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Youssef, M., T. E. Baradie, and F. F. A. saleep, " Superficial Bladder Cancer, the Problem of T1 G3 Tumours – an Egyptian Experience", European Journal of Cancer, vol. 47, issue S1, pp. S513, 2011.
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Rezk, M., A. Chandra, D. Addis, H. Møller, M. Youssef, P. Dasgupta, and H. Yamamoto, "() expression as a predictor of oncological outcomes in patients with high-grade prostate cancer treated with primary androgen deprivation therapy: a cohort study.", BMJ open, vol. 9, issue 3, pp. e025161, 2019 Mar 08. Abstract

OBJECTIVES: To determine whether () expression can be used as a biomarker to predict biochemical recurrence and prostate cancer-specific death in patients with high Gleason grade prostate cancer treated with androgen deprivation therapy (ADT) as monotherapy.

METHODS: A multicentre retrospective cohort study identifying 149 patients treated with primary ADT for metastatic or non-metastatic prostate cancer with Gleason score 8-10 between 1999 and 2006. Patients planned for adjuvant radiotherapy at diagnosis were excluded. Age at diagnosis, ethnicity, prostate-specific antigen and Charlson-comorbidity score were recorded. Prostatic tissue acquired at biopsy or transurethral resection surgery was assessed for immunohistochemical expression of . Failure of ADT defined as prostate specific antigen nadir +2. Vital status and death certification data determined using the UK National Cancer Registry. Primary outcome measures were overall survival (OS) and prostate cancer specific survival (CSS). Secondary outcome was biochemical recurrence-free survival (BRFS).

RESULTS: The median OS of our cohort was 60.2 months (CI 52.0 to 68.3). expression observed in 51/149 cases (34%). Multivariate Cox proportional hazards analysis showed no significant association between expression and OS (p=0.41), CSS (p=0.92) and BRFS (p=0.31). Cox regression analysis showed Gleason score (p=0.003) and metastatic status (p<1×10) to be the only significant predictors of prostate CSS.

CONCLUSIONS: No significant association was found between status and any of our outcome measures. Despite a limited sample size, our results suggest that does not appear to be a useful biomarker in predicting response to ADT in patients with high risk prostate cancer.

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Mylvaganam, S., E. J. Conroy, P. R. Williamson, N. L. P. Barnes, R. I. Cutress, M. D. Gardiner, A. Jain, J. M. Skillman, S. Thrush, L. J. Whisker, et al., "Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey.", European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, vol. 44, issue 5, pp. 708-716, 2018 05. Abstract

INTRODUCTION: The 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study.

METHODS: A questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines.

RESULTS: 81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable.

CONCLUSIONS: The iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.

Townsend, G., N. Siddiqi, M. Youssef, and T. Graja, "Are we doing too many re-excisions? Review of practice in breast conserving surgery", European Journal of Surgical Oncology, vol. 40, issue 11, pp. S76, 2014.
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Manie, T. M., M. M. G. Youssef, S. N. Taha, A. Rabea, and A. M. Farahat, "Batwing mammoplasty: a safe oncoplastic technique for breast conservation in breast cancer patients with gigantomastia.", Annals of the Royal College of Surgeons of England, pp. 1-5, 2019. Abstract

BACKGROUND: Surgical management of breast cancer with gigantomastia can be challenging when planning breast conservation, as major breast reduction is required. Complex oncoplastic procedures can carry an additional surgical risk in this situation. We suggest batwing mammoplasty as a simple and safe oncoplastic procedure for those patients.

MATERIALS AND METHODS: Fourteen patients with gigantomastia diagnosed with breast cancer were included in this prospective cohort study. All underwent batwing mammoplasty and contralateral symmetrisation procedure between May 2016 and June 2018. Patient satisfaction assessed by the Breast-Q questionnaire.

RESULTS: All patients had a body mass index above 30 kg/m with a mean of 36.7 kg/m (range 31.6-44.9 kg/m). The mean distance from midclavicular point to nipple was 42 cm (range 38-50 cm). The mean operative time was 83 minutes for procedures done by a single surgeon. Mean specimen weight was 1.2 kg (ranging from 1.035-1.63 kg). Postoperative complications occurred in 14.2% of patients. Nipple-areola complex viability was not compromised nor sensation impaired. The mean Breast-Q score for patient satisfaction with breasts was 68.6 (range 61-74). The mean score for physiological wellbeing was 77.3 (range 64-84) and the mean score for physical wellbeing was 35 (range 31-40).

