Factors associated with postsurgical wound infections among breast cancer patients: A retrospective case‐control record review

Women with non‐metastatic breast cancer will be offered surgery as their first option. Unfortunately, studies have shown that the most common postoperative complication is surgical wound infection (SWI). We investigated the prevalence of SWI in breast cancer patients and identified the factors predictive of its development. The study was conducted at the breast cancer centre in Singapore. A retrospective case‐control review of medical records was used. During the 2013 to 2016 study period, there were 657 postsurgical breast cancer patients with only 105 records eligible for the study. The sample consisted of one to four case:control (21:84), matched according to their age at the time of their surgery. Patients presenting with SWI were grouped into cases, while those without SWI were grouped into the controls. Chi‐square test and Mann‐Whitney U test were used to identify risk factors associated with SWI. Regression analysis of predictive variables from the univariate analyses was included. These variables were type of breast surgery, implants, comorbidities, previous surgery, previous chemotherapy, surgical drains, seroma, blood transfusion, surgeon department, and length of stay. The prevalence of SWI was 9%. Demographic, clinical, and comorbidities were not associated with SWI. However, multivariate analysis found that “surgeon department,” “discharged with surgical drains,” and “postoperative seroma” were predictive of SWI. Monitoring SWI is indispensable to minimise burdens on individuals and institutions. Health care professionals should identify high‐risk patients based on the identified predictive variables. A cross‐institutional record review of SWI in postoperative breast cancer patients should be conducted.     

Defining a Place for Nipple Sparing Mastectomy in Modern Breast Care: An Evidence Based Review

Abstract: Breast cancer is a diverse disease that requires a fully integrated multidisciplinary approach. Breast surgery has undergone a revolutionary change leading us from the conventional radical mastectomy of the Halstedian era to the current motion of nipple sparing mastectomy (NSM). Despite the lack of randomized controlled trials, the technique of NSM continues to gain popularity as a prophylactic procedure in high risk patients. The current indications for NSM, if any, in the treatment of early invasive breast cancer remains uncertain and requires rigorous scientific scrutiny. This article aims to critically review the indications and limitations of NSM, discuss evidence based intra‐operative protocols and to discuss ways in which radiation therapy may be incorporated in treatment planning following NSM. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to nipple sparing mastectomy. The search focused specifically on technique, current management, safety, and complications of these procedures. Keywords searched included “Nipple sparing mastectomy,”“breast conserving surgery,”“Nipple areola complex preservation” and “skin sparing mastectomy.” NSM offers an opportunity to preserve native breast envelope without mutilation of nipple‐areola complex (NAC), and avoids multiple surgical procedures required for reconstruction. NSM may be a reasonable alternative for prophylactic and select breast cancer patients without NAC involvement; however, oncological safety of NSM has not yet been fully demonstrated. Best available evidence suggests that patients should be selected based on study of breast duct anatomy by breast Magnetic Resonance Imaging, mammographic distance between tumor and nipple and obligatory intra‐operative frozen section from retro‐areolar tissue. Additional factors such as tumor size, axillary lymph node status, lymphovascular invasion and degree of intraductal component are also being used to either include or exclude NSM candidates based on institutional protocols. Heterogeneity of patients selected for NSM is great and the lack of standardization of preoperative investigations, intra‐operative technique and pathologic sampling of retro‐areola tissues mandates a multi‐institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis or sloughing is an important problem after NSM which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra‐operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces the psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.     

Natural language processing and its role in spine surgery: A narrative review of potentials and challenges

In recent years, the volume and complexity of electronic patient-generated health data has increased exponentially leading to unprecedented opportunities for automated extraction of clinical features from free-text medical note and speech. Natural language processing (NLP), a branch of computer science that focuses on enabling computers to process human language, can process this rich resource of data for clinical and research purposes. In this narrative review, we provide the fundamentals of NLP and discuss the potentials and challenges in the spinal community. This lays a foundation for the reader to better understand and appreciate the role that NLP will play in the evolving field of artificial intelligence.     

