Breast conserving surgery versus mastectomy: cancer practice by general surgeons in Iran

BACKGROUND: There appear to be geographical differences in decisions to perform mastectomy or breast conserving surgery for early-stage breast cancer. This study was carried out to evaluate general surgeons' preferences in breast cancer surgery and to assess the factors predicting cancer practice in Iran. METHODS: A structured questionnaire was mailed to 235 general surgeons chosen from the address list of the Iranian Medical Council. The questionnaire elicited information about the general surgeons' characteristics and about their work experience, posts they have held, number of breast cancer operations performed per year, preferences for mastectomy or breast conserving surgery, and the reasons for these preferences. RESULTS: In all, 83 surgeons returned the completed questionnaire. The results indicated that only 19% of the surgeons routinely performed breast conserving surgery (BCS) and this was significantly associated with their breast cancer case load (P < 0.01). There were no associations between BCS practice and the other variables studied. The most frequent reasons for not performing BCS were uncertainty about conservative therapy results (46%), uncertainty about the quality of available radiotherapy services (32%), and the probability of patients' non-compliance in radiotherapy (32%). CONCLUSION: The findings indicate that Iranian surgeons do not routinely perform BCS as the first and the best treatment modality. Further research is recommended to evaluate patients' outcomes after BCS treatment in Iran, with regard to available radiotherapy facilities and cultural factors (patients' compliance)

Oncological Outcome of Oncoplastic Breast Surgery: A Review of the Literature

Oncoplastic breast surgery (OBS) has gained widespread acceptance during the last two decades as an integral component of breast cancer surgery. OBS combines oncological principles of breast cancer surgery with plastic surgery techniques to provide the best cosmetic results without compromising oncological outcome of breast cancer treatment and it has opened up the possibility to perform breast conservation in large tumors. The purpose of this review is assessment of the oncological outcome of OBS in the treatment of breast cancer. We performed an extensive search of PubMed for articles published on oncological results and safety of OBS. There are few randomized clinical trials (RCTs) comparing the results of OBS with standard breast conservation techniques; however, based on the results of several prospective studies, it can be concluded that in terms of oncological outcome, OBS is at least as safe as standard techniques for breast conservation

Acute Immunologic Reaction to Silicone Breast Implant after Mastectomy and Immediate Reconstruction: Case Report and Review of the Literature

Background: Since the introduction of silicone based medical devices in to clinical practice, several reports appeared in the medical literature regarding their adverse effects. However, there are few reports of immunologic reactions to these implants. Case presentation: A case of systemic reaction to a breast implant inserted for immediate breast reconstruction in a breast cancer patient is presented. The patient developed fever and skin rash two months after the surgery. Investigations disclosed no infectious origin for the fever and a dramatic response to steroid therapy was observed. Conclusion: Immunologic reaction should be considered in case of systemic signs and symptoms after silicone breast implant placement as a rare complication.

Sternal Resection for Sternal Metastasis from Breast Cancer: Report of a Case and Review of the Literature

Background: There has been increasing trend towards surgical treatment of metastases across different cancer types, including breast cancer, in the recent decade. Single metastasis of breast cancer to sternum is a rare situation. We present a case of sternectomy for metastasis from breast cancer. Case presentation: A 58-year-old woman with a history of modified radical mastectomy for breast cancer 13 years earlier, presented with a mass over sternum. Diagnostic work up revealed a mass involving sternum and no evidence of systemic spread. She underwent resection of sternum and reconstruction of chest wall. Pathology revealed an invasive carcinoma that was hormone receptor positive on immunohistochemistry. Chemotherapy and radiotherapy were delivered after surgery and hormone therapy with Letrozole was initiated. She is disease free 37 months after surgery. Conclusion: Surgical treatment of solitary sternal metastasis of breast cancer is justifiable and may result in long term disease-free survival

Stereotactic Breast Core Needle Biopsy in a Tertiary Breast Center of Tehran University of Medical Sciences

Background: The purpose of this study was to evaluate the results of stereotactic breast core needle biopsy in a tertiary breast center of Tehran University of Medical Sciences. Methods: Patients who were candidates for mammography-guided stereotactic breast core biopsy from March 2011 to December 2013 were included in this study. Stereotactic biopsy was performed by a dedicated prone Hologic mammography unit employing an automatic biopsy device with a 14-gauge needle. Patients with malignant or premalignant biopsy results were followed up with surgical pathology reports and patients with benign core biopsy findings were followed up with mammograms. Results: Among the 150 patients who were included in the final analyses, 30 had malignant findings on stereotactic biopsy and 10 patients had a premalignant pathology result on stereotactic biopsy. The remaining 110 patients had benign results on histopathology; however, in 30 patients, wire localization and surgery of the same area were performed due to either discordant mammography-pathology findings or clinical suspicion of malignancy and in two of them, advancing pathologic grade was witnessed. A total of 80 patients with benign histopathologic results had follow-up mammograms and the follow-up period was between 12 months to 3 years. The sensitivity and specificity of stereotactic breast core biopsy in this study were 94% and 96%, respectively. Conclusions: Stereotactic breast core needle biopsy is an effective and safe method in evaluation of suspicious mammography-detected lesions but caution should be warranted when taking results into account, especially in mammography-pathology discordance and in patients with premalignant pathology reports