CONCLUSION: Batwing mammoplasty is a safe and simple oncoplastic procedure in patients who have breast cancer with gigantomastia. It has short operative time and low complications rate. In our cohort of patients, there was no delay in the delivery of adjuvant treatment. The cosmetic outcome was favourable with a high patient satisfaction.

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Youssef, M. M. G., D. Cameron, S. Olsen, and D. Ferguson, "Does axillary lymph node dissection impact survival in patients with breast cancer and isolated tumour cells or micrometastasis in sentinel node?", European journal of cancer (Oxford, England : 1990), vol. 75, pp. 167-168, 2017 Feb 21.
de Joode, K., D. W. Dumoulin, J. Tol, H. M. Westgeest, L. V. Beerepoot, F. W. P. J. van den Berkmortel, P. G. N. J. Mutsaers, N. G. J. van Diemen, O. J. Visser, E. Oomen-de Hoop, et al., "Dutch Oncology COVID-19 consortium: Outcome of COVID-19 in patients with cancer in a nationwide cohort study.", European journal of cancer (Oxford, England : 1990), vol. 141, pp. 171-184, 2020. Abstract

AIM OF THE STUDY: Patients with cancer might have an increased risk for severe outcome of coronavirus disease 2019 (COVID-19). To identify risk factors associated with a worse outcome of COVID-19, a nationwide registry was developed for patients with cancer and COVID-19.

METHODS: This observational cohort study has been designed as a quality of care registry and is executed by the Dutch Oncology COVID-19 Consortium (DOCC), a nationwide collaboration of oncology physicians in the Netherlands. A questionnaire has been developed to collect pseudonymised patient data on patients' characteristics, cancer diagnosis and treatment. All patients with COVID-19 and a cancer diagnosis or treatment in the past 5 years are eligible.

RESULTS: Between March 27th and May 4th, 442 patients were registered. For this first analysis, 351 patients were included of whom 114 patients died. In multivariable analyses, age ≥65 years (p < 0.001), male gender (p = 0.035), prior or other malignancy (p = 0.045) and active diagnosis of haematological malignancy (p = 0.046) or lung cancer (p = 0.003) were independent risk factors for a fatal outcome of COVID-19. In a subgroup analysis of patients with active malignancy, the risk for a fatal outcome was mainly determined by tumour type (haematological malignancy or lung cancer) and age (≥65 years).

CONCLUSION: The findings in this registry indicate that patients with a haematological malignancy or lung cancer have an increased risk of a worse outcome of COVID-19. During the ongoing COVID-19 pandemic, these vulnerable patients should avoid exposure to severe acute respiratory syndrome coronavirus 2, whereas treatment adjustments and prioritising vaccination, when available, should also be considered.

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Rabie, M. A., A. Rankin, A. Burger, and M. M. G. Youssef, "The effect of Oncotype DX on adjuvant chemotherapy treatment decisions in early breast cancer.", Annals of the Royal College of Surgeons of England, pp. 1-6, 2019. Abstract

INTRODUCTION: The aim of this study was to objectively establish the value of the Oncotype DX (ODX) gene assay in adjuvant treatment decisions for intermediate risk patients with early, oestrogen receptor positive, human epidermal growth factor receptor 2 negative, lymph node negative breast cancer at a district general hospital.

METHODS: All patients who underwent surgery for breast cancer between January 2015 and December 2017 at Queen Elizabeth Hospital in King's Lynn were considered for inclusion in the study. Those who did not meet the criteria for ODX referral were excluded. Patients were divided into two cohorts based on whether they were treated before or after the introduction of ODX testing in this hospital (June 2016): the pre-ODX and post-ODX groups. The primary outcome was the percentage of patients for whom adjuvant chemotherapy (AC) was recommended in each group.

RESULTS: Of the 462 patients who underwent surgery during the study period, 43 met the eligibility criteria for ODX testing: 18 in the pre-ODX group and 25 in the post-ODX group. AC was recommended and given to 11 (61%) of the patients in the pre-ODX group. In the post-ODX group, AC was recommended for seven patients with an ODX Recurrence Score (RS) of >25; this was given to six patients (24%). One patient (with a RS of 26) declined AC. ODX testing led to a significant reduction in the proportion of patients who received AC (=0.015).

CONCLUSIONS: In intermediate risk patients with breast cancer, the results of the ODX gene assay may change the decision for adjuvant treatment. It represents a valuable tool to assist patients' and clinicians' decision making regarding adjuvant chemotherapy.

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O'Connell, R. L., T. Rattay, R. V. Dave, A. Trickey, J. Skillman, N. L. P. Barnes, M. Gardiner, A. Harnett, S. Potter, and C. Holcombe, "The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study.", British journal of cancer, vol. 120, issue 9, pp. 883-895, 2019. Abstract

BACKGROUND: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy.

