Innovation in Breast Surgery: Practical and Ethical Considerations

The adoption of innovation is essential to the evolution of patient care. Breast surgical oncology advances through incorporating new techniques, devices, and procedures. Historical changes in practice standards from radical to modified radical mastectomy or axillary node dissection to sentinel node biopsy reduced morbidity without sacrifice in oncologic outcome. Contemporary oncoplastic techniques afford broader consideration for breast conservation and the potential for improved cosmetic outcomes. At present, many breast surgeons face the decision of which wireless device to use for localization of nonpalpable lesions. Consideration for future changes, such as robotic mastectomy, are on the horizon. No guideline exists to assist breast surgeons in the adoption of innovation into practice. The Ethics Committee of the American Society of Breast Surgeons acknowledges that breast surgeons confront many questions associated with onboarding innovation. This paper aims to provide a framework for asking relevant questions along with the ethical principles to consider when integrating an innovation into practice

Breast Resource Assessment (B.R.A.) Project

How can a clinical leader better support breast care providers & patients in MaineHealth’sclinical alignment initiative? Goals: •Assess local & regional breast care resources•Enhance communication & collaboration with providers •Identify areas to improve the quality & delivery of breast car

Management of the asymptomatic BRCA mutation carrier

Paige Teller1, Rita K Kramer21Surgical Oncology, 2Medical Oncology, Medical University of South Carolina, Charleston, SC, USAAbstract: Current management of an asymptomatic BRCA mutation carrier includes early initiation and intensive cancer screening in combination with risk reduction strategies. The primary objectives of these interventions are earlier detection and cancer prevention to increase quality of life and prolonged survival. Existing recommendations are often based on the consensus of experts as there are few, supportive, randomized control trials. Management strategies for unaffected patients with BRCA mutations are continually redefined and customized as more evidence-based knowledge is acquired with regard to current intervention efficacy, mutation-related histology, and new treatment modalities. This review provides an outline of current, supported management principles, and interventions in the care of the asymptomatic BRCA mutation carrier. Topics covered include surveillance modalities and risk reduction achieved through behavioral modification, chemoprevention, and prophylactic surgery.Keywords: high risk, screening, risk reduction, hereditary breast cancer syndrom

Molecular Tumor Boards: The Next Step towards Precision Therapy in Cancer Care

The application of molecular tumor profiles in clinical decision making remains a challenge. To aid in the interpretation of complex biomarkers, molecular tumor boards (MTBs) have been established worldwide. In the present study, we show that a multidisciplinary approach is essential to the success of MTBs. Our MTB, consisting of pediatric oncologists, pathologists, and pharmacists, evaluated 115 cases diagnosed between March 2016 and September 2021. If targetable mutations were identified, pharmacists aided in the evaluation of treatment options based on drug accessibility. Treatable genetic alterations detected through molecular testing most frequently involved the cell cycle. For 85% of the cases evaluated, our MTB provided treatment recommendations based on the patient’s history and results of molecular tumor testing. Only three patients, however, received MTB-recommended targeted therapy, and only one of these patients demonstrated an improved clinical outcome. For the remaining patients, MTB-recommended treatment often was not administered because molecular tumor profiling was not performed until late in the disease course. For the three patients who did receive MTB-recommended therapy, such treatment was not administered until months after diagnosis due to physician preference. Thus, the education of healthcare providers regarding the benefits of targeted therapy may increase acceptance of these novel agents and subsequently improve patient survival

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: A Potential Anatomic Risk Factor for the Development of Breast Cancer Related Lymphedema

BACKGROUND: The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity via the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo. METHODS: Indocyanine green (ICG) lymphography was performed pre-operatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data. RESULTS: Sixty patients underwent ICG lymphography prior to axillary lymph node dissection between June 2019 and October 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during post-operative surveillance, of which 71% demonstrated the short bundle variant. CONCLUSIONS: While the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle) and, in this pilot report, appears to represent a potential risk factor for the development of lymphedema

A Four-Year Institutional Experience of Immediate Lymphatic Reconstruction

INTRODUCTION: Up to 1 in 3 patients may go on to develop breast cancer-related lymphedema (BCRL) after treatment. Immediate Lymphatic Reconstruction (ILR) is a surgical procedure that has been shown in early studies to reduce the risk of BCRL. However, long-term outcomes are limited due to its recent introduction and different institutions\u27 eligibility requirements. This study evaluates the incidence of BCRL in a cohort that underwent ILR over the long-term. METHODS: A retrospective review of all patients referred for ILR at our institution from September 2016 through September 2020 was performed. Patients with preoperative measurements, a minimum 6-months follow-up data and at least one completed lymphovenous bypass were identified. Medical records were reviewed for demographics, cancer treatment data, intra-operative management and lymphedema incidence.Results: A total of 186 patients with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at ILR over the study period. Ninety patients underwent successful ILR and met all eligibility criteria, with a mean patient age of 54 (sd: 12.1) years and median BMI of 26.6 (q1-q3: 24.0-30.7) kg/m2. Median number of lymph nodes removed was 14 (q1-q3: 8-19). Median follow-up was 17 months (range: 6-49). 87% of patients underwent adjuvant radiotherapy of which 97% received regional lymph node radiation. At the end of the study period, we found an overall 9% rate of LE. CONCLUSION: Utilizing strict follow-up guidelines over the long-term, our findings support ILR at time of axillary lymph node dissection is an effective procedure that reduces the risk of BCRL in a high-risk patient population

Ethical Considerations of Medical Photography in the Management of Breast Disease.

BACKGROUND: Medical photography has become an important component of the evaluation and management of patients across many specialties. It is increasingly utilized in contemporary practice with modern smartphones and enhanced digital media. Photography can enhance and improve treatment plans and communication between providers and patients. Additionally, photography supplements education, research, and marketing in both print and social media. Ethical and medicolegal standards for medical photography, specifically for patients with breast disease, have not been formally developed to guide medical providers. PURPOSE: To provide guidelines for breast care physicians using medical photography, the Ethics Committee of the American Society of Breast Surgeons presents an updated review of the literature and recommendations for ethical and practical use of photography in patient care. METHODS: An extensive PubMed review of articles in English was performed to identify studies and articles published prior to 2018 investigating the use of medical photography in patient care and the ethics of medical photography. After review of the literature, members of the Ethics Committee convened a panel discussion to identify best practices for the use of medical photography in the breast care setting. Results of the literature and panel discussion were then incorporated to provide the content of this article. CONCLUSION: The Ethics Committee of the American Society of Breast Surgeons acknowledges that photography of the breast has become an invaluable tool in the delivery of state-of-the-art care to our patients with breast disease, and we encourage the use of this important medium. Physicians must be well informed regarding the concerns associated with medical photography of the breast to optimize its safe and ethical use in clinical practice