Sentinel lymph node biopsy and neoadjuvant chemotherapy in the management of early breast cancer: Safety considerations and timing

Over the last decades, breast cancer treatment has become more personalised. Treatment plans are based on the biology of the tumour rather than the stage. Consequently, neoadjuvant chemotherapy (NACT) is commonly the primary therapy for early breast cancer as well as locally advanced disease. Sentinel lymph node biopsy (SLNB) is standard axillary management for women with node-negative disease. This review looks at the relevant literature and gives guidance on the timing of SLNB when NACT is planned and evaluates the safety of performing an SLNB rather than an axillary clearance

Sentinel lymph node biopsy and neoadjuvant chemotherapy in the management of early breast cancer: Safety considerations and timing

Over the last decades, breast cancer treatment has become more personalised. Treatment plans are based on the biology of the tumour rather than the stage. Consequently, neoadjuvant chemotherapy (NACT) is commonly the primary therapy for early breast cancer as well as locally advanced disease. Sentinel lymph node biopsy (SLNB) is standard axillary management for women with node-negative disease. This review looks at the relevant literature and gives guidance on the timing of SLNB when NACT is planned and evaluates the safety of performing an SLNB rather than an axillary clearance

Localization Techniques for Non-Palpable Breast Lesions : Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411)

Funding: The MELODY study will be financially supported by: Hologic, Merit Medical, Endomag and Sirius Medical.Peer reviewedPublisher PD

Roux-en-Y gastric bypass versus sleeve gastrectomy: a meta-analysis

Morbid obesity is a growing pandemic and is a direct cause of diseases such as type 2 diabetes. Bariatric surgery is an effective long-term treatment modality. There are several procedures that have been described, however, sleeve gastrectomy (SG) has gained popularity despite a paucity of evidence for its use. In contrast, the Roux-en-Y gastric bypass (RYGB) has been validated and is considered the gold standard in bariatric surgery. Currently there is no evidence proving superiority of RYGB over SG. Objectives To determine whether SG is as effective as RYGB. Methods Randomized controlled trials (RCTs) comparing adults undergoing laparoscopic RYGB or SG for treatment of morbid obesity were compared in a fixed-effect model meta-analysis. Outcomes included measures of weight loss, improvement of comorbidities, procedurerelated morbidity and mortality, and changes in gut hormone levels. Heterogeneity was assessed using the I2 test, and all studies were assessed for bias. Results Eight RCTs were included in this review. No mortalities were reported. SG had lower rates of morbidity, re-operation and re-hospitalization, but this was not statistically significant. There was no significant difference between SG and RYGB for parameters of weight loss and diabetes resolution after 12 months follow-up. RYGB significantly improved dyslipidaemia with statistical differences in triglyceride and LDL reduction (MD=-0.17, 14 p=0.05 and MD=-0.43, p=0.002 respectively). SG lowered fasting ghrelin levels (MD=342.96, p=<0.00001), RYGB lowered leptin levels (MD= -6.96, p=0.02), and there was no difference in PYY levels. Conclusions SG and RYGB were equivalent in procedural morbidity and mortality, weight loss and parameters of diabetes resolution at 12 month follow-up. RYGB had a superior resolution of dyslipidaemia

Quality indicators for the diagnosis and surgical management of breast cancer in South Africa

Introduction: Quality indicators (QIs) for breast cancer care have been developed and applied in high-income countries and contributed to improved quality of care and patient outcomes over time. Materials and methods: A modified Delphi process was used to derive expert consensus. Potential QIs were rated by a panel of 17 breast cancer experts from various subspecialties and across South African provinces. Each QI was rated according to importance to measure, scientific acceptability and feasibility. Scoring ranged from 1 (no agreement) to 5 (strong agreement). Inclusion thresholds were set a priori at mean ratings >= 4 with a coefficient variation of >= 25%. Levels of evidence were determined for each indicator. Results: The literature review identified 790 potential QIs. After categorisation and removal of duplicates, 52 remained for panel review. There was strong consensus for 47 which were merged to 30 QIs by exclusion of similar indicators and indicator grouping. The final set included eight QIs with level I or II evidence and two QIs with level III evidence which were deemed "mandatory" due to clinical priority and impact on care. The remaining QIs with lower-level evidence were grouped as eight "recommended" QIs (regarded as standard of care) and twelve "optional" QIs (not regarded as standard of care). Conclusion: A regional set of QIs was developed to facilitate standardised treatment and auditing of surgical care for breast cancer patients in South Africa. Routine monitoring of the ten mandatory QIs, which were selected to have the most substantial impact on patient outcome, is proposed. (C) 2020 The Authors. Published by Elsevier Ltd