Applications of artificial intelligence for patients with peripheral artery disease

ObjectiveApplications of artificial intelligence (AI) have been reported in several cardiovascular diseases but its interest in patients with peripheral artery disease (PAD) has been so far less reported. The aim of this review was to summarize current knowledge on applications of AI in patients with PAD, to discuss current limits, and highlight perspectives in the field.MethodsWe performed a narrative review based on studies reporting applications of AI in patients with PAD. The MEDLINE database was independently searched by two authors using a combination of keywords to identify studies published between January 1995 and December 2021. Three main fields of AI were investigated including natural language processing (NLP), computer vision and machine learning (ML).ResultsNLP and ML brought new tools to improve the screening, the diagnosis and classification of the severity of PAD. ML was also used to develop predictive models to better assess the prognosis of patients and develop real-time prediction models to support clinical decision-making. Studies related to computer vision mainly aimed at creating automatic detection and characterization of arterial lesions based on Doppler ultrasound examination or computed tomography angiography. Such tools could help to improve screening programs, enhance diagnosis, facilitate presurgical planning, and improve clinical workflow.ConclusionsAI offers various applications to support and likely improve the management of patients with PAD. Further research efforts are needed to validate such applications and investigate their accuracy and safety in large multinational cohorts before their implementation in daily clinical practice.     

The Role of Nitrosamine (NNK) in Breast Cancer Carcinogenesis

Smoking cigarettes is one of the most concerning issues that leads to tobacco-related cancers and can even result in death. Therefore, these issues should be addressed with a great sense of urgency with low-cost and simple approaches. Over the past several years, the scientific community has attempted to find solutions to overcome this issue. Thus, a large number of excellent studies have been reported in this field, and summarizing these results and providing important roadmaps for future studies is currently of great importance. Finding an outstanding solution to address aforementioned issue would be of great value to the community and to the social. Tobacco contains thousands of chemicals, and sixty-nine compounds have been established as human carcinogens; specifically, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is the strongest carcinogen among the tobacco-specific nitrosamines. Tobacco carcinogens are also linked to mammary gland pathogenesis and increased risk of developing many cancers, including breast cancer, the most common cancer in women worldwide. This mini-review summarizes the role of NNK and the mechanisms of its receptor, nicotine acetylcholine receptor (nAChR), signaling in breast cancer based on publications identified using the keywords “secondhand smoke (SHS)”, “Nitrosamines” and “breast cancer”. Furthermore, this review considers the risk of NNK to the public in an effort to reduce exposure to SHS in women and their chances of developing breast cancer.     

In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast‐Conserving Therapy

The absence of a widely accepted method for aesthetic evaluation following breast‐conserving surgery for breast cancer limits the ability to evaluate cosmetic outcomes. In this study, two different panel scoring approaches were compared in an attempt to identify a gold standard scoring system for subjectively assessing cosmetic outcomes following breast‐conserving therapy. Standardized photographs of each participant were evaluated independently by twelve health care professionals involved in breast cancer diagnosis and treatment using the Danoff four‐point scale. Individual Danoff scores were combined using two methods, a random sample “three‐panel” score and an iterative “Delphi‐panel” score, in order to create a final cosmetic score for each patient. Agreement between these two aggregative approaches was assessed with a weighted kappa (wk) statistic. Patient and professional recruitment occurred at two separate tertiary care multi‐disciplinary breast health centers. Women with unilateral breast cancer who underwent breast‐conserving therapy (segmental mastectomy or lumpectomy and radiotherapy) and were at least 2 years after radiotherapy were asked to participate. Ninety‐seven women were evaluated. The Delphi approach required three rounds of evaluation to obtain greater than 50% agreement in all photographs. The wk statistic between scores generated from the “three‐panel” and “Delphi‐panel” approaches was 0.80 (95% CI: 0.71–0.89), thus demonstrating substantial agreement. Evaluation of cosmetic outcomes following breast‐conserving therapy using a “three‐panel” and “Delphi‐panel” score provide similar results, confirming the reliability of either approach for subjective evaluation. Simplicity of use and interpretation favors the “three‐panel” score. Future work should concentrate on the integration of the three‐panel score with objective and patient‐reported scales to generate a comprehensive cosmetic evaluation platform.     

Therapies for castration‐resistant prostate cancer in a new era: The indication of vintage hormonal therapy,chemotherapy and the new medicines

When advanced prostate cancer recurred during hormonal therapy and became the castration‐resistant prostate cancer, “vintage hormonal therapy,” such as antiandrogen alternating therapy or estrogen‐related hormonal therapy, was widely carried out in Japan until 2013. This vintage hormonal therapy controlled the progression of castration‐resistant prostate cancer. When castration‐resistant prostate cancer relapses during these therapies, chemotherapy using docetaxel has been carried out subsequently. Since new hormonal therapies using abiraterone acetate and enzalutamide, which improve the prognosis of castration‐resistant prostate cancer, became available in Japan from 2014, therapeutic options for castration‐resistant prostate cancer have increased. Furthermore, the improvement of the further prognosis is promising by using cabazitaxel for docetaxel‐resistant castration‐resistant prostate cancer and radium‐223 for castration‐resistant prostate cancer with bone metastasis. An increase in therapeutic options gives rise to many questions, including best timing to use them and the indication. Furthermore, physicians have to consider the treatment for the recurrence after having carried out chemotherapy. We want to argue the difference in hormonal therapy between Japan and Western countries, and problems when carrying out new treatments, and the importance of imaging in the present review article.     

