Imperial College London

Mr Daniel Richard Leff

Faculty of MedicineDepartment of Surgery & Cancer

Reader in Breast Surgery
 
 
 
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d.leff Website

 
 
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016Paterson WingSt Mary's Campus

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Summary

 

Publications

Publication Type
Year
to

233 results found

Leiloglou M, Kedrzycki M, Chalau V, Chiarini N, Thiruchelvam P, Hadjiminas D, Hogben K, Rashid F, Ramakrishnan R, Darzi A, Leff D, Elson Det al., 2022, Indocyanine Green Fluorescence Image Processing Techniques for Breast Cancer Macroscopic Demarcation, Scientific Reports, ISSN: 2045-2322

Journal article

Thiruchelvam PTR, Leff DR, Godden AR, Cleator S, Wood SH, Kirby AM, Jallali N, Somaiah N, Hunter JE, Henry FP, Micha A, O'Connell RL, Mohammed K, Patani N, Tan MLH, Gujral D, Ross G, James SE, Khan AA, Rusby JE, Hadjiminas DJ, MacNeill FA, PRADA Trial Management Groupet al., 2022, Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer (PRADA): a multicentre, prospective, non-randomised, feasibility study, The Lancet Oncology, Vol: 23, Pages: 682-690, ISSN: 1213-9432

BACKGROUND: Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy. METHODS: We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3-4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42·72 Gy in 16 fractions (over 3·2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2-6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment. FINDINGS: Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12·1%, 95% CI 3·4-28·2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths. INTERPRETATION: Preoperative radiotherapy followed by skin-sparing mastectomy and immediat

Journal article

Jiwa N, Ezzat A, holt J, wijayatilake D, Takats Z, Leff Det al., 2022, Nipple Aspirate Fluid and its Use for the Early Detection of Breast Cancer, Annals of Medicine and Surgery, ISSN: 2049-0801

Journal article

Ezzat A, Vyas K, Holford N, Leff Det al., 2022, Systematic review of clinical applications of confocal fluorescence microscopy for intra-operative breast cancer diagnostics, Publisher: SPRINGER, Pages: 189-190, ISSN: 1068-9265

Conference paper

Ezzat A, Vyas K, Asenov M, Chauhan M, Jha A, Ramamoorthy S, Leff Det al., 2022, Portable confocal endomicroscopy for ductal feature characterization: Toward margin assessment in breast-conserving surgery, Publisher: SPRINGER, Pages: 190-191, ISSN: 1068-9265

Conference paper

Chauhan H, Jiwa N, Leff D, 2022, Clinico-pathological predictors of positive resection margins, Publisher: SPRINGER, Pages: 191-192, ISSN: 1068-9265

Conference paper

Bakri NAC, Kwasnicki R, Khan N, Ghandour O, Lee A, Grant Y, Darzi A, Ashrafian H, Leff Det al., 2022, Impact of axillary lymph node dissection and sentinel lymph node biopsy on upper-limb morbidity in breast cancer patients: Systematic review and meta-analysis, Publisher: SPRINGER, Pages: 92-93, ISSN: 1068-9265

Conference paper

Courtney A, Parks R, Wilkins A, Brown R, O'Connell R, Dave R, Dillon M, Fatayer H, Gallimore R, Gandhi A, Gardiner M, Harmer V, Hookway L, Irwin G, Ives C, Mathers H, Murray J, O'Leary P, Patani N, Paterson S, Potter S, Prichard R, Satta G, Teoh TG, Ziprin P, Leff Det al., 2022, Mastitis and mammary abscess management audit (MAMMA), Publisher: SPRINGER, Pages: 90-91, ISSN: 1068-9265

Conference paper

Shanthakumar D, Elson D, Darzi A, Leff Det al., 2022, Tissue optical imaging as an emerging technique for intraoperative margin assessment in breast-conserving surgery, Publisher: SPRINGER, Pages: 153-154, ISSN: 1068-9265

Conference paper

Lee A, Kwasnicki R, Hasaan K, Yasmin G, Abigail C, Angela F, Leff Det al., 2021, Outcome reporting in therapeutic mammaplasty: a systematic review, BJS Open, Vol: 5, Pages: 1-12, ISSN: 2474-9842

BackgroundTherapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes such as quality of life, aesthetic and functional outcomes are limited, piecemeal or inconsistent. This systematic review aims to identify all outcomes reported in clinical studies of TM to facilitate development of a Core Outcome Set.MethodsMedline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors independently screened articles for eligibility. Data was extracted regarding the outcome definition and classification type (e.g., oncologic, quality of life, etc), time of outcome reporting and measurement tools. ResultsOf 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n=102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n=75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n=75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time-point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a pre-operative baseline for comparison. Few studies reported quality of life (n=30, 20.3 per cent), functional outcomes (n=5, 3.4 per cent) or resource use (n=28, 18.9 per cent).ConclusionsGiven the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.PROSPERO: CRD42020200365

Journal article

Maier-Hein L, Eisenmann M, Sarikaya D, Maerz K, Collins T, Malpani A, Fallert J, Feussner H, Giannarou S, Mascagni P, Nakawala H, Park A, Pugh C, Stoyanov D, Vedula SS, Cleary K, Fichtinger G, Forestier G, Gibaud B, Grantcharov T, Hashizume M, Heckmann-Noetzel D, Kenngott HG, Kikinis R, Muendermann L, Navab N, Onogur S, Ross T, Sznitman R, Taylor RH, Tizabi MD, Wagner M, Hager GD, Neumuth T, Padoy N, Collins J, Gockel I, Goedeke J, Hashimoto DA, Joyeux L, Lam K, Leff DR, Madani A, Marcus HJ, Meireles O, Seitel A, Teber D, Ueckert F, Mueller-Stich BP, Jannin P, Speidel Set al., 2021, Surgical data science-from concepts toward clinical translation, MEDICAL IMAGE ANALYSIS, Vol: 76, ISSN: 1361-8415

Journal article

Jiwa N, Kumar S, Gandhewar R, Chauhan H, Nagarajan V, Wright C, Hadjiminas D, Takats Z, Ashrafian H, Leff DRet al., 2021, Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature, Publisher: SPRINGER, Pages: 1774-1786, ISSN: 1068-9265

Conference paper

Jiwa N, Leff D, 2021, ASO Authors Reflection: Diagnostic Accuracy of Nipple Discharge Fluid Cytology: A Meta-Analysis and Systematic Review of the Literature, ANNALS OF SURGICAL ONCOLOGY, Vol: 29, Pages: 1787-1788, ISSN: 1068-9265

Journal article

Patel R, Suwa Y, Kinross J, von Roon A, Woods AJ, Darzi A, Singh H, Leff DRet al., 2021, Neuroenhancement of surgeons during robotic suturing, SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES, ISSN: 0930-2794

BackgroundThe initial phases of robotic surgical skills acquisition are associated with poor technical performance, such as low knot-tensile strength (KTS). Transcranial direct-current stimulation (tDCS) can improve force and accuracy in motor tasks but research in surgery is limited to open and laparoscopic tasks in students. More recently, robotic surgery has gained traction and is now the most common approach for certain procedures (e.g. prostatectomy). Early-phase robotic suturing performance is dependent on prefrontal cortex (PFC) activation, and this study aimed to determine whether performance can be improved with prefrontal tDCS.MethodsFifteen surgical residents were randomized to either active then sham tDCS or sham then active tDCS, in two counterbalanced sessions in a double-blind crossover study. Within each session, participants performed a robotic suturing task repeated in three blocks: pre-, intra- and post-tDCS. During the intra-tDCS block, participants were randomized to either active tDCS (2 mA for 15 min) to the PFC or sham tDCS. Primary outcome measures of technical quality included KTS and error scores.ResultsSignificantly faster completion times were observed longitudinally, regardless of active (p < 0.001) or sham stimulation (p < 0.001). KTS was greater following active compared to sham stimulation (median: active = 44.35 N vs. sham = 27.12 N, p < 0.001). A significant reduction in error scores from “pre-” to “post-” (p = 0.029) were only observed in the active group.ConclusiontDCS could reduce error and enhance KTS during robotic suturing and warrants further exploration as an adjunct to robotic surgical training.

