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R D Macmillan

Publications and source records attributed to R D Macmillan.

At least 19 recordsLinked to original sources
PubMed2006

Accuracy of mammography in predicting histological extent of ductal carcinoma in situ (DCIS).

UNLABELLED: Accuracy of mammography in predicting pathological extent of ductal carcinoma in situ (DCIS). BACKGROUND AND AIMS: Mammographic extent is the main determinant for offering wide local excision (WLE) for DCIS. It is recognized that this is not always accurate. Patients who prove to have larger lesions than predicted require further surgery. The aim of this study was to define the degree of variance between mammographic (MMG) and pathological (path) measurements of DCIS and to analyse the factors predicting a significant discrepancy. METHODS: The pathological and mammographic data for 174 cases of DCIS were reviewed. RESULTS: The mammographic size was bigger than the histological size in 97 (55.7%) and there was >10mm difference in 18 (10.3%) cases. The histological size was bigger than the mammographic size in 69 (39.7%) cases and >10mm difference was found in 30 (17.2%) cases. There was a significant relationship between larger MMG size, MMG size measured in two dimensions (MMG bi-dimensional product) and MMG-path size discrepancy (p<0.01). In addition, the larger the size discrepancy, the greater the chance of requiring more than one therapeutic procedure (p<0.01). There was no significant correlation between age, histological grade, mammographic density and shortest distance from nipple with degree of mammographic-pathological size discrepancy.

Adult↗
PubMed2006

Therapeutic mammaplasty for centrally located breast tumors.

BACKGROUND: Central breast tumors are difficult to manage using breast-conserving treatment. Mastectomy has often been cited as the favored option for these tumors, because lumpectomies that remove the nipple-areola complex often result in poor cosmesis. This article describes the use of therapeutic mammaplasty (a term used to describe breast reduction techniques utilized to treat breast cancer) for centrally sited breast tumors. METHODS: The techniques can be broadly divided into two categories: (1) wedge excision, involving wedge excision and a form of wedge closure, and (2) advancement flaps with nipple reconstruction. RESULTS: These techniques were used in 11 patients. Excision margins were complete in all cases except one, due to extensive ductal carcinoma in situ. There have been no other complications and no cases of recurrence to date. CONCLUSIONS: When compared with mastectomy and total reconstruction, therapeutic mammaplasty has cosmetic, functional, and recovery time advantages. The techniques described need further evaluation and long-term follow-up. However, they can be added to the repertoire of techniques already established for breast-conserving surgery.

Adult↗
PubMed2005

Prognostic value of lymphovascular invasion in women with lymph node negative invasive breast carcinoma.

This study aimed to test the hypothesis that lymphovascular invasion adds prognostic information to histological grade and tumour size in node-negative invasive carcinoma of the breast. Lymphovascular invasion was assessed in haematoxylin and eosin tumour sections from 2760 patients with node-negative invasive breast carcinoma treated with definitive surgery. Patients were divided into two groups: 990 in the no adjuvant therapy series (diagnosed in 1974-1988) with median follow-up of 13 years; and 1765 in the selective adjuvant therapy series (1988-2000) with median follow-up of 6.8 years. Lymphovascular invasion was identified in 19% of tumours and was associated with larger tumour size, higher histological grade and younger age. Overall, survival was associated on multivariate analysis with lymphovascular invasion, histological grade and tumour size in both patient series, and with histological type in the no adjuvant therapy series. In conclusion, lymphovascular invasion is an independent prognostic factor in node-negative breast cancer and should be considered in decisions about adjuvant treatment in this group of women.

Adult↗
PubMed2005

Therapeutic mammaplasty--analysis of 50 consecutive cases.

