Publications
245 results found
Che Bakri NA, Kwasnicki RM, Giannas E, et al., 2023, ASO Visual Abstract: The Use of Wearable Activity Monitors to Measure the Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy., Ann Surg Oncol
Kedrzycki M, Elson D, Leff D, 2023, Guidance in breast-conserving surgery: tumour localization versus identification, British Journal of Surgery, Vol: 110, Pages: 920-922, ISSN: 0007-1323
In breast-conserving surgery (BCS), the tumour is removed with the goal of preserving as much healthy breast tissue as possible. Breast conservation comes with a risk of positive resection margins, an independent predictor of ipsilateral tumour recurrence, necessitating reoperation1. Contemporary data from the UK Get it Right First Time1 suggest high average reoperation rates of around 19 %. Current tumour localization techniques can only guide surgeons to the tumour epicentre, but fail to provide identification of the boundary between tumour and normal tissue. Imaging techniques, such as intraoperative ultrasonography (IOUS), intraoperative MRI (iMRI) or fluorescence-guided surgery (FGS), enable visualization of the tumour in its entirety and may provide improved operative precision2–5.
Che Bakri NA, Kwasnicki R, Giannas E, et al., 2023, The Use of Wearable Activity Monitors to Measure the Upper Limb Physical Activity after Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy, Annals of Surgical Oncology, ISSN: 1068-9265
Che Bakri NA, Kwasnicki RM, Giannas E, et al., 2023, ASO author reflections: objective outcome measure of upper limb function following axillary lymph node dissection and sentinel lymph node biopsy, Annals of Surgical Oncology, ISSN: 1068-9265
Shanthakumar D, Leiloglou M, Kelliher C, et al., 2023, A comparison of spectroscopy and imaging techniques utilizing spectrally resolved diffusely reflected light for intraoperative margin assessment in breast-conserving surgery: a systematic review and meta-analysis, Cancers, Vol: 15, ISSN: 2072-6694
Up to 19% of patients require re-excision surgery due to positive margins in breast-conserving surgery (BCS). Intraoperative margin assessment tools (IMAs) that incorporate tissue optical measurements could help reduce re-excision rates. This review focuses on methods that use and assess spectrally resolved diffusely reflected light for breast cancer detection in the intraoperative setting. Following PROSPERO registration (CRD42022356216), an electronic search was performed. The modalities searched for were diffuse reflectance spectroscopy (DRS), multispectral imaging (MSI), hyperspectral imaging (HSI), and spatial frequency domain imaging (SFDI). The inclusion criteria encompassed studies of human in vivo or ex vivo breast tissues, which presented data on accuracy. The exclusion criteria were contrast use, frozen samples, and other imaging adjuncts. 19 studies were selected following PRISMA guidelines. Studies were divided into point-based (spectroscopy) or whole field-of-view (imaging) techniques. A fixed-or random-effects model analysis generated pooled sensitivity/specificity for the different modalities, following heterogeneity calculations using the Q statistic. Overall, imaging-based techniques had better pooled sensitivity/specificity (0.90 (CI 0.76-1.03)/0.92 (CI 0.78-1.06)) compared with probe-based techniques (0.84 (CI 0.78-0.89)/0.85 (CI 0.79-0.91)). The use of spectrally resolved diffusely reflected light is a rapid, non-contact technique that confers accuracy in discriminating between normal and malignant breast tissue, and it constitutes a potential IMA tool.
Dave R, Elsberger B, Taxiarchi V, et al., 2023, Bridging pre-surgical endocrine therapy for breast cancer during the COVID-19 pandemic: outcomes from the B-MaP-C study, BREAST CANCER RESEARCH AND TREATMENT, ISSN: 0167-6806
Che Bakri NA, Kwasnicki R, Khan N, et al., 2023, Impact of axillary lymph node dissection and sentinel lymph node biopsy on upper limb morbidity in breast cancer patients: a systematic review and meta-analysis, Annals of Surgery, Vol: 277, Pages: 572-580, ISSN: 0003-4932
Objective: To evaluate the impact of ALND and SLNB on upper limb (UL) morbidity in breastcancer patients.Summary Background: Axillary de-escalation is motivated by a desire to reduce harm ofALND. Understanding the impact of axillary surgery and disparities in operative procedureson post-operative arm morbidity would better direct resources to the point of need and cementthe need for de-escalation strategies.Methods: Embase, Medline, CINAHL and PsychINFO were searched from 1990 until March2020. Included studies were randomized-controlled and observational studies focusing on ULmorbidities, in breast surgery patients. The study followed the Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of upper limbmorbidity comparing SLNB and ALND at less than 12 months, 12-24 months and beyond 24months were analyzed.Results: Sixty-seven studies were included. All studies reported a higher rate of lymphedemaand pain after ALND compared to SLNB. The difference in lymphedema and pain prevalencebetween SLNB and ALND was 13.7% (95% CI 10.5-16.8, p<0.005) and 24.2% (95% CI 12.1-36.3, p<0.005) respectively. Pooled estimates for prevalence of reduced strength and rangeof motion after SLNB and ALND were 15.2% vs 30.9% and 17.1% vs 29.8% respectively.Type of axillary surgery, greater BMI, and radiotherapy were some of the predictors for ULmorbidities.Conclusions: Prevalence of lymphedema after ALND was higher than previously estimated.ALND patients experienced greater rates of lymphedema, pain, reduced strength, and ROMcompared to SLNB. The findings support the continued drive to de-escalate axillary surgery.