Journal article

Teh JJ, Cai W, Kedrzycki M, Thiruchelvam P, Leff D, Elson Det al., 2021, 392 Magseed-guided wide local excision during the COVID-19 pandemic: a tenable solution to barriers in accessing elective breast cancer surgery, Association of Surgeons in Training, Publisher: British Journal of Surgery Society, ISSN: 0007-1323

Conference paper

Gandhewar R, Jiwa N, Leff D, 2021, Improving Confidence and Technique When Preparing Nipple Smears for Cytology, Publisher: OXFORD UNIV PRESS, Pages: 113-113, ISSN: 0007-1323

Conference paper

Che Bakri NA, Kwasnicki RM, Dhillon K, Khan N, Ghandour O, Cairns A, Darzi A, Leff DRet al., 2021, ASO visual abstract: objective assessment of postoperative morbidity following breast cancer treatments with wearable activity monitors: The "BRACELET" study., Annals of Surgical Oncology, Vol: 28, Pages: 1-1, ISSN: 1068-9265

Journal article

Koh A, Parks RM, Courtney A, Leff DRet al., 2021, The Mastitis and Mammary abscess Management Audit (MAMMA), British Journal of Surgery, Vol: 108, Pages: e286-e287, ISSN: 0007-1323

Journal article

Dave RV, Kim B, Courtney A, O'Connell R, Rattay T, Taxiarchi VP, Kirkham JJ, Camacho EM, Fairbrother P, Sharma N, Cartlidge CWJ, Horgan K, McIntosh SA, Leff DR, Vidya R, Potter S, Holcombe C, Copson E, Coles CE, Cutress RI, Gandhi A, Kirwan CC, B-MaP-C study collaborativeet al., 2021, Publisher Correction: Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK 'Alert Level 4' phase of the B-MaP-C study., Br J Cancer, Vol: 125

Journal article

Kedrzycki MS, Leiloglou M, Chalau V, Chiarini N, Thiruchelvam PTR, Hadjiminas DJ, Hogben KR, Rashid F, Ramakrishnan R, Darzi AW, Elson DS, Leff DRet al., 2021, ASO visual abstract: the impact of temporal variation in indocyanine green administration on tumor identification during fluorescence-guided breast surgery, Annals of Surgical Oncology, Vol: 28, Pages: 650-651, ISSN: 1068-9265

Journal article

Che Bakri NA, Kwasnicki RM, Dhillon K, Khan N, Ghandour O, Cairns A, Darzi A, Leff DRet al., 2021, ASO author reflections: Improving management of upper limb complications after breast cancer treatments, Annals of Surgical Oncology, ISSN: 1068-9265

Journal article

Leiloglou M, Kedrzycki MS, Elson DS, Leff DRet al., 2021, ASO author reflections: towards fluorescence guided tumor identification for precision breast conserving surgery., Annals of Surgical Oncology, ISSN: 1068-9265

Journal article

Kedrzycki MS, Leiloglou M, Chalau V, Chiarini N, Thiruchelvam PTR, Hadjiminas DJ, Hogben KR, Rashid F, Ramakrishnan R, Darzi AW, Elson DS, Leff DRet al., 2021, The impact of temporal variation in indocyanine green administration on tumor identification during fluorescence guided breast surgery., Annals of Surgical Oncology, Vol: 28, Pages: 5617-5625, ISSN: 1068-9265

BACKGROUND: On average, 21% of women in the USA treated with Breast Conserving Surgery (BCS) undergo a second operation because of close positive margins. Tumor identification with fluorescence imaging could improve positive margin rates through demarcating location, size, and invasiveness of tumors. We investigated the technique's diagnostic accuracy in detecting tumors during BCS using intravenous indocyanine green (ICG) and a custom-built fluorescence camera system. METHODS: In this single-center prospective clinical study, 40 recruited BCS patients were sub-categorized into two cohorts. In the first 'enhanced permeability and retention' (EPR) cohort, 0.25 mg/kg ICG was injected ~ 25 min prior to tumor excision, and in the second 'angiography' cohort, ~ 5 min prior to tumor excision. Subsequently, an in-house imaging system was used to image the tumor in situ prior to resection, ex vivo following resection, the resection bed, and during grossing in the histopathology laboratory to compare the technique's diagnostic accuracy between the cohorts. RESULTS: The two cohorts were matched in patient and tumor characteristics. The majority of patients had invasive ductal carcinoma with concomitant ductal carcinoma in situ. Tumor-to-background ratio (TBR) in the angiography cohort was superior to the EPR cohort (TBR = 3.18 ± 1.74 vs 2.10 ± 0.92 respectively, p = 0.023). Tumor detection reached sensitivity and specificity scores of 0.82 and 0.93 for the angiography cohort and 0.66 and 0.90 for the EPR cohort, respectively (p = 0.1051 and p = 0.9099). DISCUSSION: ICG administration timing during the angiography phase compared with the EPR phase improved TBR and diagnostic accuracy. Future work will focus on image pattern analysis and adaptation of the camera system to targeting fluorophores specific to breast cancer.

