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1.	Aristokleous, Iliana, et al. (author) Effect of standardised surgical assessment and shared decision-making on morbidity and patient satisfaction after breast conserving therapy : A cross-sectional study 2023 In: European Journal of Surgical Oncology. - : Elsevier. - 0748-7983 .- 1532-2157. ; 49:1, s. 60-67 Journal article (peer-reviewed)abstract Background: The role of oncoplastic breast conserving therapy (OPBCT) on physical function, morbidity and patient satisfaction has yet to be defined. Additionally, technique selection should be individualised and incorporate patient preference. The study aim was to investigate differences between "standard" (sBCT) and oncoplastic breast conservation (OPBCT) in patient-reported outcomes (PROs) when patients have been assessed in a standardised manner and technique selection has been reached through shared decision-making (SDM).Methods: This is a cross-sectional study of 215 women treated at a tertiary referral centre. Standardised surgical assessment included breast and lesion volumetry, definition of resection ratio, patient-related risk factors and patient preference. Postoperative morbidity and patient satisfaction were assessed by validated PROs tools (Diseases of the Arm, Shoulder and Hand-DASH and Breast-Q). Patient experience was assessed by semi-structured interviews.Results: There was no difference of the median values between OPBCT and sBCT in postoperative morbidity of the upper extremity (DASH 3.3 vs 5, p = 0.656) or the function of the chest wall (Breast-Q 82 vs 82, p = 0.758). Postoperative satisfaction with breasts did not differ either (Breast-Q 65 vs 61, p = 0.702). On the individual level, women that opted for OPBCT after SDM had improved satisfaction when compared to baseline (+3 vs -1, p = 0.001). Shared decision-making changed patient attitude in 69.8% of patients, leading most often to de-escalation from mastectomy.Conclusions: These findings support that a combination of standardised surgical assessment and SDM allows for tailored treatment and de-escalation of oncoplastic surgery without negatively affecting patient satisfaction and morbidity.
2.	Banys-Paluchowski, Maggie, et al. (author) Localization Techniques for Non-Palpable Breast Lesions : Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411) 2023 In: Cancers. - : MDPI. - 2072-6694. ; 15:4 Research review (peer-reviewed)abstract Background: Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics.Methods: We performed a systematic review on localization techniques for non-palpable breast cancer.Results: For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons’ and radiologists’ attitudes towards these techniques.Conclusions: Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.Simple summaryMost breast cancers are small and can be treated using breast-conserving surgery. Since these tumors are non-palpable, they require a localization step that helps the surgeon to decide which tissue needs to be removed. The oldest localization technique is a guidewire placed into the tumor before surgery, usually using ultrasound or mammography. Afterwards, the surgeon removes the tissue around the wire tip. However, this technique has several disadvantages: It can cause the patient discomfort, requires a radiologist or another professional specialized in breast diagnostics to perform the procedure shortly before surgery, and 15–20% of patients need a second surgery to completely remove the tumor. Therefore, new techniques have been developed but most of them have not yet been examined in large, prospective, multicenter studies. In this review, we discuss all available techniques and present the MELODY study that will investigate their safety, with a focus on patient, surgeon, and radiologist preference.
3.	Catanuto, Giuseppe, et al. (author) Natural Language Processing to Extract Meaningful Information from a Corpus of Written Knowledge in Breast Cancer : Transforming Books into Data 2023 In: Breast Care. - : S. Karger AG. - 1661-3791 .- 1661-3805. ; 18:3, s. 209-212 Journal article (peer-reviewed)abstract Introduction: Books and papers are the most relevant source of theoretical knowledge for medical education. New technologies of artificial intelligence can be designed to assist in selected educational tasks, such as reading a corpus made up of multiple documents and extracting relevant information in a quantitative way.Methods: Thirty experts were selected transparently using an online public call on the website of the sponsor organization and on its social media. Six books edited or co-edited by members of this panel containing a general knowledge of breast cancer or specific surgical knowledge have been acquired. This collection was used by a team of computer scientists to train an artificial neural network based on a technique called Word2Vec.Results: The corpus of six books contained about 2.2 billion words for 300d vectors. A few tests were performed. We evaluated cosine similarity between different words.Discussion: This work represents an initial attempt to derive formal information from textual corpus. It can be used to perform an augmented reading of the corpus of knowledge available in books and papers as part of a discipline. This can generate new hypothesis and provide an actual estimate of their association within the expert opinions. Word embedding can also be a good tool when used in accruing narrative information from clinical notes, reports, etc., and produce prediction about outcomes. More work is expected in this promising field to generate "real-world evidence." (c) 2023 S. Karger AG, Basel
4.	Catanuto, G., et al. (author) Text mining and word embedding for classification of decision making variables in breast cancer surgery 2022 In: European Journal of Surgical Oncology. - : Elsevier. - 0748-7983 .- 1532-2157. ; 48:7, s. 1503-1509 Journal article (peer-reviewed)abstract IntroductionDecision making in surgical oncology of the breast has increased its complexity over the last twenty years.This Delphi survey investigates the opinion of an expert panel about the decision making process in surgical procedures on the breast for oncological purposes.MethodsTwenty-seven experts were invited to partake into a Delphi Survey. At the first round they have been asked to provide a list of features involved in the decision making process (patient's characteristics; disease characteristics; surgical techniques, outcomes) and comment on it. Using text-mining techniques we extracted a list of mono-bi-trigrams potentially representative of decision drivers. A technique of “natural language processing” called Word2vec was used to validate changes to texts using synonyms and plesionyms. Word2Vec was also used to test the semantic relevance of n-grams within a corpus of knowledge made up of books edited by panel members. The final list of variables extracted was submitted to the judgement of the panel for final validation at the second round of the Delphi using closed ended questions.Results52 features out of 59 have been approved by the panel. The overall consensus was 87.1%ConclusionsText mining and natural language processing allowed the extraction of a number of decision drivers and outcomes as part of the decision making process in surgical oncology on the breast. This result was obtained transforming narrative texts into structured data. The high level of consensus among experts provided validation to this process.
5.	Charalampoudis, Petros, et al. (author) Neoadjuvant chemotherapy for early breast cancer 2018 In: The Lancet Oncology. - 1470-2045 .- 1474-5488. ; 19:3, s. E128-E128 Journal article (other academic/artistic)
6.	Daskalakis, Kosmas, et al. (author) Association of a Prophylactic surgical approach to Stage IV Small Intestinal Neuroendocrine Tumors with Survival. 2018 In: JAMA Oncology. - : American Medical Association (AMA). - 2374-2437 .- 2374-2445. ; 4:2, s. 183-189 Journal article (peer-reviewed)abstract Importance: Primary tumor resection and mesenteric lymph node dissection in asymptomatic patients with stage IV Small Intestinal Neuroendocrine Tumors (SI-NETs) is controversial.Objective: To determine whether locoregional surgery performed at diagnosis in asymptomatic SI-NETs patients with distant metastases affects overall survival (OS), morbidity and mortality, length of hospital stay (LOS) and re-operation rates.Design: This investigation was a cohort study of asymptomatic patients with stage IV SI-NET, diagnosed between 1985 and 2015, using the prospective Uppsala database of SI-NETs and the Swedish National Patient Register. Patients included were followed until May 2016 and divided to a first group, which underwent Prophylactic Upfront Surgery within six months from diagnosis Combined with Oncological treatment (PUSCO group) and a second group, which was either treated non-surgically or operated later (Delayed Surgery As Needed Combined with Oncological treatment [DSANCO group]).Setting: A tertiary referral center with follow-up data from the Swedish National Patient Register.Participants: We included 363 stage IV SI-NET patients without any abdominal symptoms within 6 months from diagnosis, treated either with PUSCO (n=161) or DSANCO (n=202).Exposure: PUSCO vs DSANCO.Main Outcomes and Measures: Overall survival (OS), length of hospital stay (LOS), postoperative morbidity and mortality and re-operation rates measured from baseline. Propensity score match was performed between the two groups.Results: Two isonumerical groups (n=91) occurred after propensity score matching. There was no difference between groups in OS (PUSCO median 7.9 vs DSANCO 7.6 years; [hazard ratio] HR, 0.98; [95% CI, 0.70-1.37]; log-rank P=.93) and cancer-specific survival (median 7.7 vs 7.6 years, HR, 0.99; [95%CI, 0.71-1.40]; log-rank P=.99). There was no difference in 30-day mortality (0% in both matched groups) or postoperative morbidity (2% vs 1%; P>.99), LOS (median 73 vs 76 days; P=.64), LOS due to local tumor-related symptoms (median 7 vs 11.5 days; P=.81) or incisional hernia repairs (4% in both groups; P>.99). Patients from the PUSCO group underwent more re-operative procedures (14%) compared to the DSANCO group (3%) due to intestinal obstruction (P< .001).Conclusion: Prophylactic upfront locoregional surgery confers no survival advantage in asymptomatic stage IV SI-NET patients. Delayed surgery as needed seems to be comparable in all examined outcomes, whilst offering the advantage of less re-operations for intestinal obstruction. The value of a priori locoregional surgery in the presence of distant metastases is challenged and needs to be elucidated in a randomized controlled study.
7.	Daskalakis, Kosmas, et al. (author) Clinical signs of fibrosis in small intestinal neuroendocrine tumours 2017 In: British Journal of Surgery. - : John Wiley & Sons. - 0007-1323 .- 1365-2168. ; 104:1, s. 69-75 Journal article (peer-reviewed)abstract BACKGROUND: In patients with small intestinal neuroendocrine tumours (SI-NETs), serotonin and other cytokines released from tumour cells may induce fibrosis, leading to carcinoid heart disease and abdominal fibrotic reactions. The aim of this study was to assess the prevalence, clinical complications and management of this reaction in the abdomen.METHODS: This was a retrospective cohort study of patients with SI-NETs diagnosed between 1985 and 2015. Clinical data, outcomes, radiological findings, and surgical and radiological interventions were reviewed.RESULTS: A total of 824 patients were diagnosed with SI-NETs in the study interval. Clinically significant abdominal signs and symptoms of fibrosis occurred in 36 patients. Of these, 20 had critically symptomatic central mesenteric fibrosis causing obstruction of mesenteric vessels, and 16 had retroperitoneal fibrosis causing obstructive uropathy with hydronephrosis. Extensive fibrosis causing mesenteric vessel obstruction and/or obstructive uropathy was more often associated with symptomatic and advanced disease encompassing lymph node metastases in the mesenteric root, para-aortic lymph node metastases, as well as liver metastases and peritoneal carcinomatosis. Palliative intervention in terms of superior mesenteric vein stenting or resection of central mesenteric metastases and/or percutaneous nephrostomy and J stent treatment was beneficial in the majority of the patients.CONCLUSION: Extensive abdominal fibrosis associated with clinically significant symptoms of intestinal ischaemia and/or obstructive uropathy was linked to advanced disease in patients with SI-NETs. Prompt recognition and minimally invasive intervention was effective in disease palliation.