This is a descriptive analysis of 50 consecutive cases of therapeutic mammaplasty, the use of reduction mammaplasty and radiotherapy to treat breast tumours. Breast cancers may lie within the normal excision site of a recognised mammaplasty method (scenario A) or outside of the expected excision sites (scenario B), then requiring a modified mammaplasty. A third group are central tumours requiring removal of the nipple. This series includes 13 scenario A, 27 scenario B and 10 central tumours. Wise pattern skin incision was used in 29 (58%) and vertical in 14 (28%). Seven different pedicles were employed but inferior (11), superior (9) and superio-medial (19) comprised the majority (78%). In the 27 scenario B cases an extension of the nipple aereolar pedicle was used to fill the tumour defect in 19 (70%) and a secondary pedicle in 8 (30%). There were no incomplete excisions of invasive tumour but incomplete excision of DCIS requiring mastectomy occurred in 4 (8%) patients. There are no deaths or recurrences to date (mean follow-up 13 months, range 3-32). Complications have occurred in 8 (16%) with a return to theatre for one complication (2%) and the four patients (8%) requiring mastectomy. No patient has had a delay in adjuvant treatment. Cosmetic outcome was deemed good/excellent in 63%, satisfactory in 33%, poor in 4%. Follow-up is restricted to 3-32 months.

Adult↗
PubMed2005

Planning and use of therapeutic mammoplasty--Nottingham approach.

Therapeutic mammaplasty, the use of reduction mammaplasty and radiotherapy to surgically treat breast cancer, is an established technique for selected breast cancers and can extend the role of breast conserving surgery. Most frequently described is the use of a wise pattern reduction for tumours that lie within the expected mammaplasty excision. However, mammaplasty techniques can be safely adapted to treat patients with cancers in all areas of the breast. An approach to selection and planning surgery is presented which has evolved from the experience of other units and our first 50 clinical cases over a 3-year period. The outcomes of these 50 cases are found in the accompanying article. Technique will vary depending upon the tumour position. Breast cancers may lie within the normal excision site of a recognised mammaplasty method (scenario A) or outside of the expected excision sites (scenario B). In scenario A, a range of recognised techniques can be performed without adaptation to widely excise the tumour and re-shape the breasts. In scenario B the techniques need to be adapted. Three decisions are needed for planning in scenario B; the skin incision, the nipple-aereola complex (NAC) pedicle orientation and finally the method of filling the cancer defect. The latter can be achieved by either extending the nipple pedicle or by creating a secondary pedicle within the breast dissection. Either method will move tissue that is normally excised into the cancer defect. For central tumours an inferior pedicle is usually used to both fill the defect and re-create the nipple.

Adult↗
PubMed2005

Oncological and cosmetic outcomes of oncoplastic breast conserving surgery.

BACKGROUND: Breast-conserving surgery and radiotherapy is firmly established as a good and safe option for most women with early breast cancer. The important outcome measures of breast conservation are survival, local recurrence, cosmesis and patient satisfaction. Partial breast reconstructive techniques may improve cosmesis and patient satisfaction without compromising the oncological outcomes. METHODS: A search of the Medline and Pubmed databases of studies on breast conserving surgery where partial breast reconstructive techniques were employed. The keywords used were breast conserving surgery, oncoplastic breast surgery, partial breast reconstruction and reduction mammoplasty. The oncological and cosmetic outcomes of these studies were analysed. RESULTS: Studies on partial breast reconstructive techniques often lack oncological outcomes and long-term results are not available. On intermediate follow-up (up to 4.5 years) local recurrence rates vary from 0 to 1.8% per year. Cosmetic failure rates vary from 0 to 18%. To date, detailed studies are small and outcome measures vary. CONCLUSIONS: Breast surgeons should be aware of the range of surgical techniques that may enhance the aesthetic results of breast-conserving surgery as well as expand the indications for its use. There is a need for routine assessment of oncological and cosmetic outcomes and long-term results of partial breast reconstructive techniques in relation to these outcomes are awaited.

Breast Neoplasms↗
PubMed2004

Randomized clinical trial comparing radioisotope occult lesion localization and wire-guided excision for biopsy of occult breast lesions.