Journal article

Che Bakri NA, Kwasnicki R, Dhillon K, Ghandour O, Khan N, Cairns A, Darzi A, Leff Det al., 2021, Objective assessment of post-operative morbidity following breast cancer treatments with wearable activity monitors, Annals of Surgical Oncology, Vol: 28, Pages: 5597-5606, ISSN: 1068-9265

BackgroundCurrent validated tools to measure upper limb dysfunction after breast cancer treatment, such as questionnaires, are prone to recall bias and do not enable comparisons between patients. This study aimed to test the feasibility of wearable activity monitors (WAMs) for achieving a continuous, objective assessment of functional recovery by measuring peri-operative physical activity (PA).MethodsA prospective, single-center, non-randomized, observational study was conducted. Patients undergoing breast and axillary surgery were invited to wear WAMs on both wrists in the peri-operative period and then complete upper limb function (DASH) and quality-of-life (EQ-5D-5L) questionnaires. Statistical analyses were performed to determine the construct validity and concurrent validity of WAMs.ResultsThe analysis included 39 patients with a mean age of 55 ± 13.2 years. Regain of function on the surgically treated side was observed to be an increase of arm activity as a percentage of preoperative levels, with the greatest increase observed between the postoperative days 1 and 2. The PA was significantly greater on the side not treated by surgery than on the surgically treated side after week 1 (mean PA, 75.8% vs. 62.3%; p < 0.0005) and week 2 (mean PA, 91.6% vs. 77.4%; p < 0.005). Subgroup analyses showed differences in recovery trends between different surgical procedures. Concurrent validity was demonstrated by a significant negative moderate correlation between the PA and DASH questionnaires (R = −0.506; p < 0.05).ConclusionThis study demonstrated the feasibility and validity of WAMs to objectively measure postoperative recovery of upper limb function after breast surgery, providing a starting point for personalized rehabilitation through early detection of upper limb physical morbidity.

Journal article

Kedrzycki MS, Leiloglou M, Ashrafian H, Jiwa N, Thiruchelvam PTR, Elson DS, Leff DRet al., 2021, Meta-analysis comparing fluorescence imaging with radioisotope and blue dye-guided sentinel node identification for breast cancer surgery., Annals of Surgical Oncology, Vol: 28, Pages: 3738-3748, ISSN: 1068-9265

INTRODUCTION: Conventional methods for axillary sentinel lymph node biopsy (SLNB) are fraught with complications such as allergic reactions, skin tattooing, radiation, and limitations on infrastructure. A novel technique has been developed for lymphatic mapping utilizing fluorescence imaging. This meta-analysis aims to compare the gold standard blue dye and radioisotope (BD-RI) technique with fluorescence-guided SLNB using indocyanine green (ICG). METHODS: This study was registered with PROSPERO (CRD42019129224). The MEDLINE, EMBASE, Scopus, and Web of Science databases were searched using the Medical Subject Heading (MESH) terms 'Surgery' AND 'Lymph node' AND 'Near infrared fluorescence' AND 'Indocyanine green'. Studies containing raw data on the sentinel node identification rate in breast cancer surgery were included. A heterogeneity test (using Cochran's Q) determined the use of fixed- or random-effects models for pooled odds ratios (OR). RESULTS: Overall, 1748 studies were screened, of which 10 met the inclusion criteria for meta-analysis. ICG was equivalent to radioisotope (RI) at sentinel node identification (OR 2.58, 95% confidence interval [CI] 0.35-19.08, p < 0.05) but superior to blue dye (BD) (OR 9.07, 95% CI 6.73-12.23, p < 0.05). Furthermore, ICG was superior to the gold standard BD-RI technique (OR 4.22, 95% CI 2.17-8.20, p < 0.001). CONCLUSION: Fluorescence imaging for axillary sentinel node identification with ICG is equivalent to the single technique using RI, and superior to the dual technique (RI-BD) and single technique with BD. Hospitals using RI and/or BD could consider changing their practice to ICG given the comparable efficacy and improved safety profile, as well as the lesser burden on hospital infrastructure.

