperative complication rates. Clinicians should be mindful of these increased risks when counselling patients and consider weight reduction strategies where possible.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Systematic review on the management of ileoanal pouch-vaginal fistulas after restorative proctocolectomy in the treatment of ulcerative colitis

AIM

Ileoanal pouch-vaginal fistula (PVF) is a relatively common complication of restorative proctocolectomy with ileal pouch-anal anastomosis. There are several operative approaches in the management of PVF. There is currently no consensus as to which approach is the most effective or which should be attempted first.

METHOD

A systematic review was undertaken following a publicly available protocol registered with PROSPERO (CRD42019133750) in accordance with PRISMA guidelines. Online searches of databases MEDLINE and Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials and ISRCTN registry were performed.

RESULTS

Twenty-seven articles met the criteria for inclusion in the study: 13 retrospective cohort studies, two prospective cohort studies, eight case series, three case reports and a case-control study. A narrative synthesis was performed due to heterogeneity between included articles. Our study included 577 PVFs, and the incidence rate was 2.1%-17.1%. Both local and abdominal approaches were used in the management of PVF. The overall success of local and abdominal procedures was 44.9% and 60.2% respectively. ROBINS-I assessment revealed a critical risk of bias. GRADE assessment indicated a very low certainty in effect size and evidence quality.

CONCLUSION

Local interventions and abdominal approaches have a high failure rate. The results of this review will aid the counselling of patients with this condition. Furthermore, we provide an algorithm for discussion on the management of PVF based on experience at our local centre. The studies available on the management of PVF are low quality; a large prospective registry and Delphi consensus are required to further this area of research.

A systematic review of the management of synthetic mesh erosion of the rectum following urogynaecological surgery

AIM

Synthetic rectal mesh erosion is a challenging complication following urogynaecological surgery. The aim of this study was to determine the optimal management of rectal mesh erosion following urogynaecological surgery.

METHOD

A systematic review was undertaken following a pre-defined protocol registered with PROSPERO (CRD42018112425) in accordance with PRISMA guidelines. Searches of MEDLINE online database, Cochrane Library and clinical trial registries (ClinicalTrials.gov, EU Clinical Trials, ISRCTN registry) were performed. The included articles were heterogeneous - therefore a narrative synthesis was performed.

RESULTS

Fourteen studies were included in the review: 11 case reports, one case series, one retrospective cohort and one prospective multicentre trial. Fourteen rectal mesh erosions were identified. Eight (57%) of the rectal erosions underwent major abdominal surgery. In two of these cases, the abdominal approach was used only after failure of the transanal route. Five (36%) of the mesh erosions were managed using a transanal approach. In one case, the mesh passed without intervention.

CONCLUSION

Synthetic rectal mesh erosion can be managed successfully via either a transanal or a transabdominal approach with a partial or complete excision of the mesh. An examination under anaesthetic with an attempted transanal removal of mesh should be considered the first step in the management of this condition before consideration of more invasive surgery.

Unraveling the interplay: early-stage atrial functional mitral regurgitation and left atrial electrical substrate in atrial fibrillation patients

Background

Atrial fibrillation (AF) triggers atrial remodeling, impacting atrial function and ablation efficacy. This remodeling leads to atrial cardiomyopathy and dilatation, linked to mitral regurgitation, forming atrial functional mitral regurgitation (aFMR). Our study explores the relationship between early-stage-aFMR and the atrial electrical architecture, focusing on left atrial bipolar voltage and low-voltage areas (LVAs) in AF patients.

Methods

We enrolled 282 patients undergoing redo-PVI after AF recurrence post-PVI. Echocardiography was performed prior to ablation, and only patients with no, mild, or mild-to-moderate aFMR were included. Ablation used radiofrequency and a 3D mapping system, with atrial voltage documented on each atrial wall. LVAs were calculated using high-density maps, and patients were followed for 15 months.