Axillary Reverse Mapping: A Potentially Safe Procedure in Oncology

Background: In an attempt to reduce the risk of developing lymphedema following breast cancer surgery, some researchers suggested that by identifying and preserving the lymphatic plexus which drains ipsilateral arm we can minimize the risk of lymphedema. The procedure is known as axillary reverse mapping (ARM). In the current study, we investigated the oncological safety of this technique. Methods: A total of 60 patients who were undergoing axillary lymph node dissection were involved. The indications for axillary dissection were whether clinically node-positive axilla or positive sentinel lymph node biopsy. ARM was performed by injecting 2 ml of methylene blue subcutaneously in the upper and medial part of ipsilateral patients’ arm along the intermuscular groove. Results: ARM nodes were identified by means of methylene blue injection in 51(85%) patients (identification rate = 85%). For the subgroup of clinically positive axillary lymph nodes, identification rate was 93.1%, and the corresponding figure was 77.4% for positive SLNB group (P = 0.148). Pathological evaluation of harvested ARM nodes demonstrated metastatic involvement in 8(27.5%) and 1(3.2%) patients in clinically positive and SLNB positive groups respectively (P = 0.026). Conclusions: Based on the findings of this study it seems that ARM could be considered as a safe procedure in patients who are a candidate for ALND when SLNB is positive. In contrast, in patients with clinically positive axillary nodes, there is a considerable risk of tumoral metastasis in ARM nodes

Surgeons' Perspectives on Surgery of Breast Cancer in Iran: The Pattern and Determinants

Background: The purpose of this study was to assess Iranian surgeons' perceptions toward mastectomy and breast conserving therapy (BCT) and determine the contributing factors. Methods: In this cross-sectional study, a structured questionnaire was devised and hosted on survey.tums.ac.ir and a link to the questionnaire was emailed to surgeons registered in Iranian Medical Council, branch of Tehran. The results of the current study were compared to a similar study which was performed in 2004 on a comparable sample of surgeons in Tehran, Iran. Results: A total 166 surgeons filled out the study questionnaire. Only 24 surgeons declared that they have not performed BCT before. Variables that showed a significant association with performing BCT were attending a breast surgery or surgical oncology fellowship (P = 0.010) and breast surgery workshop (P = 0.042). No associations were observed between performance of BCT and age category (P = 0.951), gender (P = 0.416), duration of practice (P = 0.821), number of breast cancer patients per year (P = 0.083), and setting of practice categorized as teaching – nonteaching hospitals (P = 0.417). Comparing the results of the current study with the study performed in 2004 revealed a significant increase in the frequency of surgeons who performed BCT (85.5% vs 19.3%, respectively) (P < 0.001). Participants of the current study were more likely to mention "lack of experience" as the reason for not performing BCT compared to the previous study (P = 0.004). Conclusions: Our results delineated that there was a significant increase in the percentage of surgeons performing BCT compared to the previous study. Factors significantly associated with performing BCT were participating in a surgical oncology or breast surgery fellowship or short courses in breast surgery

Performance of the Gail Model for Breast Cancer Risk Assessment in Iranian Women

Background: The Gail model has been widely used for estimation of absolute risk of breast cancer development. The original model and most of the validation studies have been performed among western populations and controversial results have been reported regarding the applicability of this model in Asian populations. Our aim was to investigate the performance of this model in Iranian women. Methods: In a cross-sectional study, a total of 280 patients with breast cancer and 280 participants with normal screening results were enrolled as case and control groups, respectively. Risk factors used in the latest version of the Gail model were compared between the two study groups. Gail score was calculated by using Breast Cancer Risk Assessment Tool and based on the cut-off point of 1.67, patients were categorized in order to assess model performance. Results: In total, 560 patients with a mean age of 43.07±8.60 years were enrolled. Comparison of different risk factors between the two groups revealed significant associations of patients’ age (P < 0.001), age at first pregnancy (P = 0.022), previous history of breast biopsy (P < 0.001) and atypical hyperplasia (P = 0.002) with risk of breast cancer. No association was found between age at menarche (P = 0.115) or first-degree family history (P = 0.117) and increased risk. Considering the Gail score for 5-year risk of breast cancer development, the difference between the two groups failed to reach significance (P = 0.052). The sensitivity and specificity of the model were 13.9% and 94%, respectively. Conclusions: Based on the current findings, it can be suggested that employing the current version of the Gail model for breast cancer risk assessment will underestimate the risk of cancer development in Iranian women

Effects of Wound Irrigation with Topical Phenytoin Solution During Modified Radical Mastectomy on Postoperative Seroma Formation

Background: Modified radical mastectomy (MRM), as a surgical treatment in breast cancer patients, may lead to important complications with significant morbidities including seroma formation. In this study, we used topical phenytoin to evaluate its impact on breast and axillary wound drainage and seroma formation after MRM. Methods: In a double-blinded randomized clinical trial, patients with breast cancer who were candidates for modified radical mastectomy (MRM) were enrolled. The patients were randomly assigned to two groups using a simple randomization method. Group A received topical phenytoin 1% solution for the irrigation of the mastectomy wound during the MRM procedure while group B (control group) underwent wound irrigation with normal saline solution. In addition to demographic data, postoperative variables including daily drainage of breast and axillary drains, drain removal days, and possible complications including seroma formation and their management were recorded. Results: Except for daily drainage recorded on the fifth postoperative day, the drainage of both axillary and breast drains were significantly different between group A and B in the following days. Compared to group B, axillary drains could be removed significantly earlier in group A. In regard to the breast drains, they were removed earlier in group A with no statistically difference compared to group B, the difference was not statistically significant. Seroma was detected in 7(8.3%) patients, 3 patients in group A and 4 patients in group B, with no significant differences between the two groups. All the patients underwent repeated aspirations. Conclusions: Our findings showed that topical irrigation of the surgery site with phenytoin was effective in reducing axillary surgical wound drainage