BACKGROUND: Accurate localization of impalpable breast lesions that require biopsy is important. This randomized trial compared radioisotope occult lesion localization (ROLL) with the standard hooked-wire technique. METHODS: Ninety-five patients were randomized to receive either ROLL or wire localization of an occult breast lesion. Correct placement of isotope was confirmed by mammography and a hand-held gamma probe was used to guide the surgical excision. Radiological, surgical and pathological data were compared for accuracy, duration and ease of technique, and histopathological diagnosis. Procedure-related pain was also assessed. RESULTS: Of the 95 patients entered, 48 were randomized to ROLL and 47 to wire localization. Two ROLL procedures failed. Marking was accurate in 46 of 48 ROLL procedures and 44 of 47 of wire localizations (P = 0.242). Difficulty in localization (Likert score 2.6 for ROLL versus 4.4 for wire localization; P < 0.001) and the degree of surgical difficulty (2.6 versus 4.0; P < 0.001) were significantly less for ROLL. ROLL was associated with less pain (score 2.7 versus 3.6; P = 0.012). There were no significant differences in mean duration of operation, specimen weight, need for intraoperative re-excision or second therapeutic operation. CONCLUSION: ROLL and wire-guided localization were similarly effective for breast biopsy, but ROLL was easier for both radiologist and surgeon, and less painful for the patient.

Biopsy↗
PubMed2004

Breast imaging findings in women with BRCA1- and BRCA2-associated breast carcinoma.

AIM: To document the breast imaging findings of women with BRCA1 and BRCA2-associated breast carcinoma. MATERIALS AND METHODS: Family history clinic records identified 18 BRCA1 and 10 BRCA2 cases who collectively were diagnosed with 27 invasive breast carcinomas and four ductal carcinoma in situ (DCIS) lesions. All underwent pre-operative imaging (29 mammogram and 22 ultrasound examinations). All invasive BRCA-associated breast carcinoma cases were compared with age-matched cases of sporadic breast carcinoma. RESULTS: Within the BRCA cases the age range was 26-62 years, mean 36 years. Two mammograms were normal and 27 (93%) abnormal. The most common mammographic features were defined mass (63%) and microcalcifications (37%). Thirty-four percent of women had a dense mammographic pattern, 59% mixed and 7% fatty. Ultrasound was performed in 22 patients and in 21 (95%) indicated a mass. This was classified as benign in 24%, indeterminate in 29% and malignant in 48%. Mammograms of BRCA1-associated carcinomas more frequently showed a defined mass compared with BRCA2-associated carcinomas, 72 versus 36% (73% control group) whilst mammograms of BRCA2-associated carcinomas more frequently showed microcalcification, 73 versus 12% (8% control group; p < 0.001). Thirty-six percent of the BRCA2-associated carcinomas were pure DCIS while none of the BRCA1 associated carcinomas were pure DCIS (p = 0.004). Of those patients undergoing regular mammographic screening, 100% of BRCA2-associated carcinomas were detected compared with 75% of BRCA1-associated carcinomas. CONCLUSION: These data suggest that the imaging findings of BRCA1 and BRCA2-associated carcinomas differ from each other and from age-matched cases of sporadic breast carcinoma.

Adult↗
PubMed2004

Woman feels breast lump--surgeon cannot: the role of ultrasound in arbitration.

The role of ultrasound scanning (USS) in patients complaining of a breast lump where the clinical examination (CE) is normal is not clearly defined. To determine this in greater detail, all patients complaining of a breast lump underwent CE. Where no lump could be found, but was still reported by the patient, an USS was performed. All lesions underwent biopsy and/or aspiration, as well as mammography in suspicious cases or those over 40 years of age. This cohort represented 5% of all referrals in the study period. Four hundred and twenty women were prospectively studied in this way. Median follow up is 3.4 years (range 2.5-4.2 years). Twenty two had solid lumps (of which 3 were cancers) and 48 had cysts. Nineteen patients re-presented with symptoms in the same breast (median time = 12 months (range 4.5-20 months), all of which were imaged on USS: 15 cysts and 4 further cancers (3 in the same quadrant as the original lump, one contralateral) were identified. Women with symptomatic breast lumps and a normal CE can be considered a reliable indication that cancer is very unlikely to be present (negative predictive value = 0.98). Ultrasound may be a suitable complimentary investigation, which will relieve symptoms in those with cysts and can detect small clinically--and sometimes mammographically--occult breast cancers.