Results

Significant differences in left atrial voltage and LVA extent were observed based on aFMR severity. Patients with aFMR 1 + had significantly lower atrial voltage compared to no-aFMR, but no significant increase in LVAs. Patients with aFMR 2 + showed lower voltage amplitudes in all atrial regions and larger LVAs compared to no-aFMR patients. AF recurrence was significantly higher in the aFMR group (62.9% vs. 48.3%, p = 0.027) within 1 year. aFMR was associated with AF recurrence after adjusting for sex, age, and AF types (HR: 1.517, 95% CI: 1.057-2.184, p = 0.025).

Conclusion

aFMR in AF patients may indicate progressive atrial remodeling and left atrial cardiomyopathy, characterized by reduced atrial voltage and increased LVAs. aFMR is linked to PVI outcomes, suggesting its consideration in AF therapy decision-making.

Unipolar voltage electroanatomic mapping detects structural atrial remodeling identified by LGE-MRI

BACKGROUND

In atrial fibrillation (AF) management, understanding left atrial (LA) substrate is crucial. While both electroanatomic mapping (EAM) and late gadolinium enhancement magnetic resonance imaging (LGE-MRI) are accepted methods for assessing the atrial substrate and are associated with ablation outcome, recent findings have highlighted discrepancies between low-voltage areas (LVAs) in EAM and LGE areas.

OBJECTIVE

The purpose of this study was to explore the relationship between LGE regions and unipolar and bipolar LVAs using multipolar high-density mapping.

METHODS

Twenty patients scheduled for AF ablation underwent preablation LGE-MRI. LA segmentation was conducted using a deep learning approach, which subsequently generated a 3-dimensional mesh integrating the LGE data. High-density EAM was performed in sinus rhythm for each patient. The electroanatomic map and LGE-MRI mesh were coregistered. LVAs were defined using cutoffs of 0.5 mV for bipolar voltage and 2.5 mV for unipolar voltage. The correspondence between LGE areas and LVAs in the LA was analyzed using confusion matrices and performance metrics.

RESULTS

A considerable 87.3% of LGE regions overlapped with unipolar LVAs, compared with only 16.2% overlap observed with bipolar LVAs. Across all performance metrics, unipolar LVAs outperformed bipolar LVAs in identifying LGE areas (precision: 78.6% vs 61.1%; sensitivity: 87.3% vs 16.2%; F1 score: 81.3% vs 26.0%; accuracy: 74.0% vs 35.3%).

CONCLUSION

Our findings demonstrate that unipolar LVAs strongly correlate with LGE regions. These findings support the integration of unipolar mapping alongside bipolar mapping into clinical practice. This would offer a nuanced approach to diagnose and manage AF by revealing critical insights into the complex architecture of the atrial substrate.

CT angiography-derived three-dimensional pulmonary vein topography is related to the outcome after cryoballoon ablation

Background

Following cryoballoon ablation, 20%-30% of the patients show recurrent atrial fibrillation (AF) in long-term follow-up as a consequence of incomplete circumferential ablation lines. Patient selection using computer tomography angiography (CTA)-derived parameters might be feasible to assign patients for cryoballoon ablation according to pulmonary vein (PV) anatomy and topography.

Methods

We aimed to analyze the impact of anatomical and topographic PV parameters on the procedural outcome of cryoballoon PVI using a retrospective analysis of 106 patients with paroxysmal AF and preprocedural CTA.

Results

Clinical follow-up of the study cohort revealed 78 patients (73.6%, PVI success group) without and 28 patients (26.4%, PVI failure group) with recurrent AF 12 months after cryoablation. Anatomical measurements such as PV diameter, PV area, PV perimeter, or PV eccentricity were not associated with procedural success. The number of occlusion attempts in the right inferior PV was significantly higher in the PVI failure group indicating a technical more complex balloon occlusion. The septum angle α (septum-PV) was significantly lower in the superior PVs of the PVI failure group indicating a direct relation of transseptal puncture site to procedural success. Furthermore, orifice angle β (PV orifice-PV course) was increased and intra-atrial angle γ (septum-PV course) was decreased in the inferior PVs of the PVI failure group.