Goble M, Caddick V, Patel R, et al., 2023, Optical neuroimaging and neurostimulation in surgical training and assessment: a state-of-the-art review, Frontiers in Neuroergonomics, Vol: 4, Pages: 1-8, ISSN: 2673-6195
Introduction: Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical neuroimaging technique used to assess surgeons' brain function. The aim of this narrative review is to outline the effect of expertise, stress, surgical technology, and neurostimulation on surgeons' neural activation patterns, and highlight key progress areas required in surgical neuroergonomics to modulate training and performance.Methods: A literature search of PubMed and Embase was conducted to identify neuroimaging studies using fNIRS and neurostimulation in surgeons performing simulated tasks.Results: Novice surgeons exhibit greater haemodynamic responses across the pre-frontal cortex than experts during simple surgical tasks, whilst expert surgical performance is characterized by relative prefrontal attenuation and upregulation of activation foci across other regions such as the supplementary motor area. The association between PFC activation and mental workload follows an inverted-U shaped curve, activation increasing then attenuating past a critical inflection point at which demands outstrip cognitive capacity Neuroimages are sensitive to the impact of laparoscopic and robotic tools on cognitive workload, helping inform the development of training programs which target neural learning curves. FNIRS differs in comparison to current tools to assess proficiency by depicting a cognitive state during surgery, enabling the development of cognitive benchmarks of expertise. Finally, neurostimulation using transcranial direct-current-stimulation may accelerate skill acquisition and enhance technical performance.Conclusion: FNIRS can inform the development of surgical training programs which modulate stress responses, cognitive learning curves, and motor skill performance. Improved data processing with machine learning offers the possibility of live feedback regarding surgeons' cognitive states during operative procedures.
Godden AR, Micha A, O'Connell RL, et al., 2023, Pre-operative Radiotherapy And Deep Inferior Epigastric Artery Perforator (DIEP) flAp study (PRADA): Aesthetic outcome and patient satisfaction at one year., J Plast Reconstr Aesthet Surg, Vol: 78, Pages: 19-28
INTRODUCTION: The optimal combination of radiotherapy and breast reconstruction has not yet been defined. Post-mastectomy radiotherapy (PMRT) has deleterious effects on breast reconstruction, leading to caution amongst surgeons. Pre-operative radiotherapy (PRT) is a growing area of interest, is demonstrated to be safe, and spares autologous flaps from radiotherapy. This study evaluates the aesthetic outcome of PRT and deep inferior epigastric artery perforator (DIEP) flap reconstruction within the Pre-operative Radiotherapy And Deep Inferior Epigastric artery Perforator (DIEP) flAp (PRADA) cohort. METHODS: PRADA was an observational cohort study designed to evaluate the feasibility and safety of PRT for women undergoing neoadjuvant chemotherapy and DIEP reconstruction. Panel evaluation of 3D surface images (3D-SIs) and patient-reported outcome measures (BREAST-Q) for a subset of women in the study were compared with those of a DIEP-PMRT cohort who had undergone DIEP reconstruction and PMRT. RESULTS: Seventeen out of 33 women from the PRADA study participated in this planned substudy. Twenty-eight women formed the DIEP-PMRT cohort (median follow-up 23 months). The median (inter-quartile range [IQR]) 'satisfaction with breasts' score at 12 months for the PRADA cohort was significantly better than the DIEP-PMRT cohort (77 [72-87] versus 64 [54-71], respectively), p=0.01). Median [IQR] panel evaluation (5-point scale) was also significantly better for the PRADA cohort than for the DIEP-PMRT cohort (4.3 [3.9-4.6] versus 3.6 [2.8-4] p=0.003). CONCLUSIONS: Aesthetic outcome for the PRADA cohort was reported to be 'good' or 'excellent' in 93% of cases using a bespoke panel assessment with robust methodology. Patient satisfaction at one year is encouraging and superior to DIEP-PMRT at 23 months. Switching surgery-radiotherapy sequencing leads to similar breast aesthetic outcomes and warrants further large-scale, multi-centre evaluation in a randomised trial.