Advances in sentinel node dissection in prostate cancer from a technical perspective

The most important feature of sentinel node biopsy for prostate cancer procedure is that staging can be improved. Sentinel nodes might be found outside the extended pelvic lymph node dissection template what renders the sentinel node additive of extended pelvic lymph node dissection. At the same time, staging within the template can be further refined. We reviewed the literature regarding the sentinel node biopsy procedure for prostate cancer. PubMed and Embase were searched for all English‐language publications from January 1999 to September 2014 by using the keywords as “prostate cancer” and “sentinel lymph node” plus “biopsy” “dissection” and/or “procedure.” The present review discusses step‐by‐step sentinel node biopsy for prostate cancer. Topics of discussion are: (i) preoperative sentinel node mapping (tracers and imaging); (ii) intraoperative sentinel node identification (surgical procedure and outcome); and (iii) novelties to improve sentinel node identification (pre‐ and intraoperative approaches). Conventional sentinel node mapping is carried out after the injection of a ^99mTc‐based tracer and subsequent preoperative imaging; for example, lymphoscintigraphy and single‐photon emission computed tomography/computed tomography. This approach allowed the detection of sentinel nodes outside the extended lymph node dissection template in 3.6–36% of men with intermediate‐ and high‐risk prostate cancer. Hereby, an overall false negative rate of sentinel nodes was reported between 0% and 24.4%. To further refine the intraoperative sampling procedure, novel imaging methods such as fluorescence imaging have been introduced. Prospective randomized comparison studies are required to confirm the added benefit of sentinel template directed nodal dissection. A proper and obtainable end‐point of such a study could be the number of removed positive nodes for carrying out nodal dissection with or without sentinel template directed dissection. Similarly, the clinical impact of novel imaging technologies requires further investigation.     

Breast cancer and pregnancy: a diagnostic and management dilemma

Background: The purpose of the present paper was to review the current knowledge of pregnancy concurrent with a diagnosis of breast cancer, and how best to manage this group of women and those breast cancer survivors who may subsequently conceive. Results: Pregnancy‐associated breast cancer or gestational breast cancer is defined as breast cancer diagnosed during pregnancy or in the 12 months post‐partum. A review of the current literature on breast cancer‐related pregnancy suggests an incidence of between 0.7 and 3.9%. The prognosis is thought not to be significantly different from non‐pregnancy‐associated breast cancer, except in cases where a delay in diagnosis is associated with more advanced disease. The treatment is similar to non‐pregnant cases, with the exception of radiotherapy, which is contraindicated throughout pregnancy; and chemotherapy, which is contraindicated during the first trimester. Few breast cancer survivors go on to conceive, but those who do have no worse breast cancer or pregnancy outcomes. Conclusion: Most of the research in this field has come from small, specialized institutions and may not reflect what occurs in the wider community. Further population‐based research in this area is needed, and is currently being undertaken in Western Australia.     

Sentinel lymph node biopsy in early-stage breast cancer patients: improved survival through better staging?

Purpose

The objective of this review is to summarize the evidence demonstrating that the sentinel lymph node (SLN) procedure is not only associated with significantly less morbidity compared to the axillary dissection, but may also result in better staging and improved patient outcomes.

Methods

A search of MedLine and PubMed articles using the terms “sentinel lymph node biopsy”, “breast cancer”, “staging”, “morbidity”, “survival”, and “outcomes” was conducted.

Results

Breast cancer staging includes axillary evaluation as an integral component. Over the past two decades, sentinel lymph node biopsy has evolved as a technique that has an improved morbidity over traditional axillary dissection. The sentinel node(s) undergo a more intensive pathologic examination than traditional axillary contents. In the node-negative group of patients, this may have led to stage migration and potentially improved disease-free and overall survival.

Conclusion

The SLN procedure is not only associated with significantly less morbidity compared to the axillary lymph node dissection, it may also result in more accurate staging, better axillary tumor control and improved survival.     

