published_or_final_version / Surgery / Master / Master of Surgery

No description available.

No description available.

published_or_final_version / Surgery / Master / Master of Medical Sciences

This thesis consisted a series of sentinel node biopsy (SNB) studies in Chinese patients to evaluate its impact on the management of breast cancer. Pilot studies The first SNB pilot study was performed in 30 patients using the blue dye technique. Accuracy was verified by axillary lymph node dissection (ALND). The success rate was 83% and the false-negative rate was 25%. The second pilot study was performed in 50 patients using combined mapping with isotope and dye. The success rate was 94% with no false-negative. SNB is shown to be feasible and accurate in Chinese. The optimal mapping method Combined mapping was superior to the blue dye technique. This could be due to the mapping technique or improved experience. One hundred and twenty-three women were randomly assigned to either the blue dye or combined mapping. Combined mapping had a higher success rate than the blue dye technique (100% versus 86%). False-negative rates were similar (0% versus 4.5%). Combined mapping is the preferred method. Accuracy of frozen section (FS) FS was used intra-operatively to guide the need of ALND. In 260 SNB, FS was compared to serial section and immuno-histochemical staining. FS detected 53 of 86 patients with SN metastases with a false-negative rate of 38.4%. The false-negative rates for macro-, micro-metastases and isolated tumour cells (ITC) were 2.4%, 57.7% and 94.4%. FS was accurate to diagnose macro-metastases but not micro-metastases and ITC. Can we skip ALND in SN metastases? 139 patients with SNB and ALND were studied to identify predictive factors for non-SN metastases. 55 had metastatic SN but 38 (69%) had no residual metastases in non-SN. Tumours <3 cm, a single metastatic SN, micro-metastases and absence of extra-capsular spread were significant factors to predict no residual nodal disease. Non-SN metastases were found in 42%, 19% and 0% when SN contained macro-, micro-metastases and ITC. Based on risk of non-SN involvement, ALND is indicated for macro- and micro-metastases but not for ITC. Extended indication for ductal carcinoma in situ (DCIS) SNB may be useful for staging of patients with a pre-operative diagnosis of DCIS because invasive cancer is not infrequently found on pathological examination of resected specimens after surgical excision. One hundred and seven patients with DCIS on core biopsy underwent SNB. Thirty-two patients (29.9%) were upstaged to invasive cancer and 9 (28.1%) had SN metastases. Performing SNB reduced the re-operation rate from 29.9% to 1.9%. Palpable mass and radiological mass lesion were associated with upstage. Extended indication: Sentinel Node Occult Lesion Localisation (SNOLL) Radioisotope is used to localise non-palpable breast cancer and SN. Seventy-four patients with non-palpable breast cancers underwent SNOLL. Radioisotope was injected into cancer and gamma probe guided breast cancer and SN resection. Primary cancer was removed in 73 patients (99%) after the first-round excision and 82% had complete excision. Gamma probe identified SN in 82% and supplementary blue dye increased SN detection to 97%. SNB modified the practice of breast cancer surgery. It has a major impact on the diagnosis, staging and treatment of breast cancer. / published_or_final_version / Surgery / Master / Master of Surgery