8.	Daskalakis, Kosmas, et al. (author) Ex vivo activity of cytotoxic drugs and targeted agents in Small Intestinal NETs Other publication (other academic/artistic)abstract Introduction: Small Intestinal Neuroendocrine Tumours (SI-NET) are considered to be generally resistant to systemic treatment. To date predictive markers for drug activity are lacking.Patients and Methods: Tumour samples from 27 patients with SI-NET were analyzed ex vivo for sensitivity to a panel of cytotoxic drugs and targeted agents using a short-term total cell kill assay. Samples of renal cancer, colorectal cancer (CRC), ovarian cancer, and chronic lymphocytic leukemia (CLL) were included for comparison. For the SI-NET subset, drug sensitivity was analyzed in relation to clinico-pathological variables and pre-treatment biomarkers.Results: For standard cytotoxic drugs, SI-NETs demonstrated similar or higher sensitivity to 5-FU, platinums, gemcitabine and doxorubicin compared with CRC. For targeted kinase inhibitors, SI-NET was among the most sensitive diagnoses. CLL and ovarian cancer were generally the most sensitive diagnoses to both cytotoxic drugs and protein kinase inhibitors. The mTOR inhibitor sirolimus exhibited modest cytotoxic activity.Individual SI-NET samples demonstrated great variability in ex vivo sensitivity for most drugs. Cross-resistance between different drugs also varied considerably, being higher among protein kinase inhibitors.Age, stage, grade, peritoneal carcinomatosis and extra-abdominal metastases as well as serum chromogranin A and urine 5-HIAA concentrations at diagnosis did not correlate to drug sensitivity ex vivo.Conclusions: SI-NETs exhibit variable but generally intermediate sensitivity ex vivo to cytotoxic and targeted drugs. Clinico-pathological factors and currently used biomarkers were not clearly associated to ex vivo sensitivity, challenging these criteria for treatment decisions in SI-NETs. The great variability in drug sensitivity calls for individualized selection of therapy.
9.	Daskalakis, Kosmas, et al. (author) Ex Vivo Activity of Cytotoxic Drugs and Targeted Agents in Small Intestinal Neuroendocrine Tumors 2018 In: Neuroendocrinology. - : S. Karger AG. - 0028-3835 .- 1423-0194. ; 106:Supplement: 1, s. 189-189 Journal article (other academic/artistic)
10.	Daskalakis, Kosmas, et al. (author) Ex vivo activity of cytotoxic drugs and targeted agents in small intestinal neuroendocrine tumors 2018 In: Endocrine-Related Cancer. - 1351-0088 .- 1479-6821. ; 25:4, s. 471-480 Journal article (peer-reviewed)abstract Small intestinal neuroendocrine tumors (SI-NETs) are generally considered resistant to systemic treatment. To date, predictive markers for drug activity are lacking. Tumor samples from 27 patients with SI-NETs were analyzed ex vivo for sensitivity to a panel of cytotoxic drugs and targeted agents using a short-term total cell kill assay. Samples of renal cancer, colorectal cancer (CRC), ovarian cancer and chronic lymphocytic leukemia (CLL) were included for comparison. For the SI-NET subset, drug sensitivity was analyzed in relation to clinicopathological variables and pre-treatment biomarkers. For cytotoxic drugs, SI-NETs demonstrated similar or higher sensitivity to 5-FU, platinum, gemcitabine and doxorubicin compared with CRC. For several of the targeted kinase inhibitors, SI-NET was among the most sensitive solid tumor types. CLL and ovarian cancer were generally the most sensitive tumor types to both cytotoxic drugs and protein kinase inhibitors. SI-NET was more sensitive to the mTOR inhibitor sirolimus than the other solid tumor types tested. Individual SI-NET samples demonstrated great variability in ex vivo sensitivity for most drugs. Cross-resistance between different drugs also varied considerably, being higher among protein kinase inhibitors. Age, stage, grade, peritoneal carcinomatosis and extra-abdominal metastases as well as serum chromogranin A and urine 5-HIAA concentrations at diagnosis did not correlate to drug sensitivity ex vivo. SI-NETs exhibit intermediate sensitivity ex vivo to cytotoxic and targeted drugs. Clinicopathological factors and currently used biomarkers are not clearly associated to ex vivo sensitivity, challenging these criteria for treatment decisions in SI-NET. The great variability in drug sensitivity calls for individualized selection of therapy.
11.	Daskalakis, Kosmas, et al. (author) Midkine Is a New Novel Serum Biomarker in Small Intestinal Neuroendocrine Tumors (SI-NETs) 2016 In: Neuroendocrinology. - 0028-3835 .- 1423-0194. ; 103, s. 45-45 Journal article (peer-reviewed)
12.	Hersi, Abdi-Fatah, et al. (author) A combined, totally magnetic technique with a magnetic marker for non-palpable tumour localization and superparamagnetic iron oxide nanoparticles for sentinel lymph node detection in breast cancer surgery 2019 In: European Journal of Surgical Oncology. - : Elsevier BV. - 0748-7983 .- 1532-2157. ; 45:4, s. 544-549 Journal article (peer-reviewed)abstract Background: Surgery for non-palpable breast cancer may often be a challenging procedure. Recently, a magnetic seed (Magseed®) used for tumour localization has been developed. Superparamagnetic iron oxide nanoparticles (SPIO) for sentinel lymph node (SN) detection is a novel tracer that may be injected up to four weeks preoperatively. This study is the first combining the magnetic seed and SPIO.Material and methods: Patients planned for breast conserving surgery and SN-biopsy (SNB) were recruited from two units in Sweden. Patients underwent lesion localization with Magseed® and SPIO injection (Magtrace™) by the breast radiologist in the preoperative period. Feasibility of successful lesion localization and excision together with a successful SNB detection was evaluated. Seed migration, number of SNs, specimen volume and calculated resection ratio (CRR) were reported.A survey of the physicians’ experience was conducted.Results: Localization was performed at a median of three days before surgery (range 0–25). All 32 patients underwent microscopically radical resection with a CRR of 1.49. No seed migration was noticed. SNB was successful in all patients. A median of two SNs was retrieved. Radiologists and surgeons reported the procedure easy to learn and outperformed guidewire localization in terms of localization and excision time. They thought the technique facilitated planning localization and surgery.Conclusions: The combined magnetic technique provided accuracy in tumour localization and SN detection without excess tissue excision and with promising results for flexibility in delivery of care. Larger studies are needed to confirm these findings.
13.	Hersi, Abdi-Fatah, 1989-, et al. (author) A Randomised Clinical Trial comparing Magseed® with Guide Wire localization in nonpalpable breast cancer scheduled for Magtrace® assisted sentinel lymph node biopsy: The MagTotal RCT Other publication (other academic/artistic)abstract Guidewire localization is widely regarded as the gold standard method of localizing non-palpable breast tumors even though it has drawbacks. Magnetic seed (magseed®) localization is a safe and feasible alternative for localizing and excising non-palpable breast tumors. The combination of magnetic seed localization together with superparamagnetic iron oxide nanoparticles (SPIO) for breast cancer scheduled for breast-conserving surgery (BCS) together with sentinel lymph node biopsy (SLNB) have also been reported. In this multicentre randomized pilot study, we aimed to compare localization with either Magseed® or guidewire in breast cancer patients scheduled for BCS + SLNB between September 2018 and May 2021. All patients received SPIO peritumoral and preoperatively for identification of the sentinel lymph nodes (SLN). If randomized to magseed® localization (n = 91) the patient received it by the radiologist up until 30 days before surgery and if allocated to guidewire localization (n = 116) the patient received it on the day of the surgery. All patients were injected with SPIO, ultrasound guided by radiologist if allocated to magnetic seed or by the surgeon if allocated to guidewire, up until 30 days before surgery. Primary endpoint was reoperation rate due to positive margins. In 207 patients (n = 91 in magseed and n = 116 in guidewire) there was no significant difference in reoperation rate (3.3% in magseed vs 7% in guidewire group, p = 0.354). Furthermore, there was no significant difference in SLN detection rate (97.8% vs 100%, p = 0.187) and both groups had comparable mean number of SLNs retrieved (2.52 vs 2.62 nodes, p = 0.763). Magnetic seed localization together with SPIO for SLNB is a viable and safe alternative to guidewire localization.
14.	Hersi, Abdi-Fatah, et al. (author) Optimizing Dose and Timing in Magnetic Tracer Techniques for Sentinel Lymph Node Detection in Early Breast Cancers: The Prospective Multicenter SentiDose Trial 2021 In: Cancers. - : MDPI AG. - 2072-6694. ; 13:4 Journal article (peer-reviewed)abstract Simple Summary Superparamagnetic iron oxide (SPIO) nanoparticles have comparable performance to the combination of radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) biopsy in breast cancer. In this multicenter prospective study, lower SPIO doses (undiluted 1.5 vs. 1.0 mL) in different timeframes (perioperative vs. 1-7 days preoperative) and injection sites (subareolar vs. peritumoral) were compared to the previous standard (diluted 2.0 mL perioperatively) from the earlier Nordic trial. RI + BD were co-administered as background. In total, 534 patients were analyzed. SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and respectively non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 mL and the Nordic cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Thus, SPIO at 1.5 and 1.0 mL was non-inferior to both Sienna+(R) and the dual technique for SLN detection. Superparamagnetic iron oxide nanoparticles (SPIO) are non-inferior to radioisotope and blue dye (RI + BD) for sentinel lymph node (SLN) detection. Previously, 2 mL SPIO (Sienna+(R)) in 3 mL NaCl was used. In this dose-optimizing study, lower doses of a new refined SPIO solution (Magtrace(R)) (1.5 vs. 1.0 mL) were tested in different timeframes (0-24 h perioperative vs. 1-7 days preoperative) and injections sites (subareolar vs. peritumoral). Two consecutive breast cancer cohorts (n = 328) scheduled for SLN-biopsy were included from 2017 to 2019. All patients received isotope +/- blue dye as back-up. SLNs were identified primarily with the SentiMag(R) probe and thereafter a gamma-probe. The primary endpoint was SLN detection rate with SPIO. Analyses were performed as a one-step individual patient-level meta-analysis using patient-level data from the previously published Nordic Trial (n = 206) as a third, reference cohort. In 534 patients, the SPIO SLN detection rates were similar (97.5% vs. 100% vs. 97.6%, p = 0.11) and non-inferior to the dual technique. Significantly more SLNs were retrieved in the preoperative 1.0 mL cohort compared with 1.5 and the 2.0 mL cohorts (2.18 vs. 1.85 vs. 1.83, p = 0.003). Lower SPIO volumes injected up to 7 days before the operation have comparable efficacy to standard SPIO dose and RI + BD for SLN detection.