Journal article

Che Bakri NA, Kwasnicki R, Dhillon K, Ghandour O, Khan N, Cairns A, Darzi A, Leff Det al., 2021, Improving management of upper limb complications after breast cancer treatments, Annals of Surgical Oncology, ISSN: 1068-9265

Journal article

Lee A, Kwasnicki R, Leff D, 2021, Outcomes and outcome measures reported in clinical studies of therapeutic mammaplasty: a systematic review protocol, BMJ Open, Vol: 11, ISSN: 2044-6055

ntroduction Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated oncological safety of TM, but poor and inconsistent reporting of quality-of-life, aesthetic and functional outcomes, often with non-validated measurement tools. Moreover, there is a paucity of patient-reported outcome measures. Standardisation of outcome reporting is required to enable study results to be compared and combined, for example, through core outcome set (COS) development. This systematic review aims to comprehensively describe the outcomes reported in clinical studies of TM, their respective outcome measures and the time points at which they were evaluated. The overall objective is to facilitate the development of a COS for TM.Methods and analysis A systematic review of clinical studies evaluating outcomes following TM will be completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following electronic databases have been searched from inception to 5 August 2020: Ovid MEDLINE, Embase, CINAHL and Web of Science. Primary outcomes will include the number of reported outcomes of various types (clinical, aesthetic, functional, quality-of-life and cost-effectiveness), whether these are patient-reported or clinician-reported, how outcomes are defined and the outcome measurement tool(s) used. The time point(s) at which outcomes were measured will be a secondary outcome. No studies will be excluded on the basis of methodological quality in order to generate a comprehensive list of reported outcomes and outcome measures; hence, risk of bias assessment is not required. The data will be described narratively. This protocol has been reported in line with PRISMA-Protocols.Ethics and dissemination This study does not involve human or animal participants, hence ethical approval is not required. The findings will be p

Journal article

Vidya R, Leff DR, Green M, McIntosh SA, St John E, Kirwan CC, Romics L, Cutress R, Potter S, Carmichael A, Subramanian A, O'Connell R, Fairbrother P, Fenlon D, Benson J, Holcombe Cet al., 2021, Innovations for the future of breast surgery, BRITISH JOURNAL OF SURGERY, Vol: 108, Pages: 908-916, ISSN: 0007-1323

Journal article

Dave RV, Kim B, Courtney A, O'Connell R, Rattay T, Taxiarchi VP, Kirkham JJ, Camacho EM, Fairbrother P, Sharma N, Cartlidge CWJ, Horgan K, McIntosh SA, Leff DR, Vidya R, Potter S, Holcombe C, Copson E, Coles CE, Cutress RI, Gandhi A, Kirwan CC, B-MaP-C study collaborativeet al., 2021, Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK 'Alert Level 4' phase of the B-MaP-C study, British Journal of Cancer, Vol: 124, Pages: 1785-1794, ISSN: 0007-0920

BACKGROUND: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. METHODS: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated 'standard' or 'COVID-altered', in the preoperative, operative and post-operative setting. FINDINGS: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had 'COVID-altered' management. 'Bridging' endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2-9%) using 'NHS Predict'. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. CONCLUSIONS: The majority of 'COVID-altered' management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown.

Journal article

Grant Y, Thiruchelvam P, Al-Mufti R, Hadjiminas D, Hogben K, Leff D, Grant Yet al., 2021, Staged unilateral versus immediate bilateral symmetrising mammoplasty: a sensitivity analysis of patient level costs, EJSO - European Journal of Surgical Oncology, ISSN: 0748-7983

Journal article

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