Conclusion

Patient selection using CTA prior to cryoballoon ablation might influence the procedural success of cryoballoon PVI. While PV anatomy in regard to vein size and shape was not associated with procedural outcome, septum, orifice, and intra-atrial angulation were related to procedural success.

Coronary sinus signal amplitude: A predictor of the atrial substrate and low voltage areas

BACKGROUND

Low voltage areas (LVA) are pivotal in atrial fibrillation (AF) pathogenesis, influencing local left atrial LA excitation and perpetuating AF occurrences. While pulmonary vein isolation (PVI) with cryo-balloon (CB) ablation is effective for AF, it doesn't provide insights into the LA substrate or detect LVA, which affects ablation success rates. This study examines whether LA voltage and LVAs can be anticipated by analyzing the voltage signal amplitude at the coronary sinus (CS) catheter, which is standard in CB and radiofrequency ablation procedures.

METHODS

A retrospective analysis of 284 patients with recurrent AF undergoing RF catheter ablation was conducted at a high-volume EP center in Germany. The correlation between LA voltage and LVA with the CS signal was explored.

RESULTS

The signal amplitude in the CS significantly correlated with voltage in LA walls, particularly in the proximal CS (correlation coefficient ρ = 0.81, p < 0.001). A CS signal cut-off of 1.155 mV effectively predicted severe atrial LVAs (>40%) with a sensitivity of 90.7% and a specificity of 100%. While a threshold of 1.945 mV identified patients with no significant atrial LVAs (<5%) with a sensitivity of 88% and a specificity of 50% (AUC: 0.81, 95% CI: 0.71-0.89, p < 0.001).

CONCLUSION

The CS signal amplitude is associated with the LA voltage. Due to its potential as a diagnostic tool for atrial LVAs, the signal amplitude in the CS could provide valuable information about the LA substrate, especially when 3D mapping is not feasible.

12 lead surface ECGs as a surrogate of atrial electrical remodeling - a deep learning based approach

BACKGROUND AND PURPOSE

Atrial fibrillation (AF), a common arrhythmia, is linked with atrial electrical and structural changes, notably low voltage areas (LVAs) which are associated with poor ablation outcomes and increased thromboembolic risk. This study aims to evaluate the efficacy of a deep learning model applied to 12‑lead ECGs for non-invasively predicting the presence of LVAs, potentially guiding pre-ablation strategies and improving patient outcomes.

METHODS

A retrospective analysis was conducted on 204 AF patients, who underwent catheter ablation. Pre-procedural sinus rhythm ECGs and electroanatomical maps (EAM) were utilized alongside demographic data to train a deep learning model combining Long Short-Term Memory networks and Convolutional Neural Networks with a cross-attention layer. Model performance was evaluated using a 5-fold cross-validation strategy.

RESULTS

The model effectively identified the presence of LVA on the examined atrial walls, achieving accuracies of 78 % for both the anterior and posterior walls, and 82 % for the LA roof. Moreover, it accurately predicted the global left atrial (LA) average voltage <0.7 mV, with an accuracy of 88 %.

CONCLUSION

The study showcases the potential of deep learning applied to 12‑lead ECGs to effectively predict regional LVAs and global LA voltage in AF patients non-invasively. This model offers a promising tool for the pre-ablation assessment of atrial substrate, facilitating personalized therapeutic strategies and potentially enhancing ablation success rates.

Electrograms from the coronary sinus as a predictor for the outcome of a re-do pulmonary vein isolation

Background

Voltage signals in the coronary sinus (CS) have been associated with the presence of left atrial fibrosis. The aim of the present study was to evaluate the value of CS voltage signals as a predictor for atrial fibrillation (AF)-recurrence-free outcome of pulmonary vein isolationprocedures (PVI) in patients after a first unsuccessful cryo-balloon PVI.

Method

We collected recordings from a diagnostic catheter positioned in the CS from 282 consecutive atrial fibrillation patients undergoing a re-dopulmonary vein isolation using a 3D mapping system. The patients were followed-up (Holter ECG and telephone calls) for at least one year (median of 14 months).