15.	Hersi, Abdi-Fatah, 1989- (author) Superparamagnetic iron oxide nanoparticles, a novel tracer in breast cancer surgery 2021 Doctoral thesis (other academic/artistic)abstract The most common surgical choice of treatment in breast cancer is breast-conserving surgery (BCS) together with sentinel lymph node biopsy (SNB). Around 10% of breast cancer diagnosis are ductal carcinoma in situ (DCIS). Superparamagnetic iron oxide nanoparticles (SPIO) are a novel tracer for sentinel lymph node (SN) detection. The aim of this thesis was to investigate the unique applications and functionality of a magnetic approach in breast cancer surgery.Paper I was a two-centre pilot study of 32 patients with non-palpable breast cancer who were scheduled for BCS together with SNB. They received SPIO for SNB and a magnetic seed (Magseed®) for localization of the breast tumour. All 32 patients underwent microscopically radical resection and SNB was successfully performed in all included patients.Paper II was a multicentre prospective single-cohort study. It was a pre-planned interim analysis of 189 patients with “high-risk” DCIS who received SPIO at primary surgery but without performing SNB. If an invasive breast cancer was shown by the final histopathology report, the patient was scheduled for second surgery to undergo SNB. Because SPIO has a much longer half-life than the radioisotope, the magnetic signal at the second surgery was sufficient for detecting SNs; in fact, in patients with DCIS, it reduced from around 50% to 22%. Paper III was a multicentre prospective trial. Two consecutive cohorts of patients with breast cancer scheduled for SNB (n = 328) were included. Lower doses of a refined SPIO suspension were tested in different time frames and injection sites. Analyses were performed as a one-step individual patient-level meta-analysis using patient-level data from a similar previous cohort (n = 206) as a third reference group. In 534 patients, the SPIO SN detection rates were comparable (97.5% vs. 100% vs. 97.6%, p = 0.11) and were noninferior to the dual technique. Paper IV was a multicentre randomized pilot trial aimed to compare tumour localization in nonpalpable breast cancers using either Magseed® or guidewire in patients scheduled for BCS + SNB. All patients received SPIO for the SNB preoperatively. Patients who were randomized to the magnetic seed cohort received their Magseed® at the same time as the SPIO injection preoperatively while the guidewire placement was performed on the same day as surgery. In 207 patients, there were no significant differences in reoperation rate (3% in the magnetic seed cohort vs 7% in the guidewire cohort, p = 0.35).
16.	Hosseini-Mellner, Servah, 1985-, et al. (author) Impact of neoadjuvant compared to adjuvant chemotherapy on prognosis in patients with hormone-receptor positive / HER2-negative breast cancer : A propensity score matching population-based study 2024 In: Breast. - : Churchill Livingstone. - 0960-9776 .- 1532-3080. ; 76 Journal article (peer-reviewed)abstract BACKGROUND: The aim of this population-based cohort study was to investigate the impact of neoadjuvant chemotherapy (NACT) compared to adjuvant chemotherapy in prognosis among patients with HR+/HER2 negative breast cancer.METHOD: This population-based study utilized data from the research database BCBaSe 3.0, based on the Swedish National Quality breast cancer register, including all patients with breast cancer diagnosis in Sweden between 2008 and 2019. Propensity score matching approach was applied. The outcomes of interest consisted of distant-disease free (DDFS), breast-cancer specific (BCSS), and overall survival (OS).RESULTS: In total, 14 459 patients were included in the study cohort of whom 2086 received NACT. After 1:1 propensity score matching (PSM), 1539 patients in each study group were available for analyses. No statistically significant difference in survival outcomes were observed between patients treated with NACT compared to those treated with adjuvant chemotherapy (Hazard Ratio (HR) for DDFS: 1.20; 95 % CI: 0.80-1.79; HR for BCSS: 1.16; 95 % CI: 0.54-2.49; HR for OS: 1.14; 95 % CI: 0.64-2.05).CONCLUSION: In this population-based cohort study of patients with HR+/HER2-breast cancer, the use of NACT seems to be comparable to adjuvant chemotherapy in terms of prognosis, although non-inferiority cannot be proven by this study design. Until further evidence suggesting a survival benefit in favor of either treatment is available, NACT can be pursued when surgical-de-escalation is intended.
17.	Jafer, Fatema, et al. (author) Postmastectomy radiation therapy in breast cancer patients with micrometastatic disease in sentinel node dissection : A cohort study and meta-analysis 2024 In: Clinical and translational radiation oncology. - : Elsevier. - 2405-6308. ; 46 Journal article (peer-reviewed)abstract AIM: The potential role of postmastectomy radiation therapy (PMRT) on prognosis in patients with T1-2 breast cancer and micrometastatic disease in sentinel lymph node dissection (SLND) has not yet been established. The aim of this study was to investigate the impact of PMRT on prognosis in patients with T1-2 breast cancer and micrometastatic in SLND.METHOD: A register- and population-based cohort was utilized by identifying eligible patients on the research database BcBase 3.0. Multivariate Cox regression models were applied for survival outcomes. In addition, a systematic literature review and meta-analysis including all relevant studies on this topic was performed.RESULTS: In total, 956 patients fulfilling the inclusion criteria were found through the BcBaSe 3.0 with 237 (25.0 %) receiving PMRT and 719 (75.0 %) not receiving PMRT. No statistically significant differences between the two patient groups in terms of neither breast cancer-specific (adjusted Hazard Ratio (HR): 0.49; 95 % Confidence Interval (CI): 0.14 - 1.73) nor overall survival (adjusted HR: 0.63; 95 % CI: 0.29 - 1.35) was found. In the pooled analyses after literature review, PMRT did not result in better breast cancer-specific (5 studies; pooled HR: 1.06; 95 % CI: 0.88-1.27; I2 = 1 %; low certainty of evidence) or overall survival (6 studies; pooled HR: 1.01; 95 % CI: 0.91-1.13; I2 = 10 %; low certainty of evidence).CONCLUSION: PMRT does not seem to impact survival in patients with T1 or T2 breast cancer with micrometastatic disease in SLND. Considering the low level of evidence and the relatively short follow-up of included studies, caution in interpreting the results into clinical practice is suggested.
18.	Jafer, Fatema, et al. (author) Postmastectomy radiation therapy in breast cancer patients with micrometastatic disease in sentinel node dissection : A cohort study and meta-analysis 2024 In: Clinical and Translational Radiation Oncology. - : Elsevier. - 2405-6308. ; 46 Journal article (peer-reviewed)abstract AimThe potential role of postmastectomy radiation therapy (PMRT) on prognosis in patients with T1-2 breast cancer and micrometastatic disease in sentinel lymph node dissection (SLND) has not yet been established. The aim of this study was to investigate the impact of PMRT on prognosis in patients with T1-2 breast cancer and micrometastatic in SLND.MethodA register- and population-based cohort was utilized by identifying eligible patients on the research database BcBase 3.0. Multivariate Cox regression models were applied for survival outcomes. In addition, a systematic literature review and meta-analysis including all relevant studies on this topic was performed.ResultsIn total, 956 patients fulfilling the inclusion criteria were found through the BcBaSe 3.0 with 237 (25.0 %) receiving PMRT and 719 (75.0 %) not receiving PMRT. No statistically significant differences between the two patient groups in terms of neither breast cancer-specific (adjusted Hazard Ratio (HR): 0.49; 95 % Confidence Interval (CI): 0.14 – 1.73) nor overall survival (adjusted HR: 0.63; 95 % CI: 0.29 – 1.35) was found. In the pooled analyses after literature review, PMRT did not result in better breast cancer-specific (5 studies; pooled HR: 1.06; 95 % CI: 0.88–1.27; I2 = 1 %; low certainty of evidence) or overall survival (6 studies; pooled HR: 1.01; 95 % CI: 0.91–1.13; I2 = 10 %; low certainty of evidence).ConclusionPMRT does not seem to impact survival in patients with T1 or T2 breast cancer with micrometastatic disease in SLND. Considering the low level of evidence and the relatively short follow-up of included studies, caution in interpreting the results into clinical practice is suggested.