Adolescent↗
PubMed2004

Are medullary breast cancers an indication for BRCA1 mutation screening? A mutation analysis of 42 cases of medullary breast cancer.

Recommended guidelines have limited breast cancer gene ( BRCA1 ) mutation testing to individuals with a personal or family history of early onset breast and/or ovarian cancer, and those with multiple affected close relatives. Such large breast cancer families are rare in the general population, limiting the clinical application of the BRCA1 discovery. Previous reports have suggested an association between medullary breast cancer and BRCA1 mutation carriers. To test the feasibility of using these rare histological subtypes as an alternative to epidemiological factors, 42 cases of medullary cancer unselected for family history were screened for BRCA1 point mutations and large exon rearrangements. The large majority (83%) of these patients did not have significant family of breast or ovarian cancer. Two deleterious mutations resulting in a premature stop codon, and one exon 13 duplication were found. All mutations were detected in patients with typical medullary cancer, who had family history of multiple breast and ovarian cancers. Our findings suggest that medullary breast cancers are not an indication for BRCA1 mutation screening in the absence of significant family risk factors.

Breast Neoplasms↗
PubMed2003

Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer.

The purpose of this study was to examine the use of ultrasound (US)-guided core biopsy of axillary nodes in patients with operable breast cancer. The ipsilateral axillae of 187 patients with suspected primary operable breast cancer were scanned. Nodes were classified based on their shape and cortical morphology. Abnormal nodes underwent US-guided core biopsy/fine needle aspiration (FNA), and the results correlated with subsequent axillary surgery. The nodes were identified on US in 103 of 166 axillae of patients with confirmed invasive carcinoma. In total, 54 (52%) met the criteria for biopsy: 48 core biopsies (26 malignant, 20 benign node, two normal) and six FNA were performed. On subsequent definitive histological examination, 64 of 166 (39%) had axillary metastases. Of the 64 patients with involved nodes at surgery, preoperative US identified nodes in 46 patients (72%), of which 35 (55%) met the criteria for biopsy and 27 (42%) of these were diagnosed preoperatively by US-guided biopsy. In conclusion, US can identify abnormal nodes in patients presenting with primary operable breast cancer. In all, 65% of these nodes are malignant and this can often be confirmed with US-guided core biopsy.

Adult↗
PubMed2003

Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised.

BACKGROUND: The cosmetic outcome after breast-conserving surgery correlates with psychosocial adjustment. Previous studies have shown that, among other factors, cosmesis is dependent on breast size and weight of the wide local excision specimen. This study assessed cosmetic outcome relative to a combination of these factors-the estimated percentage of breast volume excised (EPBVE). METHODS: The study group consisted of 151 women who had undergone breast-conserving surgery. All had previously completed a patient satisfaction questionnaire and an independent panel had assessed cosmetic outcome. Their mammograms were reviewed and breast volume was estimated. A validation series showed cone volume on the oblique mammogram to predict true breast weight most accurately (r = 0.93). RESULTS: Both subjective cosmetic assessment and patient satisfaction correlated strongly with EPBVE. Overall, when the EPBVE was below 10 per cent, 83.5 per cent of patients were very satisfied with their appearance and only 3.1 per cent were not satisfied, compared with 37.0 and 16.7 per cent respectively if the EPBVE was more than 10 per cent. However, tumour location in the breast was also an important factor; cosmetic outcome was worse for medial tumours. CONCLUSION: The percentage of breast volume excised was an important determinant of cosmesis and patient satisfaction after breast-conserving surgery. Calculating the EPBVE before surgery may help select women in whom breast reshaping or volume replacement should be considered.