A Systematic Review of Vinorelbine for the Treatment of Breast Cancer

The purpose of this study was to investigate the efficacy and safety profile of vinorelbine‐based chemotherapy in different settings for the treatment of breast cancer. We performed a computerized search using combinations of the following keywords: “breast cancer”, “breast neoplasms”, “trial”, “vinorelbine” and “navelbine”. A total of 20 trials were included in this analysis, with a total of 5,080 patients accrued. Taxane was associated with enhanced overall survival (OS; p = 0.027) and response rate (RR; p = 0.037) as compared with vinorelbine in monotherapy, but did not show significantly favored progression‐free survival (PFS; p = 0.136). Vinorelbine alone was equivalent to fluoropyrimidine treatment in RR (p = 0.79) for the treatment of metastatic breast cancer. For vinorelbine‐combined regimens, the analysis showed that the vinorelbine group gave similar results as other regimens for OS (p = 0.849) and PFS (p = 0.143). The RR of vinorelbine‐combined regimens was slightly better than that of the other regimens (OR, 1.17), but the difference was not statistically significant. In neoadjuvant setting, vinorelbine treatment was as active as AC (doxorubicin, cyclophosphamide) or DAC (doxorubicin, cyclophosphamide, docetaxel) regimens with respect to RR (p = 0.76) and pathologic complete response (pCR; p = 0.77), but showed lower occurrence of grade 3/4 adverse effects. The analysis also demonstrated that vinorelbine‐containing therapy is effective as adjuvant, front‐line or salvage therapy of metastatic breast cancer, even for patients who were previously treated with anthracyclines or taxanes.     

Hsp90 inhibitors in breast cancer: A systematic review

PurposePharmacological inhibition of Hsp90 shows great promise in breast cancer treatment. This is the first systematic review to synthesize all available data and to evaluate the efficacy and safety of Hsp90 inhibitors in breast cancer.MethodsThis study was performed in accordance with the PRISMA guidelines. Eligible articles were identified by a search of MEDLINE and ClinicalTrials.gov databases, using a predefined combination of the terms “breast”, “cancer”, “Hsp90”, “inhibitors”.ResultsOverall, 19 articles (190 patients) were eligible. The greatest clinical activity has been observed on the field of HER2-positive metastatic breast cancer. However, accumulating data suggest that Hsp90 inhibitors may play a significant role in the treatment of triple negative and aromatase inhibitor-resistant breast cancer.ConclusionIn the last decade, the development of Hsp90 inhibitors has moved forward rapidly; however, no phase III trials have been conducted and none agent has been approved for use in the clinical practice.     

Towards population-based genetic screenings for breast and ovarian cancer: A comprehensive review from economic evaluations to patient perspectives

Genetic testing for hereditary breast and ovarian cancer following genetic counseling is based on guidelines that take into account particular features of the personal and family history, and clinical criteria conferring a probability of having a BRCA mutation greater than 10% as a threshold for accessing the test. However, besides reducing mortality and social impact, the extension of screening programs also for healthy family members would allow a huge saving of the rising costs associated with these pathologies, supporting the choice of the “Test” strategy versus a “No Test” one. Analyses of different health care systems show that by applying the “Test” strategy on patients and their families, a decrease in breast and ovarian cancer cases is achieved, as well as a substantial decrease in costs of economic resources, including the costs of the clinical management of early detected tumors.In this review, we analyzed the most recent papers published on this topic and we summarized the findings on the economic evaluations related to breast and ovarian cancer population screenings. These results proved and validated that the population-wide testing approach is a more accurate screening and preventive intervention than traditional guidelines based on personal/family history and clinical criteria to reduce breast and ovarian cancer risk.     

The Structural Landscape of the Health Care System for Breast Cancer Care: Results from The Los Angeles Women's Health Study

Abstract:  The structure of health care has been rapidly evolving in response to financial pressures and demands to improve quality. Little work has documented the structure of care and its impact in the context of breast cancer care. We conducted a survey to characterize Los Angeles physicians caring for breast cancer patients and the structural landscape of the healthcare system in which they practice. Cross-sectional survey of physicians who treated a population-based cohort of breast cancer patients. We surveyed 477 physicians, targeting all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by patients participating in the Los Angeles Women's Health Study (77% response rate). Specialty-specific questionnaires were developed. Items were based on the structure and quality of care literature, cognitive interviews with cancer care specialists, and existing physician survey instruments. Breast cancer care providers in Los Angeles are diverse, with one-third non-white and 46% speaking a non-English language. Group practice is most common, (37% single specialty, 16% group-model HMO, 8% multi-specialty group). Minimal teaching involvement predominates. Mean new breast cancer patient volumes are relatively high (8 per month overall; six for surgeons), representing 46% of new cancer patients. Physicians reported high career satisfaction levels (83–92%). Physicians were least satisfied with the amount of time spent with patients (82%). Data from this study represent important building blocks for further analyses to determine the impact of structural characteristics on the quality of care that breast cancer patient's experience.     