19.	Jazrawi, Allan, et al. (author) A Comparison of Skin Staining after Sentinel Lymph Node Biopsy in Women Undergoing Breast Cancer Surgery Using Blue Dye and Superparamagnetic Iron Oxide Nanoparticle (SPIO) Tracers 2022 In: Cancers. - : MDPI AG. - 2072-6694. ; 14:23 Journal article (peer-reviewed)abstract Simple Summary Both superparamagnetic iron oxide nanoparticles (SPIO) and blue dye (BD) have been reported to cause skin staining after breast-conserving surgery. SPIO is a novel tracer that has been shown to identify sentinel lymph nodes (SLNs) in patients with breast cancer. Our study was the first to compare the incidence and size of skin staining between the two tracers. We reported on these outcomes in a preplanned secondary analysis of a prospective clinical trial in which women received both SPIO and BD. This study investigated whether there was a difference in the incidence and size of skin staining between SPIO and BD after SLN-dissection. In all, 270 women were operated on with breast-conserving surgery and received SPIO, and 204 of these women also received BD. After 24 months of follow up, there was no statistically significant difference between the two tracers with regard to the size and incidence of skin staining. Superparamagnetic iron oxide nanoparticles (SPIO) are a tracer for sentinel lymph node (SLN) detection. In a preplanned secondary analysis of a prospective clinical trial (SentiDose) we reported on skin staining after SPIO and blue dye (BD) injections. For SPIO, either a 1.5 mL retroareolar injection on the day of surgery or a 1.0 mL peritumoral/retroareolar injection 1-7 days before surgery was given. A 1.0 mL sub-/intradermal periareolar injection of BD was also administered to all these women. Staining was then assessed at 6, 12 and 24 months after surgery. A total of 270 women received SPIO and were operated on with breast-conserving surgery. Of these, 204 women also received BD. A total of 58 (21.5%) women had an SPIO stain 6 months postoperatively with a median size of 6.8 cm(2) (p = 0.56), while 51 (25.0%) had a BD stain with a median size of 8.5 cm(2) (p = 0.93). The incidence and size of SPIO and BD staining decreased over time reciprocally. At 24 months, the incidence and median size of SPIO was 23 (8.6%) and 4 cm(2), respectively. For BD, the incidence was 14 (6.3%, p = 0.13), and the median size was 3.5 cm(2) (p = 0.18). There was, therefore, no statistically significant difference in the incidence or size of skin staining between SPIO and BD over time.
20.	Jazrawi, Allan, et al. (author) Magnetic-Guided Axillary UltraSound (MagUS) Sentinel Lymph Node Biopsy and Mapping in Patients with Early Breast Cancer. A Phase 2, Single-Arm Prospective Clinical Trial 2021 In: Cancers. - : MDPI AG. - 2072-6694. ; 13:17 Journal article (peer-reviewed)abstract Simple Summary Superparamagnetic iron oxide nanoparticles (SPIO) have been shown to identify sentinel lymph nodes (SLNs) in patients with breast cancer. This study investigated whether a minimally invasive approach with MRI-LG after SPIO injection in the breast followed by a magnetic guided axillary ultrasound and core biopsy of the SLN (MagUS) could accurately stage the axilla. The study included not only patients planned for primary surgery but also patients with recurrent cancer after previous surgery, but also patients scheduled for neoadjuvant treatment (NAT). The latter underwent minimally invasive SLNB prior to treatment and had their SLN clipped; surgery in the axilla was performed after NAT. In 79 included patients, MagUS detected all patients with macrometastasis and performed comparably with surgical sentinel lymph node dissection (SLND). It also allowed for marking of the SLN in patients planned for PST and enabled tailored decision making in breast cancer recurrence. Lymph Node Dissection (SLND) is standard of care for diagnosing sentinel lymph node (SLN) status in patients with early breast cancer. Study aim was to determine whether the combination of Superparamagnetic iron oxide nanoparticles (SPIO) MRI-lymphography (MRI-LG) and a Magnetic-guided Axillary UltraSound (MagUS) with biopsy can allow for minimally invasive, axillary evaluation to de-escalate surgery. Patients were injected with 2 mL of SPIO and underwent MRI-LG for SN mapping. Thereafter MagUS and core needle biopsy (CNB) were performed. Patients planned for neoadjuvant treatment, the SLN was clipped and SLND was performed after neoadjuvant with the addition of isotope. During surgery, SLNs were controlled for signs of previous biopsy or clip. The primary endpoint was MagUS SLN detection rate, defined as successful SLN detection of at least one SLN of those retrieved in SLND. In 79 patients, 48 underwent upfront surgery, 12 received neoadjuvant and 19 had recurrent cancer. MagUS traced the SLN in all upfront and neoadjuvant cases, detecting all patients with macrometastases (n = 10). MagUS missed only one micrometastasis, outperforming baseline axillary ultrasound AUS (AUC: 0.950 vs. 0.508, p < 0.001) and showing no discordance to SLND (p = 1.000). MagUS provides the niche for minimally invasive axillary mapping that can reduce diagnostic surgery.
21.	Jazrawi, Allan (author) Optimizing the magnetic tracer technique for sentinel lymph node detection and tumour localization in breast cancer surgery 2024 Doctoral thesis (other academic/artistic)abstract Breast cancer is the most common form of cancer in women, and the primary treatment modalities are still breast-conserving surgery (BCS) and sentinel lymph node dissection (SLND) in most cases. Superparamagnetic iron oxide nanoparticles (SPIO) are gaining momentum as a tracer for sentinel lymph node detection. The aim of this thesis is to further refine the magnetic method and investigate its postoperative effects.Paper I: This feasibility study, involving 79 patients, explored the use of SPIO-guided Magnetic resonance imaging (MRI)-lymphography and magnetic-guided axillary ultrasound (MagUS) with core biopsy for sentinel lymph node (SLN) localization and SLN status. MagUS, outperformed baseline axillary ultrasound and successfully traced SLNs in all cases, detecting macro-metastases accurately and missed only one micro-metastasis. The findings suggest that the MagUS technique enables minimally invasive approach in axillary mapping that can meet tailored patient needs and reduce the need for diagnostic surgery. Paper II: This study aimed to compare skin staining incidence and size between different doses of SPIO and blue dye (BD), evaluating their persistence over time. Among 270 women receiving SPIO, 204 also received BD. At six months, 21.5% had SPIO stains and 25% had BD stains Incidence and size decreased reciprocally, with no significant difference between the tracers regarding skin staining after 24 months. Paper III: This study compared the magnetic technique using Magseed® for non-palpable breast tumor localization with guidewire localization and SPIO for sentinel lymph node detection. In a prospective analysis of 426 women, reoperation rates, resection ratios, and SLN detection were assessed. No significant differences were found between the techniques in terms of re-excisions, resection ratios, or SLN detection. However, the magnetic technique showed more successful localizations, shorter operation time, and better overall experience among surgeons, radiologists, and theater coordinators, making it a good alternative for BCS.Paper IV: In this prospective observational study, the impact of postoperative MRI outcome was explored in patients undergoing BCS with a peritumoral SPIO injection for SLN detection. The study affirms SPIO as a safe tracer for SLN detection without compromising MRI interpretation after BCS, ensuring reliable breast cancer recurrence assessment.
22.	Jazrawi, Allan, et al. (author) Prospective evaluation of MRI artefacts following breast conserving surgery and sentinel lymph node dissection with the magnetic technique. Other publication (other academic/artistic)
23.	Karakatsanis, Andreas, 1980- (author) A novel technique to avoid sentinel node biopsy in patients with a preoperative diagnosis of ductal cancer in situ and its implementations on current practice. Journal article (peer-reviewed)
24.	Karakatsanis, Andreas, et al. (author) ASO Visual Abstract: Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study 2023 In: Annals of Surgical Oncology. - : SPRINGER. - 1068-9265 .- 1534-4681. ; 30, s. 4073-4074 Journal article (other academic/artistic)
25.	Karakatsanis, Andreas, et al. (author) Axillary evaluation in ductal cancer in situ of the breast: challenging the diagnostic accuracy of clinical practice guidelines 2021 In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 108:9, s. 1120-1125 Journal article (peer-reviewed)abstract Background: Staging of the axilla is not routine in ductal cancer in situ (DCIS) although invasive cancer is observed in 20-25 per cent of patients at final pathology. Upfront sentinel lymph node dissection (SLND) is advocated in clinical practice guidelines in certain situations. These include expected challenges in subsequent SLN detection and when the risk for invasion is high. Clinical practice guidelines are, however, inconsistent and lead to considerable practice variability. Methods: Clinical practice guidelines for upfront SLND in DCIS were identified and applied to patients included in the prospective SentiNot study. These patients were evaluated by six independent, blinded raters. Agreement statistics were performed to assess agreement and concordance. Receiver operating characteristic curves were constructed, to assess guideline accuracy in identifying patients with underlying invasion. Results: Eight guidelines with relevant recommendations were identified. Interobserver agreement varied greatly (kappa: 0.23-0.9) and the interpretation as to whether SLND should be performed ranged from 40-90 per cent and with varying concordance (32-88 per cent). The diagnostic accuracy was low with area under the curve ranging from 0.45 to 0.55. Fifty to 90 per cent of patients with pure DCIS would undergo unnecessary SLNB, whereas 10-50 per cent of patients with invasion were not identified as 'high risk'. Agreement across guidelines was low (kappa=0.24), meaning that different patients had a similar risk of being treated inaccurately. Conclusion: Available guidelines are inaccurate in identifying patients with DCIS who would benefit from upfront SLNB. Guideline refinement with detailed preoperative work-up and novel techniques for SLND identification could address this challenge and avoid overtreatment.