Results

Of the 282 patients (male 72%, mean age 63±10.8 years, 61% persistent AF) AF recurrences were documented in 152 pts (54%)with a signal amplitude in the proximal CS position of 2.4 mV ± 1.5 mV. Patients free of AF-recurrence showed significantly higher signal amplitude of 2.9 mV ± 2.1 mV (P&lt;0,05).

A CS voltage &lt;0.53mV could predict recurrences of AF with a sensitivity of 94.7% (95% CI 89.3% – 97.8%) and specificity of 8.6% (95% CI 4.6% – 14.8%; PLR 1.04; AUC 0.55).

Conclusion

Voltage signals in the CS, as a marker for left atrial fibrosis, are associated with the outcome of PVI. A voltage threshold of &lt;0.53mV can predict AF recurrences with a high sensitivity. However, the predictive value for AF recurrences is not high due to the low specificity of this test.

Funding Acknowledgement

Type of funding sources: None.

Optimizing fibrosis detection: a comparison of electroanatomical mapping and late enhancement gadolinium magnetic resonance imaging

BACKGROUND

Fibrotic atrial cardiomyopathy plays an important role in determining the outcome of ablation in patients with atrial fibrillation (AF). Two main methods are being used for the evaluation of fibrosis: voltage-based high-density (HD) electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI). The comparability between both methods in detecting fibrosis has not been systematically investigated.

METHODS

LGE-MRIs of the left atrium (LA) were performed in 21 patients. LA-fibrosis was evaluated using a custom-designed software generating a 3D-model of the LA. HD-electroanatomical maps were recorded in each patient. After processing the maps and the MRI models by excluding the mitral valve, pulmonary veins, and the left atrial appendage, the LGE areas were measured and compared to the low voltage areas (LVA) in the HD maps using three different cutoff values of 0.5 mV, 0.7 mV, and 1.0 mV.

RESULTS

The analysis revealed significant differences between EAM and LGE-MRI in assessing LA-fibrosis at 0.5-mV (for anterior and posterior walls) and 1.0-mV cutoffs (for anterior and posterior wall and septum). However, no significant differences were found between EAM and LGE-MRI when using a 0.7-mV cutoff for all the investigated areas.

CONCLUSIONS

A voltage cutoff of 0.7 mV provided the best correlation between EAM and LGE MRI for detecting left atrial fibrosis. It supports the idea that a 0.5-mV cutoff may underestimate fibrosis, as areas with local signal voltages between 0.6 and 0.8 mV could also show LGE on MRI. Further research is needed to determine the ideal voltage cutoff for detecting left atrial fibrosis.

Detection of left atrial fibrosis in LGE-MRI and high-density electroanatomical mapping: finding a threshold for the best match

Background

Fibrotic atrial cardiomyopathy plays an important role in determining the outcome of ablation in patients with atrial fibrillation (AF). Two main methods are being used for the evaluation of fibrosis: voltage based high-density (HD) electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI). The comparability between both methods in detecting fibrosis has not been systematically investigated.

Method

LGE-MRIs of the left atrium (LA) were performed in 21 patients (pts). The extent and distribution of fibrosis were evaluated using a custom-designed software generating a 3D model of the LA. HD-electroanatomical maps were recorded in each patient using a 3D mapping software (CARTO3, Biosense Webster). The MRI-3D-model of the LA was then integrated in the 3D mapping system. After processing the HD maps and the MRI models by excluding the mitral valve, pulmonary veins and the left atrial appendage, the atrium was then divided into three independent areas: anterior and posterior wall, and intra-atrial-septum. The LGE areas were then measured using the 3D surface measurement tool. These were then compared to the low voltage areas (LVA) measured in the HD maps using three different cut-off values of 0.5 mV, 0.7 mV, and 1.0 mV.