Is it time to address survivorship in advanced breast cancer? A review article

The outcome of advanced breast cancer has significantly improved over recent decades. As a consequence, the complex needs of patients living with the disease and their care-givers should be addressed not only in terms of supportive and palliative care but also of “survivorship” requirements. The multidisciplinary approach to advanced breast cancer should encompass – early in the history of the disease – not only physical but also functional, social, psychological and spiritual domains. It is important to clearly define the disease context with patients and families (“chronic” preferred to “incurable”), addressing the concept of uncertainty, and tailoring the treatment strategy according to both disease status and individual priorities. Specific psychosocial needs of young and elderly women and male patients – i.e. social security, job flexibility, rehabilitation (including sexuality), home and child care – should be recognized and supported. This review will address the key questions associated with survivorship in this disease context, recognizing the dearth of specific data and the urgent need for targeted clinical research and tailored interventions.     

Adaptation and clonal selection models of castration‐resistant prostate cancer: Current perspective

Prostate cancer is a leading cause of cancer deaths in men worldwide. Management of the disease has remained a great challenge and even more so is the aggressive advanced stage with castration‐resistant behavior. The mechanisms and timing of development of castration‐resistant prostate cancer are unclear and remain debatable. Progression to castration‐resistant prostate cancer is undoubtedly multifactorial, with a number of molecular‐genetic aberrations implicated. However, a key question that remains unanswered is: when in the evolution of prostate cancer do the changes that confer castration resistance occur? Earlier attempts to address this question led to two proposed models: the “adaptation” and the “clonal selection” models. Although the prevailing hypothesis is the adaptation model, there is recent evidence in favor of the clonal selection model. Clarification of the model development of castration‐resistant prostate cancer might significantly alter our diagnostic and therapeutic strategies, and potentially lead to improved outcome of management of this daunting condition. Here we review existing knowledge and current research findings addressing the timing of events in the course of prostate cancer progression to castration‐resistant prostate cancer.     

Oncological Safety of Autologous Lipoaspirate Grafting in Breast Cancer Patients: A Systematic Review

Background

Autologous lipoaspirate grafting (ALAG) has become a widely used treatment in breast reconstruction after mastectomy (MST) or breast-conserving treatment (BCT), although there is an ongoing debate about its oncological safety. The aim of this systematic review was to identify, evaluate, and synthesize all clinical evidence examining the oncological risks associated with the procedure.

Methods

An extensive electronic search was performed in PubMed, Embase, and the Cochrane Library using the keywords “breast” and “autologous lipoaspirate grafting” and synonyms.

Results

The search yielded a total of 269 unique hits. Twenty clinical trials investigated ALAG in breast reconstruction after cancer. Although nine of them provided oncological follow-up data, only one retrospective cohort and four case series were suitable for analysis. The former reported no significant differences in the locoregional recurrence (LRR) incidence rates between the intervention and control groups for patients with MST as well as BCT. A large multicenter case series reported LRR incidence rates of 1.35 and 2.19 for MST and BCT patients, respectively. The remaining two series were far smaller trials with shorter follow-up and reported no recurrences. No randomized, controlled trials were identified. Most of the available studies consisted of cohorts and case series with short follow-up and no control subjects.

Conclusions

Although the first reports on cancer recurrence after ALAG are inconclusive, they show promising results. Whether lipoaspirate grafting promotes LRR in breast cancer patients is still unclear. To be able to answer this question, larger prospective trials with longer follow-up are needed.     

Successful cryoablation of breast cancer

The current standard of care for screen‐detected breast cancers is surgical excision. Cryotherapy is a promising non‐ surgical alternative treatment for these cancers and is performed under local anesthesia as an outpatient, circumventing the risks that come with an operation. New research also shows promising results for the treatment of breast cancer when cryotherapy is combined with immune modulation as it may help prevent tumor recurrence. We herein report a case of breast cancer treated successfully with cryoablation. A brief literature review of cryoablation as a treatment for breast cancer is added.     

Another review on triple negative breast cancer. Are we on the right way towards the exit from the labyrinth?

Triple negative breast cancer is a heterogeneous group of tumors, lacking the expression of estrogen, progesterone and HER-2 receptors. As frequency, it accounts about 15–20% of all breast cancers. Although in the last years there was a “boom” in publishing over this issue, multiple molecular classifications being elaborated, “the triple negative breast cancer odyssey ” is still far away from ending, as the complicated molecular pathways of pathogenesis and drug resistance mechanisms remain yet insufficiently explored. The aim of this review is presentation of molecular signatures that could predict outcome and drug resistance in triple negative breast cancer.