26.	Karakatsanis, Andreas, et al. (author) Axillary Staging in the Setting of a Preoperative Diagnosis of Ductal Cancer In Situ (DCIS) : Results of an International Expert Panel and a Critical Guideline Performance Using Frequentist and Bayesian Analysis 2020 In: Annals of Surgical Oncology. - : Springer. - 1068-9265 .- 1534-4681. ; 27:Suppl. 2, s. S337-S338 Journal article (other academic/artistic)abstract Background/Objective: Sentinel lymph node biopsy (SLNB) is not routine in DCIS. Guidelines suggest SLNB when there is high risk for underlying invasion (large size, high grade, symptomatic lesion) or for detection failure (e.g., after mastectomy). However, guidelines and current practice patterns are inconsistent. Moreover, whilst SLNB is thought to be feasible and accurate after wide local excision (WLE), there is less consensus to support its use after oncoplastic breast-conserving surgery (OPBCS), which can reduce the need for mastectomy (Mx) and is gradually adopted as standard of care. The study aim was to assess if guidelines or individualized assessment result in optimal selection of patients for upfront SLNB.Methods: A panel of 28 international experts (20 surgeons, 8 oncologists, Europe 20, USA 5, Asia/Australia 3) was formed, all blind to the identity of the others. They reviewed anonymized patient cases from the SentiNot study (n=184, m. age 60 years, DCIS m. size 4 cm, Grade 2/3= 36%/64%, mass lesions 13,4%, underlying invasion 24.5%) and answer if they would consider upfront SLNB and why. Consensus and majority were set to >75 and >50%. At the same time, 6 independent raters (4 surgeons, 2 oncologists) reviewed guidelines and assessed the same patient cases per each guideline. Accuracy in relation to underlying invasion was assessed by Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) was reported. Agreement was investigated by kappa statistics and decision-making patterns by logistic multivariate regression and cluster analysis. To allow for flexibility and adaptation to current knowledge, both a frequentist and a Bayesian approach were undertaken. Priors were adjusted after a literature review regarding the factors that are commonly thought to be associated with higher risk for underlying invasion.Results: A total of 44,896 decisions were retrieved and analysed. The panel reached consensus/majority for upfront SLNB in 41.3/61.4%, whereas individual rates ranged from 11 to 100%. Agreement among panelists was low (kappa=0.37). In multivariate regression analysis for the entire panel, type of surgery was the most common determinant, (simple WLE=less, OPBCS=more and Mx=constant for SLNB), followed by symptomatic diagnosis and DCIS size. Most (26) members had a clear decision-making pattern regarding SLND, based mainly on DCIS size and type of surgery. Individual decision-making performed modestly in identifying patients with underlying invasion (AUC range 0,47-0,59), resulting mainly in overtreatment in 44-77% of patients. The panel performed similarly by majority (AUC 0,5) and by consensus (AUC 0,55) but “undertreated” 60-75% of patients with invasion, failing to identify them as "high-risk." After the recognition of different decision-making patterns, panelists were divided in subgroups with similar decision-making pattern. Analysis identified subgroups with difference in SLNB rate but not with better AUC. The disagreement among panelists in the same subgroups was significant, not only regarding which patients should undergo SLNB, but also on what factors that recommendation was based on. Eight guidelines with relevant recommendations were identified [USA (ASCO/NCCN), Europe (ESMO), Sweden, Denmark, UK, Netherlands and Italy, retrieval date May 2019]. Agreement among raters for each guideline separately varied (kappa: 0.23-0.9). Interpretation as to whether SLNB should be performed ranged widely (40-90%) and with varying concordance (32-88%). No guideline demonstrated accuracy (AUC range 0.45-0.55). Overtreatment risk was high (50-90%), whereas 10-50% of patients with invasion were not identified as “high- risk.” Agreement across guidelines was low (kappa=0.24), meaning that different patients had similar risk to be treated inaccurately, regardless of which guideline was examined.Conclusions: Individualized decision-making and guideline interpretation may be highly subjective and with low accuracy in terms of prediction of invasive disease, resulting in almost random risk for over- or undertreatment of the axilla in patients with DCIS. This suggests that current views and guidelines should be challenged. More accurate preoperative workup and novel techniques to allow for delayed SLNB may be of value in this setting.
27.	Karakatsanis, Andreas, et al. (author) Chest wall perforator flaps for breast reconstruction : international survey on attitudes and training needs 2023 In: British Journal of Surgery. - : Oxford University Press. - 0007-1323 .- 1365-2168. ; 110:8, s. 966-972 Journal article (peer-reviewed)abstract BACKGROUND: Volume replacement using chest wall perforator flaps (CWPFs) is a promising technique to reduce mastectomy rates without sacrificing function or aesthetics. Owing to limited availability of the technique, only a minority of patients currently have access to CWPF procedures.METHODS: An international web-based survey was disseminated through social media, dedicated webpages, and national and international societies for breast surgery. The survey explored surgeons' attitudes towards CWPFs and their perceived training needs.RESULTS: Of 619 respondents, 88.4 per cent agreed that CWPF surgery was desirable, with one-third offering it and performing a median of 10 (i.q.r. 5-15) procedures annually. They were more likely to be senior (OR 1.35, 95 per cent c.i. 1.18 to 1.55; P < 0.001), with formal oncoplastic training (OR 4.80, 3.09 to 7.48; P < 0.001), and working in larger units (OR 1.18, 1.03 to 1.35; P = 0.018) with a free-flap (OR 1.62, 1.06 to 2.48; P = 0.025) or CWPF (OR 3.02, 1.87 to 4.89; P < 0.001) service available. In cluster and latent class analysis, none showed high cohesion with performance of CWPF surgery.CONCLUSION: There is a discrepancy between perceived importance and availability of CWPF surgery, indicating that optimal training is needed.
28.	Karakatsanis, Andreas, et al. (author) Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study) 2019 In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 106:6 Journal article (peer-reviewed)abstract Background: One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen. Methods: Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs. Results: This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78.3 per cent of patients avoided SLND (P<0.001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P<0.001). Costs were reduced by a mean of 24.5 per cent in women without IBC (3990 versus 5286; P<0.001). Conclusion: Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).
29.	Karakatsanis, Andreas, et al. (author) Keeping a Breast with Social Media : "Le Marteau Sans Maitre?" 2023 In: Breast Care. - : S. Karger. - 1661-3791 .- 1661-3805. ; 18:3, s. 179-181 Journal article (other academic/artistic)
30.	Karakatsanis, Andreas, et al. (author) Meta-analysis of neoadjuvant therapy and its impact in facilitating breast conservation in operable breast cancer 2018 In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 105:5, s. 469-481 Journal article (peer-reviewed)abstract BackgroundNeoadjuvant therapy (NAT) for operable breast cancer may facilitate more breast-conserving surgery (BCS). It seems, however, that this benefit is not being realized fully.MethodsA systematic review of the literature was performed. RCTs were included. The criteria for inclusion were: documentation of surgical assessment before and after NAT, surgery performed (BCS or mastectomy), and clinical and pathological responses.ResultsA total of 1452 patients from seven RCTs met the inclusion criteria. After NAT, the feasibilityof BCS increased from 43⋅3to60⋅4 per cent (P < 0⋅001), but BCS was performed in only 51⋅8percent(P = 0⋅04). Only 31 per cent of patients who became eligible for BCS (assessed on clinical response)underwent BCS (pooled rate ratio 0⋅31, 95 per cent c.i. 0⋅22 to 0⋅44; P < 0⋅001). Of the mastectomycandidates who achieved a pathological complete response after NAT, only 41 per cent underwent BCS(pooled rate ratio 0⋅41, 0⋅23 to 0⋅74; P = 0⋅003). The main factors that influenced the decision not to shiftto BCS, even though it was feasible, were clinical assessment before NAT, multicentricity and tumoursize at presentation.ConclusionBreast surgery performed after NAT does not reflect tumour response, resulting in potentially unnecessary radical surgery, especially mastectomy. The barriers to maximizing the surgical benefits of NAT need to be better understood and explored. Still unnecessary mastectomies
31.	Karakatsanis, Andreas, et al. (author) Optimisation of breast MRI compatibility after sentinel node biopsy with paramagnetic tracers 2018 In: European Journal of Surgical Oncology. - : Elsevier BV. - 0748-7983 .- 1532-2157. ; 44:5, s. 731-732 Journal article (other academic/artistic)
32.	Karakatsanis, Andreas, 1980- (author) Sentinel Node Biopsy for Breast Cancer : Aspects and evolution 2018 Doctoral thesis (other academic/artistic)abstract Sentinel Node Biopsy (SNB) in clinical practice was pivotal to the shaping of modern diagnosis, staging and treatment of patients with breast cancer. The use of radioisotope (RI) and blue dye (BD) has led to high detection rates with low false negatives, but delivery-of-care limitations connected to these tracers as well as the need for methods addressing new clinical conundrums delineates the urge for new tracers with comparable performance, easier logistics and, ideally expanded implementations. Aim of the present thesis is to examine the outcomes of Superparamagnetic Iron Oxide (SPIO) nanoparticles, a new tracer based on magnetism for the detection of the sentinel nodes.Paper I is a prospective multicentre trial comparing SPIO to RI+BD, with all tracers injected at the same patient. In 206 patients, SPIO had a similar detection rate (97.6 vs 97.1%, p=0.76) whereas concordance between methods was 98%. The study was completed by a meta-analysis of similar trials published until that point. The detection rates were comparable (fixed OR:1.10; 0.67,1.79, p=0.71), and so was concordance between tracers (fixed RD: 0.00; -0.01, 0.01, p=0.82). Discoloration was present after periareolar SPIO injection in 39% of patients, almost exclusively treated with breast conservation, which reduced to 8.6% after 15 months of follow-up.Paper II was a pilot study of twelve patients with breast cancer and SNB performed where SPIO and the combination of RI+BD were injected, but SPIO was injected up to 15 days preoperatively, with total success in detection and complete concordance.Paper III tested the performance of SPIO as a sole tracer in a pragmatic double-arm non-randomised trial comparing it to the combination of RI+BD. Detection was 95.7% for SPIO and 96.8% for RI (p = 0.59). The preoperative injection of SPIO (1-27 d) enhanced SPIO specific detection (95.7 vs 86%, p=0.002).Paper IV is an interim analysis of a multicentre cohort study including patients with high-risk DCIS planned for breast conservation or any DCIS planned for mastectomy. SPIO was injected to “mark” the sentinel node but SNB was performed in a second operation only if invasive cancer was found at the first operation. In 151 included patients, this technique led to avoidance of 81.5% SNB, with a cost reduction of 14.1% for the entire cohort and 25.8% for the patients that did not have invasive cancer. The detection rate at reoperation was superior for SPIO and comparable with SNB detection at primary operation.In conclusion, SPIO is a novel tracer for SNB in breast cancer with comparable performance, fit for performance in a global setting and with wider clinical implementations compared to RI+BD.