METHODS: Consecutive women undergoing mastectomy ± IBR for breast cancer July-December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored.

RESULTS: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays.

CONCLUSIONS: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients.

Youssef, M. M. G., A. A. Metwally, and T. M. Manie, "The implications of a pathological complete response of the primary tumour after neoadjuvant chemotherapy for breast cancer on axillary surgery.", Journal of the Egyptian National Cancer Institute, vol. 33, issue 1, pp. 5, 2021. Abstract

BACKGROUND: Management of the node-positive axilla after neoadjuvant chemotherapy is controversial. The aim of this study is to predict the group of patients who may require a less invasive approach for axillary management. One possible group are patients with pathological complete response of the primary after chemotherapy.

RESULTS: A unicentral retrospective cohort study including all breast cancer patients with axillary node metastases at presentation who received neoadjuvant chemotherapy resulting in pathological complete response. Pathological complete response in the axillary lymph nodes was recorded. A correlation between the response in the primary tumour and the lymph nodes was assessed. A subgroup analysis was conducted for different biological groups. Complete response was seen in the axillary nodes in 80.5% of patients. Patients with lobular cancer were less likely to show a similar response in the axilla as the primary tumour (p = 0.077). A higher incidence of axillary response was observed in HER2-positive tumours (p = 0.082). All patients with grade 3 tumours achieved complete response in the axilla (p = 0.094). Patients with negative or weak positive hormone receptor status had a significantly higher rate of complete response in the axilla compared to strongly positive hormone receptor status (OR, 7.8; 95% CI, 1.7-34.5; p = 0.007).

CONCLUSION: A less invasive axillary surgery may be safely recommended in selected group of node-positive patients after neoadjuvant chemotherapy when the primary tumour shows complete response. This group may include HER2-positive, ER-negative and grade 3 tumours. Less response is expected in ER-positive and lobular carcinoma even with complete response in the primary.

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Youssef, M., D. Cameron, M. Cooper, D. Ferguson, and M. Davies, "Micrometastasis in axillary lymph nodes: A five years review", European Journal of Surgical Oncology, vol. 39, issue 5, pp. 500-501, 2013.
, "Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.", Lancet (London, England), vol. 396, issue 10243, pp. 27-38, 2020. Abstract

BACKGROUND: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection.

METHODS: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation.

FINDINGS: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).

INTERPRETATION: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.

FUNDING: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

, "Multicentre prospective observational study evaluating recommendations for mastectomy by multidisciplinary teams.", The British journal of surgery, vol. 107, issue 3, pp. 227-237, 2020. Abstract

BACKGROUND: Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates.

METHODS: Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected.

RESULTS: Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent).

CONCLUSION: Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.

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Youssef, M. M. G., A. Namour, O. M. A. R. Z. Youssef, and A. Morsi, "Oncologic and Cosmetic Outcomes of Oncoplastic Breast Surgery in Locally Advanced Breast Cancer After Neoadjuvant Chemotherapy, Experience from a Developing Country.", Indian journal of surgical oncology, vol. 9, issue 3, pp. 300-306, 2018 Sep. Abstract

Oncoplastic surgery (OPS) has emerged as a new approach for extending breast conserving surgery (BCS) possibilities, reducing both mastectomy and re-excision rates, while avoiding breast deformities. OPS is based upon the integration of plastic surgery techniques for immediate reshaping after wide excision for breast cancer. This is a prospective feasibility cohort study of oncoplastic breast surgery after neoadjuvant chemotherapy that was carried at the National Cancer Institute, Cairo University and included 70 patients. The primary outcome was the local recurrence rate. Secondary outcomes included survival and margins obtained as well as cosmetic outcomes. Survival analysis was performed. Oncoplastic breast surgery did not compromise oncologic safety in the patients included in the study. It even allowed wider margins of resection which could be associated with better oncologic outcomes. At the same time, it gave a better cosmetic outcome and therefore higher patient satisfaction. Oncoplastic breast surgery includes a wide spectrum of surgical techniques, ranging from the basic level I techniques in breast conserving surgery to the more complex procedures of level II which are broadly classified into volume replacement (therapeutic mammoplasty) and volume displacement procedures. We suggest that oncoplastic breast surgery techniques should be the standard of care in breast surgery. They are the basis for breast conserving surgery techniques in early breast cancer. In our experience, oncoplastic surgery is feasible in locally advanced tumours after downstaging with neoadjuvant chemotherapy without compromising the oncologic safety.