Adult↗
PubMed2003

Prognostic significance of BRCA1 expression in sporadic breast carcinomas.

BRCA1 is a tumour suppresser gene frequently mutated in familial breast cancer and thought to influence the progression of sporadic breast cancer. Decreased BRCA1 mRNA and protein expression has been identified in breast cancer cell lines and sporadic breast tumours. Here the prognostic significance of reduced BRCA1 protein expression is investigated in primary operable breast cancer. Immunohistochemical analysis was used to determine the level of BRCA1 protein expression in 100 breast cancers. BRCA1 expression was compared with known prognostic factors and survival to investigate its prognostic significance. BRCA1 nuclear expression was reduced by varying amounts in breast carcinomas. A progressive loss of BRCA1 expression correlated well with higher histological grade (p = 0.002) and an excess of medullary/atypical medullary/grade 3 ductal carcinomas (p = 0.0001). When adjusted for grade, patients with loss of BRCA1 expression had a significantly longer disease-free survival time. Loss of BRCA1 expression associated with high-grade breast tumours suggests that BRCA1 may play an important role in the pathogenesis of sporadic breast cancer.

Adult↗
PubMed2003

Incidence of clinically significant lymphoedema as a complication following surgery for primary operable breast cancer.

There has recently been considerable interest for the need for specialist lymphoedema nurses to be appointed in the NHS. However, we had noticed in our cancer follow-up clinics that the incidence of lymphoedema appeared to be very low. Treatment for primary breast cancer (>5 cm) has been surgery and low axillary sampling (ANS). Radiotherapy (RT) or axillary clearance is subsequently performed in patients found to be node positive. The patients are followed-up in the primary breast cancer (PBC) clinic weekly. Follow-up is initially at 3-month intervals up to 2 years and then 1 yearly indefinitely. We conducted a two phased study in patients being followed up in our post cancer clinic in order to identify the incidence of LE in these patients. Phase 1 involved symptomatic patients identified at routine follow up in a 15-week period and the number of patients reporting arm swelling was recorded. The aim of this was to provide an estimate to power a phase 2 study (prospective questionnaire based). Phase 2 was conducted over a 13-week period. All patients attending the clinic were administered modified FACT B4, EQ-50 and Speilberger questionnaires. A total of 1242 patients were examined and lymphoedema found in 5 (0.04%). Of these 5, 3 had undergone axillary clearance, 1 ANS plus radiotherapy and only 1 had ANS alone. A policy of ANS, with prophylactic treatment for lymph node positivity either by surgery or RT alone, gives a very low rate of lymphoedema.

Arm↗
PubMed2003

Size of invasive breast cancer and risk of local recurrence after breast-conservation therapy.

Risk of local recurrence is one important factor that determines a woman's suitability for breast-conservation therapy. With the evolution of oncoplastic surgery, tumours of a size that traditionally require mastectomy may be treated by breast conservation and partial breast reconstruction. This article reviews the evidence relating to tumour size as a risk factor for local recurrence to assess whether this change in practice is appropriate. A literature review through Medline and Pubmed was performed. All pathological studies analysing tumour size as a predictor of multifocality and all randomised trials and large case series of breast conservation including tumours larger than 2 cm were reviewed and critically interpreted. Pathological studies report consistent evidence that tumour size is not predictive of multifocality. Randomised trials and clinical series of breast conservation report conflicting evidence relating to tumour size as a risk factor for local recurrence, although most studies report no association. Evidence relating to cancers over 3 cm is limited. There is little evidence to justify the use of tumour size alone as an exclusion criterion for breast-conservation therapy. A registration study of patients with cancers larger than 3 cm treated by breast conservation with or without partial breast reconstruction is proposed.

Breast Neoplasms↗