33.	Karakatsanis, Andreas, et al. (author) SentiNot : A way to avoid sentinel node biopsy (SNB) in patients with a preoperative diagnosis of ductal cancer in situ (DCIS) 2017 In: Cancer Research. - Univ Uppsala Hosp, Sect Endocrine & Breast Surg, Uppsala, Sweden. Univ Uppsala Hosp, Uppsala, Sweden. Vastmanland Cty Hosp, Vasteras, Vasteras, Sweden. Uppsala Clin Res Ctr, Uppsala, Sweden. Kalmar Cty Hosp, Sect Breast Surg, Kalmar, Sweden. Univ Uppsala Hosp, Inst Radiol Oncol & Radiotherapy, Uppsala, Sweden. Norrlands Univ Hosp, Umea, Sweden. : AMER ASSOC CANCER RESEARCH. - 0008-5472 .- 1538-7445. ; 77 Journal article (peer-reviewed)
34.	Karakatsanis, Andreas, et al. (author) Simplifying Logistics and Avoiding the Unnecessary in Patients with Breast Cancer Undergoing Sentinel Node Biopsy. A Prospective Feasibility Trial of the Preoperative Injection of Super Paramagnetic Iron Oxide Nanoparticles 2018 In: Scandinavian Journal of Surgery. - : SAGE Publications. - 1457-4969 .- 1799-7267. ; 107:2, s. 130-137 Journal article (peer-reviewed)abstract PURPOSE: Sentinel node is routinely localized with the intraoperative use of a radioactive tracer, involving challenging logistics. Super paramagnetic iron oxide nanoparticle is a non-radioactive tracer with comparable performance that could allow for preoperative localization, would simplify the procedure, and possibly be of value in axillary mapping before neoadjuvant treatment. The current trial aimed to determine the a priori hypothesis that the injection of super paramagnetic iron oxide nanoparticles in the preoperative period for the localization of the sentinel node is feasible.METHODS: This is a prospective feasibility trial, conducted from 9 September 2014 to 22 October 2014 at Uppsala University Hospital. In all, 12 consecutive patients with primary breast cancer planned for resection of the primary and sentinel node biopsy were recruited. Super paramagnetic iron oxide nanoparticles were injected in the preoperative visit in the outpatient clinic. The radioactive tracer (99mTc) and the blue dye were injected perioperatively in standard fashion. A volunteer was injected with super paramagnetic iron oxide nanoparticles to follow the decline in the magnetic signal in the sentinel node over time. The primary outcome was successful sentinel node detection.RESULTS: Super paramagnetic iron oxide nanoparticles' detection after preoperative injection (3-15 days) was successful in all cases (100%). In the volunteer, axillary signal was presented for 4 weeks. No adverse effects were noted. Conclusion and relevance: Preoperative super paramagnetic iron oxide nanoparticles' injection is feasible and leads to successful detection of the sentinel node. That may lead to simplified logistics as well as the identification, sampling, and marking of the sentinel node in patients planned for neoadjuvant treatment.
35.	Karakatsanis, Andreas, et al. (author) Superparamagnetic iron oxide nanoparticles as the sole method for sentinel node biopsy detection in patients with breast cancer 2017 In: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 104:12, s. 1675-1685 Journal article (peer-reviewed)abstract BACKGROUND: Sentinel node biopsy (SNB) using superparamagnetic iron oxide (SPIO) nanoparticles is a novel method in breast cancer. Several studies have verified the non-inferiority of SPIO compared with the standard use of radioisotope (99m) Tc with or without blue dye. The aim of the MONOS study presented here was to evaluate the use of SPIO as a sole tracer and the efficacy of tracer injection in the preoperative setting.METHODS: This prospective cohort study was carried out in two hospitals, one using (99m) Tc and the other SPIO. (99m) Tc was injected in the morning of the day of surgery or the day before. SPIO was either injected before surgery in the outpatient clinic or 1 h before the operation.RESULTS: A total of 338 consecutive patients with breast cancer underwent 343 procedures; SPIO nanoparticles were used in 184 procedures and (99m) Tc-labelled tracer in 159. Detection rates for SPIO and (99m) Tc were 95·6 and 96·9 per cent respectively (P = 0·537). All nodes with SPIO uptake were coloured brown. Fewer nodes were retrieved with SPIO (mean 1·35 versus 1·89), regardless of whether blue dye was used (P < 0·001). Preoperative SPIO injection (58·7 per cent of procedures), a median of 16 (range 2-27) days before the procedure, was associated with a better tracer-specific detection rate (95·3 versus 86 per cent; P = 0·031) and retrieval of more nodes (mean 1·43 versus 1·03; P < 0·001) than perioperative administration. Skin staining was present in 39·9 per cent of patients, and was related to breast-conserving surgery and periareolar injection.CONCLUSION: The use of SPIO alone is a safe alternative, with results comparable to those of the standard dual technique using (99m) Tc and blue dye. The efficacy of injection in the preoperative setting simplifies logistics and improves performance. Skin staining can be prevented by a deeper peritumoral injection.
36.	Karakatsanis, Andreas, et al. (author) The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ : A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns 2020 In: Journal of Geriatric Oncology. - : Elsevier BV. - 1879-4068 .- 1879-4076. ; 11:6, s. 917-925 Research review (peer-reviewed)abstract Ductal cancer in situ (DCIS) is mainly a screen-detected disease and although the risk for breast cancer is age-dependent, most screening programs do not include women over the age of 75 years. Older women are usually excluded from clinical trials and treatment practices are largely based on observational studies or extrapolation of trial results from younger patients, leading to either over- or under-treatment of this population. We systematically reviewed available electronic databases for DCIS treatment patterns and outcomes in older patients 15 years. Inclusion criteria allowed for randomised controlled trials, cohort studies, case-control and cross-sectional studies, as well as meta-analyses, systematic reviews and position papers. Results showed that, although elderly are not necessarily frail, they are generally treated as such by physicians, aiming to dc-escalate therapeutic interventions. After adjusting for frailty, age seems to be a significant factor for less surgery; however, older women with DCIS are more probable to receive surgery than their counterparts with early invasive cancer. DCIS biology and subtypes are independent risk factors for local recurrence or progression to invasive carcinoma, if DCIS is under-treated. The end-benefit of surgery, radio- and endocrine-therapy depend on additional parameters, such as life expectancy, co-morbidities and competing risks of death. Screen-detected DCIS in older women is a challenging clinical problem, mainly due to the lack of high-level data. Therapeutic strategies should be tailored to life expectancy and performance status, DCIS features and patient preference, aiming at combining optimal ontological outcomes with maintenance of quality of life.
37.	Karakatsanis, Andreas, et al. (author) The Nordic SentiMag trial : a comparison of super paramagnetic iron oxide (SPIO) nanoparticles versus Tc(99) and patent blue in the detection of sentinel node (SN) in patients with breast cancer and a meta-analysis of earlier studies. 2016 In: Breast Cancer Research and Treatment. - New York : Springer-Verlag New York. - 0167-6806 .- 1573-7217. ; 157:2, s. 281-294 Journal article (peer-reviewed)abstract The aim of the study is to compare the efficacy of SPIO as a tracer in sentinel node biopsy (SNB) in breast cancer with Tc and patent blue in a multicentre prospective study and perform a meta-analysis of all published studies. It also aims to follow skin discoloration after SPIO injection and describe when and how it resolves. Totally 206 patients with early breast cancer were recruited. Tc and patent blue were administered in standard fashion. Patients were injected with SPIO (Sienna+) preoperatively. SNB was performed and detection rates were recorded for both methods. Skin discoloration was followed and documented postoperatively. Data extraction and subsequent meta-analysis of all previous studies were also performed. SN detection rates were similar between standard technique succeeded and SPIO both per patient (97.1 vs. 97.6 %, p = 0.76) as well as per node (91.3 vs. 93.3 %, p = 0.34), something which was not affected by the presence of malignancy. Concordance rates were also consistently high (98.0 % per patient and 95.9 % per node). Discoloring was present in 35.5 % of patients postoperatively, almost exclusively in breast conservation. It fades slowly and is still detectable in 8.6 % of patients after 15 months. Meta-analysis depicted similar detection rates (p = 0.71) and concordance rates (p = 0.82) per patient. However, it seems that SPIO is characterized by higher nodal retrieval (p < 0.001). SPIO is an effective method for the detection of SN in patients with breast cancer. It is comparable to the standard technique and seems to simplify logistics. Potential skin discoloration is something of consideration in patients planned for breast conservation.
38.	Karakatsanis, Andreas, et al. (author) The use of superparamagnetic iron oxide (SPIO) as sole method for the detection of sentinel node (SN) in breast cancer. The MONOS study 2016 In: European Journal of Cancer. - 0959-8049 .- 1879-0852. ; 57, s. S60-S60 Journal article (other academic/artistic)
39.	Kastora, Stavroula L., et al. (author) Comprehending the impact of #Breastcancer, #Breastsurgery and related hashtags on Twitter : A content and social network cross-sectional analysis #Breastcancer#Breastsurgery 2023 In: European Journal of Surgical Oncology. - : Elsevier. - 0748-7983 .- 1532-2157. ; 49:4, s. 716-723 Journal article (peer-reviewed)abstract Background: Early detection along with improved locoregional and systemic therapies have decreased breast cancer mortality and allowed for the clinical implementation of breast conserving surgical options, in turn reducing the clinical and psychosocial impact of mastectomy. To what extend this has been successfully conveyed through social media for breast cancer awareness, has not been previously investigated.Methods: This study presents a content and social network cross-sectional descriptive study of Twitter and Google trends data worldwide from platform launch (2006 and 2004 respectively) until May 15th, 2022, in agreement with the STROBE guidelines. Tweets associated with the hashtags #Breastcancer, #Breastsurgery, #Oncoplasticsurgery, #Mastectomy, #Breastreconstruction, #Breastconservingsurgery were licensed and downloaded through the Vincitas and Tweetbinder online platforms. Associated available demographics, namely username, biography, location, date and language of post, were extracted from the Twitter dataset while interest percentage, location and language of search were extracted from the Google trends dataset.Results: A total of 390111 unique tweets were generated by 127284 unique users, with 2 users engaging with all six hashtags. Original tweets constituted on average 39.1% [Min 30.7% to max 47.2%] of the total. Hashtag frequency increased on Twitter for all six searches during October, the breast-cancer awareness month, but not on Google trends. Cancer survivors engaged much more often with the hashtag #Breastcancer and #Mastectomy, whereas #Breastsurgery, #Oncoplasticsurgery, #Breastconservingsurgery, #Breastreconstruction were mostly used by health professionals.Conclusion: In this large qualitative and quantitative dataset, geo-temporal oscillations on Twitter and Google trends for hashtags relevant with breast cancer provide preliminary insights on information flow and user engagement. Understanding the effective use of social media platforms may provide the niche for disseminating evidence and promoting education on the surgical options of patients with breast cancer.