Results

In MRI 5 pts had no significant fibrosis (fibrotic area ≤1 cm2). 16 pts showed fibrosis on the anterior wall (7.3 cm2±6.2 cm2). 15 pts showed fibrosis at the septum (5 cm2±2.9 cm2) and 9 pts showed fibrosis on the posterior wall (3.9 cm2±2.5 cm2). Using EAM with a cut-off voltage value of 0.7 mV, 3 pts had no fibrosis. 15 pts showed fibrosis on the anterior wall (7.7 cm2±6.8 cm2). 16 pts showed fibrosis at the septum (5.3 cm2±4.1 cm2) and 8 patient showed fibrosis on the posterior wall (3.5 cm2±1.8 cm2). Using a lower voltage cut-off value of 0.5 mV, fibrosis was evident in less patients with smaller fibrotic areas in LA. Whereas when using a cut-off value of 1.0 mV more patients showed a greater extent of the LA fibrosis. We found significant differences between the two methods (MRI vs. 3D-mapping) when using a cut-off value of 0.5 mV (Wilcoxon, p&lt;0.001 for the anterior and posterior wall and the septum). A cut-off value of 1.0 mV also showed significant differences on the anterior and posterior walls (Wilcoxon, p&lt;0.001). When using a cut-off value of 0.7 mV we did not find a significant difference between the two groups (Wilcoxon, p=0.365) with a correlation coefficient of 0.97 (Pearson; p&lt;0.001) for the anterior wall, 0.69 (Pearson; p=0.007) for the posterior wall, and 0.81 (Pearson; p=0.002) for the septum.

Conclusion

A cut-off value of 0.7 mV in EAM correlated best with the findings in LGE-MRI. The currently used predefined cut-off value of 0.5 mV in EAM may lead to an underestimation of the actual extent of the fibrosis. Increasing the voltage cut-off value towards 0.7 mV may therefore lead to a better characterisation of fibrotic atrial cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.

Assessing the atrial substrate: electrograms from the coronary sinus can predict left atrial fibrosis

Background

Left atrial fibrosis plays a key role regarding the success rate of pulmonary vein isolation for atrial fibrillation. It can be analyzed using LGE-MRI or invasive LA electroanatomical mapping. Assessing LA substrate prior to performing LA ablation procedures might help in optimizing the ablation approach.

Method

We analysed highdensity-electroanatomical maps of the left atrium derived by Carto 3 from 282 consecutive atrial fibrillation patients scheduled for RF pulmonary vein isolation (PVI). Maps were divided into 5 different anatomical areas and fibrosis was defined as local voltage &lt;0.5mV. The extent of fibrosis was analyzed and compared with signal recordings from different positions of a diagnostic catheter positioned in the coronary sinus (CS) using Pearson correlation analysis.

Results

PVI was carried out in 282 patients (male 72%, mean age 63±10.8 years). A minimum of 1000 evenly distributed local electrograms were recorded in every patient. Significant LA fibrosis (&gt;5%) was present in 54% of the patients with the maximum incidence of 100% at the anterior and 80% at the posterior wall. Signal amplituds in the proximal CS position significantly correlated with presence of LA fibrosis in the posterior LA (R 0.84, p&lt;0.001), LA roof (R 0.65; p&lt;0.001), left lateral (R 0.54; p&lt;0.001), septal (R 0.47; p&lt;0.001), and even LA anterior wall (R 0.56; p&lt;0.001). Comparable results were found when using distal CS signals or a signal averaged over all individual CS signals. When used as a diagnostic tool, a CS amplitude &lt;1.9mV could predict fibrosis at the posterior left atrial wall with a specificity of 97% and a sensitivity of 67% (PLR 24, AUC 0.91, 95% CI 0.87 - 0.95; p&lt;0.001). A cut-off value of 1.9mV could be used to identify patients with only minimal LA fibrosis (&lt;5%) with specificity of 88% and a sensitivity of 50% (PLR 4.2, AUC 0.81, 95% CI 0.71–0.89; p&lt;0.001.

Conclusion

Voltage signals in the CS are significantly associated with presence of fibrosis in all left atrial areas. Moreover, CS voltage signals can be used to identify presence of significant left atrial extrapulmonary vein fibrosis and could help guiding left atrial ablation procedures and choice of ablation technique.

Funding Acknowledgement

Type of funding source: None