Background: Patients with early stage breast cancer having more aggressive surgery have been reported by several studies. Some studies from US also reported that there is an increasing trend in the use of mastectomy. A study even showed that there is 150% increase in bilateral mastectomy rate using data from Surveillance, Epidemiology, and End Results registries (SEER). The increasing use of mastectomy leads to the concerns about reasons behind the decision of surgery type. The objective of this literature review is to identify the factors which would affect the choice of surgery. We will make recommendations on guideline, implementation and the use of appropriate surgery, to prevent the unnecessary mastectomy. Methods: Literature search of articles was conducted using several database including PubMed, MEDLINE and Google Scholar. The keywords used were “Mastectomy rate” AND “breast cancer”, “Breast surgery choice” AND "factor", “Breast conserving surgery” AND “choice”. The periods were limited to 1990-2013. Results: Of 4335 articles identified, 11 studies were found to be relevant to the review. These studies were from different countries with different sample sizes, analysis method and study designs. The rate of mastectomy was widely varied across countries. The rate was clearly lower in western countries, such as Canada, UK and US, while in Asia like Hong Kong and Turkey, the rate is much higher. All of the reviewed studies evaluated different factors, which can influence the choice of treatment. These factors can be broadly categorized as demographics, clinical data, body image and sexuality, surgeon and psychological effects. Factors about age, marital status, family history, tumor size, histological type, nodal status, body image, fears of recurrence, further treatment and dying from cancer and surgeons were included in different studies found to have significant effect on individual in decision of surgery type. Conclusion: Both patient and surgeon play an important role in the selection of surgery. The evidence suggests that reducing unknown bias of surgeons and concerns from patients can help choosing the optimal surgery type. Adequate communication and information are necessary for patient in making the decision on treatment. / published_or_final_version / Public Health / Master / Master of Public Health

published_or_final_version / Surgery / Master / Master of Surgery

published_or_final_version / abstract / toc / Surgery / Master / Master of Surgery

published_or_final_version / Surgery / Master / Master of Surgery

Nasopharyngeal carcinoma (NPC) is the 7th commonest cancer in Hong Kong. Improvements in radiotherapy had increased the cure. Unfortunately, up to 10% of the patient still suffered from local recurrence. Because of the deep location, nasopharyngectomy was considered a difficult operation. Developments in surgical approaches had now established nasopharyngectomy as a standard salvage for locally recurrent NPC. With improvements of endonasal endoscopic instruments and endoscopic techniques, endoscopic nasopharyngectomy as a minimally invasive surgery for salvaging small locally recurrent NPC have been reported in several cohorts with encouraging results. Robotic nasopharyngectomy remained difficult due to tight operation space and instrument considerations. The da Vinci surgical robot was marketed in 1999 as a tool to assist surgeons in performing complex surgical manipulations in tight spaces. It was later adapted to be used in the upper aerodigestive tract for endoscopic resection of small cancers transorally. As the da Vinci surgical robot was not designed for head and neck operations, adaptations are required when we tried to apply it to resect tumours in the nasopharynx. The present study aimed to develop the use of the da Vinci surgical robot to perform minimally invasive operations on the nasopharynx in a cadaveric model. Ten procedures on 3 cadavers were performed with the surgical robot. Due to instrument clutter, a transoral approach was preferred over transnasal approach. In transoral approach, the soft palate obstructs the access to the nasopharynx. We devised three approaches, namely palatal suspension approach, midline palatal split approach and lateral palatal flap approach. We also assess the advantages and limitations of the three approaches. From 2010-2014, 18 robotic nasopharyngectomies were performed. Median operation time was 232 minutes (range 125-574). Estimated median blood loss was 100ml (range 100-1800). Negative margins were achieved in 14 patients. The two-year actuarial local control was 83% and estimated mean survival was 42.7 months (95% confidence interval 35.0-50.3 months). A positive or close margin was significant associated with poor local control but not overall survival. Results were comparable to open or endoscopic nasopharyngectomy. There was no 30 days post-operative mortality but one patient suffered from hypoxic brain damage after developing angioedema in the recovery room. Two patients developed permanent palatal fistulas and one patient had severe trismus after operation. Symptomatic osteoradionecrosis occurred in three patients. When comparing the quality of life assessment with patients after open maxillary swing nasopharyngectomy operation, robotic nasopharyngectomy patients have a higher score in social functioning scale and lower symptoms scores on pain, mouth opening and social eating. The global health score and other functioning scores were statistically not different. Robotic nasopharyngectomy is a feasible minimally invasive operation for resecting selected cases of locally recurrent NPC. The operation is associated with minor long-term complications and better quality of life. Early oncological results in are also encouraging. With rapid development of medical robotic technologies, further research in the field should be continued. / published_or_final_version / Surgery / Master / Master of Surgery