40.	Kastora, Stavroula Lila, et al. (author) Outcomes of Different Quality of Life Assessment Modalities After Breast Cancer Therapy : A Network Meta-analysis 2023 In: JAMA Network Open. - : American Medical Association (AMA). - 2574-3805. ; 6:6 Research review (peer-reviewed)abstract IMPORTANCE: Improvement in clinical understanding of the priorities of patients with breast cancer (BC) regarding postoperative aesthetic outcomes (AOs) is needed.OBJECTIVE: To assess expert panel and computerized evaluation modalities against patient-reported outcome measures (PROMs), the gold standard of AO assessment, in patients after surgical management of BC.DATA SOURCES: Embase, MEDLINE, PsycINFO, PubMed, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov were interrogated from inception through August 5, 2022. Search terms included breast conserving AND aesthetic outcome AND breast cancer. Ten observational studies were eligible for inclusion, with the earliest date of database collection on December 15, 2022.STUDY SELECTION: Studies with at least 1 pairwise comparison (PROM vs expert panel or PROM vs computerized evaluation with Breast Cancer Conservation Treatment cosmetic results [BCCT.core] software) were considered eligible if they included patients who received BC treatment with curative intent. Studies reporting solely on risk reduction or benign surgical procedures were excluded to ensure transitivity.DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted study data with an independent cross-check from a third reviewer. The quality of included observational studies was assessed using the Newcastle-Ottawa Scale, and the level of evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Confidence in network meta-analysis results was analyzed with the Confidence in Network Meta-analysis semiautomated tool. Effect size was reported using random-effects odds ratios (ORs) and cumulative ratios of ORs with 95% credibility intervals (CrIs).MAIN OUTCOMES AND MEASURES: The primary outcome of this network meta-analysis was modality (expert panel or computer software) discordance from PROMs. Four-point Likert responses across PROMs, expert panel assessment, and BCCT.core evaluation of AOs were assessed.RESULTS: A total of 10 observational studies including 3083 patients (median [IQR] age, 59 [50-60] years; median [range] follow-up, 39.0 [22.5-80.5] months) with reported AOs were assessed and homogenized in 4 distinct Likert response groups (excellent, very good, satisfactory, and bad). Overall network incoherence was low (χ22 = 0.35; P = .83). Overall, panel and software modalities graded AO outcomes worse than PROMs. Specifically, for excellent vs all other responses, the panel to PROM ratio of ORs was 0.30 (95% CrI, 0.17-0.53; I2 = 86%) and the BCCT.core to PROM ratio of ORs was 0.28 (95% CrI, 0.13-0.59; I2 = 95%), while the BCCT.core to panel ratio of ORs was 0.93 (95% CrI, 0.46-1.88; I2 = 88%).CONCLUSIONS AND RELEVANCE: In this study, patients scored AOs higher than both expert panels and computer software. Standardization and supplementation of expert panel and software AO tools with racially, ethnically, and culturally inclusive PROMs is needed to improve clinical evaluation of the journey of patients with BC and to prioritize components of therapeutic outcomes.
41.	MacNeill, Fiona, et al. (author) Over surgery in breast cancer 2017 In: Breast. - : Elsevier BV. - 0960-9776 .- 1532-3080. ; 31, s. 284-289 Journal article (peer-reviewed)abstract Breast surgery remains the original and most effective 'targeted' therapy: excision of early cancer is curative and for more advanced disease surgery improves local disease control. However in well intentioned pursuit of cure and local disease control, some cancers are over-treated resulting in major physical and emotional morbidity. Less breast surgery is safe, as evidenced by steady reductions in mortality and local recurrence; earlier diagnosis and widespread use of systemic therapies and radiotherapy have allowed more conservative surgery. As tumour biology dictates cancer outcomes not surgery extent, surgery can safely be 'minimum required' rather than ` more is better' with the focus on removal of disease rather than healthy tissue. Surgeons can reduce the burden of surgery further but it is important that less surgery is not overcompensated by more radical or unnecessary systemic therapies and/or radiotherapy with their own toxicities and morbidity. We all need to be alert to the potential drivers of over treatment and over surgery such as failure to work within a multidisciplinary team, failure to design a multimodality treatment plan at diagnosis or overuse of novel assessment technologies of uncertain clinical utility. Pursuit of wide margins and the removal of the contra-lateral healthy breast for marginal risk-reduction gains are also to be discouraged as is routine local/regional surgery in stage 4 disease. The surgeon has a pivotal role in minimizing breast surgery to what is required to achieve the best oncological, functional and aesthetic outcomes.
42.	Mokhtary, Arezo, et al. (author) Mammographic Density Changes over Time and Breast Cancer Risk : A Systematic Review and Meta-Analysis 2021 In: Cancers. - : MDPI. - 2072-6694. ; 13:19 Research review (peer-reviewed)abstract Simple Summary Although mammographic density is strongly linked to the risk of breast cancer, research on the relationship between changes in density over time and the risk of breast cancer has shown conflicting results. We found in the present meta-analysis that increased breast density over time was associated with higher breast cancer risk whereas decreased breast density might be associated with lower breast cancer risk. The results of the meta-analysis constitute a potential opportunity for more individualized screening strategies based on the evolution of breast density during mammography screening. The aim of this meta-analysis was to evaluate the association between mammographic density changes over time and the risk of breast cancer. We performed a systematic literature review based on the PubMed and ISI Web of Knowledge databases. A meta-analysis was conducted by computing extracted hazard ratios (HRs) and 95% confidence intervals (CIs) for cohort studies or odds ratios (ORs) and 95% confidence interval using inverse variance method. Of the nine studies included, five were cohort studies that used HR as a measurement type for their statistical analysis and four were case-control or cohort studies that used OR as a measurement type. Increased breast density over time in cohort studies was associated with higher breast cancer risk (HR: 1.61; 95% CI: 1.33-1.96) whereas decreased breast density over time was associated with lower breast cancer risk (HR: 0.78; 95% CI: 0.71-0.87). Similarly, increased breast density over time was associated with higher breast cancer risk in studies presented ORs (pooled OR: 1.85; 95% CI: 1.29-2.65). Our findings imply that an increase in breast density over time seems to be linked to an increased risk of breast cancer, whereas a decrease in breast density over time seems to be linked to a lower risk of breast cancer.
43.	Obondo, C., et al. (author) SentiDose - A dose optimizing study with SiennaXP, a superparamagnetic iron oxide for sentinel node detection 2018 In: European Journal of Cancer. - : Elsevier. - 0959-8049 .- 1879-0852. ; 92:Suppl. 3, s. S79-S79 Journal article (other academic/artistic)
44.	Paakkola, N.-M., et al. (author) The prognostic and predictive impact of low estrogen receptor expression in early breast cancer : a systematic review and meta-analysis 2021 In: ESMO Open. - : Elsevier. - 2059-7029. ; 6:6 Research review (peer-reviewed)abstract INTRODUCTION: Traditionally, estrogen receptor (ER)-positive breast cancer has been defined as tumors with ≥1% positive for ER. The updated American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines recommend that tumors with ER expression of 1%-10% should be classified as ER-low-positive, recognizing the limited clinical evidence on the prognostic and predictive role of low ER expression. We aimed to investigate the predictive role of ER-low expression to neoadjuvant chemotherapy (NeoCT) and the prognostic significance of ER-low expressing breast tumors compared with ER-positive or ER-negative breast tumors.METHODS: A meta-analysis was conducted using the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guidelines and eligible articles were identified on PubMed and ISI Web of Science databases. The primary outcome was pathologic complete response and secondary outcomes were disease-free survival (DFS) and overall survival (OS). Twelve retrospective cohort studies were included in the meta-analysis. NeoCT resulted in higher pathologic complete response among patients with ER-low expression compared with ER-positive and comparable to ER-negative. Patients with ER-low breast cancer had a statistically significant worse DFS and OS compared with patients with ER-positive breast cancer, whereas no difference in DFS or OS was observed between ER-low and ER-negative subgroups.DISCUSSION: The current evidence suggests that ER-low breast cancer has a more similar outcome to ER-negative than to ER-positive breast cancer in terms of DFS and OS. ER-low expression seems also to have a predictive role regarding NeoCT. Considering the certainty of current evidence categorized as low to moderate, our results urge the need for well-designed prospective studies investigating the molecular background and the most appropriate treatment strategy for ER-low expressing breast cancer.
45.	Pantiora, Eirini, et al. (author) Effect of mode of delivery of patient reported outcomes in patients with breast disease : a randomised controlled trial 2024 In: International Journal of Surgery. - : Lippincott Williams & Wilkins. - 1743-9191 .- 1743-9159. ; 110:1, s. 176-182 Journal article (peer-reviewed)abstract Background: Patient reported outcomes (PROs) have an integral role on how to improve patients' overall experience. The optimal PROs delivery in patients with breast disease is an important issue since PROs are steadily integrated in routine care.Methods: An institutional phase 3 randomised controlled, open-label trial. Eligible candidates were adult women with perceived or confirmed breast disease. Computer generated randomization was used to allocate interventions: collection of PROs in electronic or paper form. Our objective was the effectiveness of electronic versus paper form of PROs. The main outcome measures were: response rate, reported experience, administrative resources, and carbon dioxide emissions.Results: Two hundred thirty-eight patients were randomised. After loss-to-follow-up and consent withdrawals, 218 participants (median age, IQR=55, 21; n=110/n=108) were included in the per-intention-to-treat analysis. Response rate was 61.8% for electronic patient reported outcomes (ePROs) and 63.9% for paper patient reported outcomes (pPROs) (difference=-2.1%, 95% CI: -15.8-11.7%). Only known breast cancer at recruitment was predictive for response in multivariable analysis. ePROs were associated with a 57% reduction in administrative time required, a 95% reduction in incremental costs, and 84% reduction in carbon dioxide emissions, all differences being significant. No difference was detected in perception of PRO significance or ease of completion, but participants experienced that they needed less time to complete ePROs [median, (IQR) 10 (9) respectively 15(10)]. Finally, respondents would prefer ePROs over pPROs (difference 48.1%, 95% CI: 32.8-63.4%).Conclusion: ePROs do not increase the response rate in patients with perceived or confirmed breast disease. However, they can enhance patient experience, reduce incremental costs, facilitate administrative logistics, and are more sustainable. On the basis of these findings, both modalities should continue to be available.