Chromosomal radiosensitivity of triple negative breast cancer patients

Purpose: Based on clinical and molecular data, breast cancer is a heterogeneous disease. Breast cancers that have no expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) are defined as triple negative breast cancers (TNBCs); luminal cancers have different expressions of ER, PR and/or HER2. TNBCs are frequently linked with advanced disease, poor prognosis and occurrence in young African women, and about 15% of the cases are associated with germline BRCA1/2 mutations. Since radiotherapy is utilized as a principle treatment in the management of TNBC, we aimed to investigate the chromosomal instability and radiosensitivity of lymphocytes in TNBC patients compared to luminal breast cancer patients and healthy controls using the micronucleus (MN) assay. The effect of mutations in breast cancer susceptibility genes on chromosomal radiosensitivity was also evaluated. Methods: Chromosomal radiosensitivity was evaluated in the G0 (83 patients and 90 controls) and S/G2 (34 patients and 17 controls) phase of the cell cycle by exposing blood samples from all patients and controls to 2 and 4 Gy ionizing radiation (IR). Results: In the G0 MN assay, the combined cohort of all breast cancer, TNBC and luminal patients' exhibit significantly elevated spontaneous MN values compared to controls indicating chromosomal instability. Chromosomal radiosensitivity is also significantly elevated in the combined cohort of all breast cancer patients compared to controls. The TNBC patients, however, do not exhibit enhanced chromosomal radiosensitivity. Similarly, in the S/G2 phase, 76% of TNBC patients do not show enhanced chromosomal radiosensitivity compared to the controls. In both the G0 and S/G2 phase, luminal breast cancer patients demonstrate a shift toward chromosomal radiosensitivity compared to TNBC patients and controls. Conclusions: The observations of the MN assay suggest increased chromosomal instability and chromosomal radiosensitivity in South African breast cancer patients. However, in TNBC patients, the irradiated MN values are not elevated. Our results suggest that the healthy lymphocytes in TNBC patients could handle higher doses of IR

Survival of south african women with breast cancer receiving anti-retroviral therapy for HIV

Purpose: Breast cancer outcomes in sub-Saharan Africa is reported to be poor, with an estimated five-year survival of 50% when compared to almost 90% in high-income countries. Although several studies have looked at the effect of HIV in breast cancer survival, the effect of ARTs has not been well elucidated. Methods: All females newly diagnosed with invasive breast cancer from May 2015–September 2017 at Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic Hospital were enrolled. We analysed overall survival and disease-free survival, comparing HIV positive and negative patients. Kaplan-Meier survival curves were generated with p-values calculated using a log-rank test of equality while hazard ratios and their 95% confidence intervals (CIs) were estimated using Cox regression models. Results: Of 1019 patients enrolled, 22% were HIV positive. The overall survival (95% CI) was 53.5% (50.1–56.7%) with a disease-free survival of 55.8% (52.1–59.3) after 4 years of follow up. HIV infection was associated with worse overall survival (HR (95% CI): 1.50 (1.22–1.85), p < 0.001) and disease-free survival (OR (95% CI):2.63 (1.71–4.03), p < 0.001), especially among those not on ART at the time of breast cancer diagnosis. Advanced stage of the disease and hormone-receptor negative breast cancer subtypes were also associated with poor survival. Conclusion: HIV infection was associated with worse overall and disease-free survival. HIV patients on ARTs had favourable overall and disease-free survival and with ARTs now being made accessible to all the outcome of women with HIV and breast cancer is expected to improve

Neoadjuvant Chemotherapy Use for Nonmetastatic Breast Cancer at Five Public South African Hospitals and Impact on Time to Initial Cancer Therapy

In sub‐Saharan Africa, clinical decisions can be affected by resource constraints. This article analyzes the clinical and sociodemographic factors associated with receiving neoadjuvant chemotherapy among patients from a previously existing cohort: women enrolled in the prospective South African Breast Cancer and HIV Outcomes study

Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units

PURPOSE High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units. METHODS The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator. RESULTS Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens. CONCLUSION Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time