, "Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic.", Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland, 2020. Abstract

AIM: This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.

METHOD: This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data.

RESULTS: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20) and advanced cancer stage (3.43, 1.16-10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%).

CONCLUSION: Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks.

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Manie, T., A. Farahat, T. Hashem, M. Youssef, A. Abdelwahab, I. Elattar, and T. Elbaradie, "Preoperative estimation of cosmetic outcomes after immediate breast reconstruction with extended latissimus dorsi flap: A simple prediction model", JPRAS Open, vol. 15, pp. 10-17, 2018.
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Youssef, M., D. Cameron, and D. Ferguson, "Re: Acute painful breast in a non-lactating woman", The BMJ, issue 353, pp. i2646, 2016.
Youssef, M. M. G., J. Rees-Lee, M. Burden, S. Olsen, D. Ferguson, and R. Tillett, "Re: Infection prevention in implant surgery - A review of the surgical evidence, guidelines and a checklist.", European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 2016 Jul 27.
Leishman, F., M. Wiltsher, M. Youssef, S. Olsen, D. Ferguson, and R. Tillett, "Reducing implant loss rates in breast reconstruction at the Royal Devon and Exeter Hospital: A complete audit cycle", European Journal of Surgical Oncology, vol. 42, issue 5, pp. S52, 2016.
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Potter, S., E. J. Conroy, R. I. Cutress, P. R. Williamson, L. Whisker, S. Thrush, J. Skillman, N. L. P. Barnes, S. Mylvaganam, E. Teasdale, et al., "Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study.", The Lancet. Oncology, 2019 Jan 09. Abstract

BACKGROUND: Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques.

METHODS: In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281.

FINDINGS: Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (<5% for re-operation, re-admission, and implant loss, and <10% for infection).

INTERPRETATION: Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction.

FUNDING: National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Youssef, M. M. G., D. Cameron, P. H. Pucher, S. Olsen, and D. Ferguson, "The significance of sentinel lymph node micrometastasis in breast cancer: Comparing outcomes with and without axillary clearance.", Breast (Edinburgh, Scotland), vol. 30, pp. 101-104, 2016 Dec. Abstract

BACKGROUND: Management of micrometastasis in the sentinel node is a controversial topic. Most of the guidelines don't recommend further axillary treatment if micrometastasis are the only finding in the sentinel node. However, some evidence suggests that micrometastasis have significant effect on long term outcomes and therefore indicate systemic treatment.

METHOD: Retrospective cohort study reviewing the management of patients with micrometastasis in the sentinel nodes. Two groups were compared, those who had further axillary clearance and those who had not. The primary endpoints were loco-regional recurrence and lymphedema rate. The secondary endpoints were distant metastasis rate, OS and DFS.

RESULTS: 95 patients were found to have micrometastasis or ITC in the axillary SNB over a period of 10 years. Of those, 38 patients had axillary clearance after SNB, while 57 did not. Lymphedema rate was 18.4% in the axillary clearance group versus 0% in the no axillary clearance group (p < 0.001). The LRR event was rare therefore not compared. Distant metastasis rate was 7.01% in the SNB group versus 2.6% in the axillary clearance group. There were no mortalities in the axillary clearance group. This compares to 7.01% among the patients who didn't have axillary clearance. All the patients who died had developed distant metastasis as a cause of death. There was a difference in OS between the two groups in favor of the axillary clearance group (p = 0.004).

DISCUSSION: Although not an indication for axillary clearance recent guidelines, micrometastasis and ITC found in the SNB are a sign of a biologically different disease. This important information should be taken in consideration when planning the adjuvant treatment in those patients among other factors considered.

Knight, H. J., J. J. Musgrove, M. M. G. Youssef, D. J. Ferguson, S. B. Olsen, and R. L. Tillett, "Significantly reducing implant loss rates in immediate implant-based breast reconstruction: A protocol and completed audit of quality assurance.", Journal of plastic, reconstructive & aesthetic surgery : JPRAS, vol. 73, issue 6, pp. 1043-1049, 2020. Abstract

INTRODUCTION: Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions.

METHODS: Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months.

RESULTS: The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction.

CONCLUSIONS: Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.

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Potter, S., A. Trickey, T. Rattay, R. L. O'Connell, R. Dave, E. Baker, L. Whisker, J. Skillman, M. D. Gardiner, R. D. Macmillan, et al., "Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction.", The British journal of surgery, vol. 107, issue 7, pp. 832-844, 2020. Abstract

BACKGROUND: Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.

METHODS: The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.

RESULTS: A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.

CONCLUSION: TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.