Wu Z, Reyzabal MDI, Sadati SMH, et al., 2023, Towards a Physics-Based Model for Steerable Eversion Growing Robots, IEEE ROBOTICS AND AUTOMATION LETTERS, Vol: 8, Pages: 1005-1012, ISSN: 2377-3766
Che Bakri NA, Kwasnicki RM, Dhillon K, et al., 2022, ASO author reflections: Improving management of upper limb complications after breast cancer treatments, Annals of Surgical Oncology, Vol: 29, Pages: 566-567, ISSN: 1068-9265
Leiloglou M, Kedrzycki MS, Elson DS, et al., 2022, ASO author reflections: towards fluorescence guided tumor identification for precision breast conserving surgery., Annals of Surgical Oncology, Vol: 29, Pages: 564-565, ISSN: 1068-9265
St John ER, Ezzat A, Holford N, et al., 2022, Digital consent to improve patient perception of shared decision-making: comparative study between paper and digital consent processes in patients undergoing breast surgery, BRITISH JOURNAL OF SURGERY, Vol: 109, Pages: 1172-1173, ISSN: 0007-1323
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Patel R, Suwa Y, Kinross J, et al., 2022, Neuroenhancement of surgeons during robotic suturing, Surgical Endoscopy: surgical and interventional techniques, Vol: 36, Pages: 4803-4814, 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.
Grant Y, Al-Mufti R, Hogben K, et al., 2022, Patient level costs of staged unilateral versus immediate bilateral symmetrisation mammoplasty in breast conserving surgery, Association of Breast Surgery
Leiloglou M, Kedrzycki M, Chalau V, et al., 2022, Indocyanine green fluorescence image processing techniques for breast cancer macroscopic demarcation, Scientific Reports, Vol: 12, ISSN: 2045-2322
Re-operation due to disease being inadvertently close to the resection margin is a major challenge in breast conserving surgery (BCS). Indocyanine green (ICG) fluorescence imaging could be used to visualize the tumor boundaries and help surgeons resect disease more efficiently. In this work, ICG fluorescence and color images were acquired with a custom-built camera system from 40 patients treated with BCS. Images were acquired from the tumor in-situ, surgical cavity post-excision, freshly excised tumor and histopathology tumour grossing. Fluorescence image intensity and texture were used as individual or combined predictors in both logistic regression (LR) and support vector machine models to predict the tumor extent. ICG fluorescence spectra in formalin-fixed histopathology grossing tumor were acquired and analyzed. Our results showed that ICG remains in the tissue after formalin fixation. Therefore, tissue imaging could be validated in freshly excised and in formalin-fixed grossing tumor. The trained LR model with combined fluorescence intensity (pixel values) and texture (slope of power spectral density curve) identified the tumor’s extent in the grossing images with pixel-level resolution and sensitivity, specificity of 0.75 ± 0.3, 0.89 ± 0.2.This model was applied on tumor in-situ and surgical cavity (post-excision) images to predict tumor presence.
Thiruchelvam PTR, Leff DR, Godden AR, et 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
Jiwa N, Ezzat A, holt J, et al., 2022, Nipple aspirate fluid and its use for the early detection of breast cancer, Annals of Medicine and Surgery, Vol: 77, Pages: 1-6, ISSN: 2049-0801
Nipple aspirate fluid is the physiological biofluid lining ductal epithelial cells. Historically, cytology of nipple fluid has been the gold standard diagnostic method for assessment of ductal fluid in patients with symptomatic nipple discharge. The role of biomarker discovery in nipple aspirate fluid for assessment of asymptomatic and high-risk patients is highly attractive but evaluation to date is limited by poor diagnostic accuracy. However, the emergence of new technologies capable of identifying metabolites that have been previously thought unidentifiable within such small volumes of fluid, has enabled testing of nipple biofluid to be re-examined. This review evaluates the use of new technologies to evaluate the components of nipple fluid and their potential to serve as biomarkers in screening.
Ezzat A, Vyas K, Asenov M, et al., 2022, Portable confocal endomicroscopy for ductal feature characterization: Toward margin assessment in breast-conserving surgery, Publisher: SPRINGER, Pages: 190-191, ISSN: 1068-9265
Ezzat A, Vyas K, Holford N, et al., 2022, Systematic review of clinical applications of confocal fluorescence microscopy for intra-operative breast cancer diagnostics, 23rd Annual Meeting of the American-Society-of-Breast-Surgeons, Publisher: SPRINGER, Pages: 189-190, ISSN: 1068-9265
Chauhan H, Jiwa N, Leff D, 2022, Clinico-pathological predictors of positive resection margins, Publisher: SPRINGER, Pages: 191-192, ISSN: 1068-9265
Bakri NAC, Kwasnicki R, Khan N, et 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
Courtney A, Parks R, Wilkins A, et al., 2022, Mastitis and mammary abscess management audit (MAMMA), Publisher: SPRINGER, Pages: 90-91, ISSN: 1068-9265
Shanthakumar D, Elson D, Darzi A, et 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
Shanthakumar D, Chalau V, Darzi A, et al., 2022, Multiwavelength laser induced fluorescence spectroscopy for breast cancer diagnostics, Association of Breast Surgery
Lee A, Kwasnicki R, Hasaan K, et 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
Maier-Hein L, Eisenmann M, Sarikaya D, et al., 2021, Surgical data science-from concepts toward clinical translation, MEDICAL IMAGE ANALYSIS, Vol: 76, ISSN: 1361-8415
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Jiwa N, Kumar S, Gandhewar R, et 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
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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
Teh JJ, Cai W, Kedrzycki M, et 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
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