What is the clinical significance of the volume of tissue excised in ROLL?
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LETTER TO THE EDITOR
What is the clinical significance of the volume of tissue excised in ROLL? Muneer Ahmed • Michael Douek
Received: 6 April 2013 / Accepted: 29 April 2013 / Published online: 21 May 2013 Ó Springer Science+Business Media New York 2013
To the Editor, I read with great interest the article by Postma et al. [1], entitled, ‘Efficacy of ‘‘radioguided occult lesion localisation’’ (ROLL) versus ‘‘wire-guided localisation’’ (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial’, in Breast Cancer Res Treat (2012) 136:469–478. This is without doubt the most robust randomised controlled trial (RCT) out of the six RCTs performed to date comparing ROLL to WGL [1– 6]. The authors comprehensively reviewed this very important subject area of the management of non-palpable breast cancers. The authors concluded that ROLL cannot replace WGL as the standard of care because of larger volume excisions. This was based on their finding that the median volume of specimens excised was 71 versus 64 cm3 for the ROLL and WGL groups, respectively and this was statistically significant (P \ 0.017). However, what is the true clinical significance of this difference? Traditionally the concern has always been due to the risk of poor cosmetic outcomes. Postma et al. [1] state clearly that despite the differences in volumes of excised specimens, there is no measurable difference in cosmetic outcome. It is true that several studies have demonstrated the relationship between poor cosmetic outcome and greater volumes of excised tissue [7–9]. However, the latest of these studies was performed over 10 years ago [7–9] and the oldest nearly 20 years ago [8]. Twenty years in a rapidly evolving specialty like breast surgery is the equivalent of a lifetime. In particular, a dramatic shift from purely oncological
M. Ahmed (&) M. Douek Department of Research Oncology, King’s College London, Guy’s Hospital Campus, Great Maze Pond, London SE1 9RT, UK e-mail: [email protected]
considerations to also consideration of patient psychological morbidity from poor cosmetic outcome has evolved into the specialist breast surgeon’s mindset. This has led to a separation from the performance of breast surgery by the general surgeon who could achieve oncological control but was not trained in plastic reconstruction techniques, to the oncoplastic surgeon who has not only the skills to achieve oncological clearance but also the skills to achieve appropriate cosmetic outcomes. Indeed, one can consider extreme examples of breast-conserving surgery where oncoplastic techniques have been applied to achieve excellent cosmetic outcomes. Clough et al. [10] in their cohort of 101 patients requiring extensive resections in breast-conserving surgery were able to achieve favourable cosmesis in 82 % of patients who required extensive resections with mean weights of excised specimens of 222 g. Petit et al. [11] demonstrated that from 111 patients treated with quadrantectomy and concomitant oncoplastic surgery,
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