46.	Pantiora, Eirini, et al. (author) Evolution and refinement of magnetically guided sentinel lymph node detection in breast cancer : meta-analysis 2023 In: British Journal of Surgery. - : Oxford University Press. - 0007-1323 .- 1365-2168. ; 110:4, s. 410-419 Research review (peer-reviewed)abstract BACKGROUND: Superparamagnetic iron oxide nanoparticles (SPIO) have been used as a tracer for sentinel lymph node (SLN) localization in breast cancer, demonstrating comparable performance to the combination of radioisotope (RI) and blue dye (BD).METHODS: A systematic literature search and meta-analysis with subgroup and meta-regression analysis were undertaken to update the available evidence, assess technique evolution, and define knowledge gaps. Recommendations were made using the GRADE approach.RESULTS: In 20 comparative studies, the detection rate was 97.5 per cent for SPIO and 96.5 per cent for RI ± BD (risk ratio 1.006, 95 per cent c.i. 0.992 to 1.019; P = 0.376, high-certainty evidence). Neoadjuvant therapy, injection site, injection volume or nodal metastasis burden did not affect the detection rate, but injection over 24 h before surgery increased the detection rate on meta-regression. Concordance was 99.0 per cent and reverse concordance 97.1 per cent (rate difference 0.003, 95 per cent c.i. -0.009 to 0.015; P = 0.656, high-certainty evidence). Use of SPIO led to retrieval of slightly more SLNs (pooled mean 1.96 versus 1.89) with a higher nodal detection rate (94.1 versus 83.5 per cent; RR 1.098, 1.058 to 1.140; P < 0.001; low-certainty evidence). In meta-regression, injection over 24 h before surgery increased the SPIO nodal yield over that of RI ± BD. The skin-staining rate was 30.8 per cent (very low-certainty evidence), and possibly prevented with use of smaller doses and peritumoral injection.CONCLUSION: The performance of SPIO is comparable to that of RI ± BD. Preoperative injection increases the detection rate and nodal yield, without affecting concordance. Whether skin staining and MRI artefacts are reduced by lower dose and peritumoral injection needs to be investigated.
47.	Pantiora, Eirini, et al. (author) Magnetic Seed vs Guidewire Breast Cancer Localization With Magnetic Lymph Node DetectionA Randomized Clinical Trial 2024 In: JAMA SURGERY. - : American Medical Association (AMA). - 2168-6254 .- 2168-6262. ; 159:3, s. 239-246 Journal article (peer-reviewed)abstract IMPORTANCE Guidewires have been the standard for breast lesion localization but pose operative and logistic challenges. Paramagnetic seeds have shown promising results, but to the authors' knowledge, no randomized comparison has been performed.OBJECTIVE To determine whether the combination of a paramagnetic seed and superparamagnetic iron oxide (SPIO) is equivalent to guidewire and SPIO for breast cancer localization and sentinel lymph node detection (SLND).DESIGN, SETTING, AND PARTICIPANTS This was a phase 3, pragmatic, equivalence, 2-arm, open-label, randomized clinical trial conducted at 3 university and/or community hospitals in Sweden from May 2018 to May 2022. Included in the study were patients with early breast cancer planned for breast conservation and SLND. Study data were analyzed July to November 2022.INTERVENTIONS Participants were randomly assigned 1:1 to a paramagnetic seed or a guidewire. All patients underwent SLND with SPIO.MAIN OUTCOMES AND MEASURES Re-excision rate and resection ratio (defined as actual resection volume / optimal resection volume).RESULTS A total of 426 women (median [IQR] age, 65 [56-71] years; median [IQR] tumor size, 11 [8-15] mm) were included in the study. The re-excision rate was 2.90% (95% CI, 1.60%-4.80%), and the median (IQR) resection ratio was 1.96 (1.15-3.44). No differences were found between the guidewire and the seed in re-excisions (6 of 211 [2.84%] vs 6 of 209 [2.87%]; difference, -0.03%; 95% CI, -3.20% to 3.20%; P = .99) or resection ratio (median, 1.93; IQR, 1.18-3.43 vs median, 2.01; IQR, 1.11-3.47; P = .70). Overall SLN detection was 98.6% (95% CI, 97.1%-99.4%) with no differences between arms (203 of 207 [98.1%] vs 204 of 206 [99.0%]; difference, -0.9%; 95% CI, -3.6% to 1.8%; P = .72). More failed localizations occurred with the guidewire (21 of 208 [10.1%] vs 4 of 215 [1.9%]; difference, 8.2%; 95% CI, 3.3%-13.2%; P < .001). Median (IQR) time to specimen excision was shorter for the seed (15 [10-22] minutes vs 18 [12-30] minutes; P = .01), as was the total operative time (69 [56-86] minutes vs 75.5 [59-101] minutes; P = .03). The experience of surgeons, radiologists, and surgical coordinators was better with the seed.CONCLUSIONS AND RELEVANCE The combination of SPIO and a paramagnetic seed performed comparably with SPIO and guidewire for breast cancer conserving surgery and resulted in more successful localizations, shorter operative times, and better experience.
48.	Pantiora, Eirini, et al. (author) Magnetically guided surgery after primary systemic therapy for breast cancer: implications for enhanced axillary mapping 2024 In: BRITISH JOURNAL OF SURGERY. - : Oxford University Press. - 0007-1323 .- 1365-2168. ; 111:2 Journal article (peer-reviewed)abstract Background Superparamagnetic iron nanoparticles perform comparably to radioisotope +/- blue dye for sentinel lymph node detection in breast cancer, even when injected up to 8 weeks before surgery. Using superparamagnetic iron nanoparticles for sentinel lymph node detection after primary systemic therapy, and the maximum time frame of superparamagnetic iron nanoparticle administration have not been investigated. Methods This cohort study included cN0/1-to-ycN0 patients undergoing sentinel lymph node detection or targeted axillary dissection. All patients received superparamagnetic iron nanoparticles either before primary systemic therapy or before surgery, and radioisotope on the day of surgery. Results For 113 patients analysed, superparamagnetic iron nanoparticles were injected a median of 3 (range 0-248) days before surgery, with a 97.4% detection rate compared with 91.2% for radioisotope (P = 0.057). Concordance for radioisotope was 97.1% and this was not affected by timing of superparamagnetic iron nanoparticle injection (Kendall's tau 0.027; P = 0.746). The median sentinel lymph node yield was 3 (interquartile range (i.q.r.) 2-3) for superparamagnetic iron nanoparticles and 2 (i.q.r. 2-3) for radioisotope (P < 0.001). In targeted axillary dissection, detection was 100% for superparamagnetic iron nanoparticles and 81.8% for radioisotope (P = 0.124). The index node was magnetic in 93.9% and radioactive in 66.7% (P = 0.007), an outcome that was not affected by any factors. For patients with metastases, superparamagnetic iron nanoparticle detection was 100% and radioisotope-based detection was 84.2% (P = 0.083), with superparamagnetic iron nanoparticles detecting more metastatic sentinel lymph nodes (median of 1 (i.q.r. 1-2) for superparamagnetic iron nanoparticles compared with a median of 1 (i.q.r. 0-1) for radioisotope; P = 0.005). Conclusion Injection before primary systemic therapy is feasible and does not affect concordance with radioisotope. Superparamagnetic iron nanoparticles perform comparably to radioisotope, but detect more sentinel lymph nodes and have a higher rate of detection of metastatic sentinel lymph nodes.
49.	Rubio, Isabel T., et al. (author) EUSOMA quality indicators for non-metastatic breast cancer : An update 2024 In: European Journal of Cancer. - : Elsevier. - 0959-8049 .- 1879-0852. ; 198 Journal article (peer-reviewed)abstract IntroductionQuality care in breast cancer is higher if patients are treated in a Breast Center with a dedicated and specialized multidisciplinary team. Quality control is an essential activity to ensure quality care, which has to be based on the monitoring of specific quality indicators. Eusoma has proceeded with the up-dating of the 2017 Quality indicators for non-metastatic breast cancer based on the new diagnostic, locoregional and systemic treatment modalities.MethodsTo proceed with the updating, EUSOMA setup a multidisciplinary working group of BC experts and patients’ representatives. It is a comprehensive set of QIs for early breast cancer care, which are classified as mandatory, recommended, or observational. For the first time patient reported outcomes (PROMs) have been included. As used in the 2017 EUSOMA QIs, evidence levels were based on the short version of the US Agency for Healthcare Research and Quality.ResultsThis is a set of quality indicators representative for the different steps of the patient pathway in non-metastatic setting, which allow Breast Centres to monitor their performance with referring standards, i.e minimum standard and target.ConclusionsMonitoring these Quality Indicators, within the Eusoma datacentre will allow to have a state of the art picture at European Breast Centres level and the development of challenging research projects.
50.	Sjökvist, Olivia, et al. (author) Challenging the current norm : Does health related quality of life data from reference populations accurately reflect baseline values in breast cancer patients? An observational cohort study comparing EORTC QLQ-C30 scores between the general Swedish population and baseline scores in breast cancer patients 2021 In: European Journal of Surgical Oncology. - : Elsevier. - 0748-7983 .- 1532-2157. ; 47:12, s. 2971-2977 Journal article (peer-reviewed)abstract Background: Increased overall survival in breast cancer patients has led to a growing recognition of long-term effects of cancer treatment of patients' quality of life. Health related quality of life (HRQoL) data, as measured by patient reported outcome measures (PROMs), is increasingly incorporated into clinical practice and research. A commonly used method current available to interpret HRQoL PROMs data is by comparison to reference values, often obtained from sampling of the general population. The aim of this study was to assess whether HRQoL reference values derived from the general population are an accurate representation of the baseline values of an outpatient breast clinic population.Methods: A prospective observational cohort study was conducted by obtaining EORTC QLQ-C30 values for all patients offered an appointment in the outpatient breast clinic. These results were then compared to published baseline values in the general Swedish population, matched by gender and age.Results: 568 questionnaires were returned with a response rate of 81,1 %. The outpatient breast clinic cohort reported a higher grade of symptoms, lower function and lower quality of life compared to the equivalent reference population.Conclusion: This study challenges the assumption that the reference values accurately reflect those of the study population which clinicians and researchers need to account for in study design and clinical practice.

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