Breast cancer is the leading cause of cancer death among women worldwide. Imaging plays a key role in the early detection of breast cancer, and there is strong evidence that mammography screening has proven to be effective in reducing breast cancer mortality. Organized mammography screening programmes have been established around the globe, mostly in developed countries. Screening is important for an early diagnosis; however, the follow-up of patients with breast cancer is of importance, too. This review article is divided into two sections. The first section provides a general overview of mammography screening, including quality standards, controversial issues and aspects of high-risk screening. In the second section, we describe the potential uses of imaging modalities in the follow-up of breast cancer patients.

Not so long ago, most breast cancer patients were treated with mastectomy (without reconstruction) and routine axillary lymph node dissection (ALND). With the increased emphasis on minimally invasive and less morbid surgical procedures, most patients today undergo breast-conserving surgery (BCS) without ALND. The surgical options for patients who require or desire mastectomy have dramatically expanded with the development of skin- and nipple-sparing mastectomies and better access to reconstructive options. Surprisingly, an increasing proportion of patients with unilateral breast cancer are undergoing bilateral mastectomy with contralateral prophylactic mastectomy. Today, surgeons are more involved in the delivery of partial breast irradiation therapy with the development of balloon-catheter brachytherapy and intraoperative radiation therapy. As a result of new technologies, improved surgical techniques and practice-changing studies, the surgeons’ role in breast cancer treatment has become increasingly more complex. The purpose of this review article is to outline the rapidly changing landscape of breast cancer management and to highlight the surgeons’ role in this multifaceted disease.

Breast cancer-specific mortality has declined over the last two decades as a result of the introduction of screening programmes and advances in adjuvant systemic therapy. The most notable progress has been achieved in the case of Her2-positive disease, following the introduction of trastuzumab, a humanized monoclonal antibody targeting the extracellular domain of Her2. Indeed, addition of trastuzumab to chemotherapy for a total duration of 1 year increases progression-free survival (PFS) as well as overall survival (OS) compared with chemotherapy alone. In hormone receptor-positive disease, treatment with aromatase inhibitors (AIs) prolongs PFS compared with tamoxifen, and in some clinical trials they have been found to increase OS also. Chemotherapy remains the mainstay of treatment for patients with triple-negative disease and also plays a role in Her2-positive and high-risk hormone receptor-positive tumours. Although, overall, only limited progress has been achieved in this field, most trials suggest that the introduction of taxanes has resulted in improved outcomes. Dose-dense chemotherapy is superior to older adjuvant regimens comprising 3-weekly administration of paclitaxel, while high-dose chemotherapy with autologous stem cell support currently has no place in the treatment of breast cancer. Neoadjuvant chemotherapy increases the rate of breast-conserving surgeries; importantly, the pathological complete remission (pCR) rate has been identified as a surrogate for improved OS in hormone receptor-negative patients. Thus, clinical trials have aimed to increase pCR rates by addition of further cytotoxic substances or biologicals such as trastuzumab, lapatinib or bevacizumab. However, the optimum treatment strategy for hormone receptor-negative patients without pCR remains elusive. This review discusses recent developments and open questions in the field of adjuvant systemic therapy for early breast cancer.

For almost 100 years radiotherapy has been an uncontested treatment modality for patients with breast cancer. In the past 20 years patient treatment has been substantially improved by technological advances. In this contribution, state-of-the-art irradiation techniques and regimens tailored to local tumour conditions and patient age used in the clinical setting are reviewed.

Aim. Transoral fundoplication has been repeatedly shown to be effective in selected patients suffering from gastro-oesophageal reflux disease (GERD) refractory to conservative treatment. In this series the safety and efficacy of this approach was evaluated in a group of patients suffering from recurrent reflux problems following previous surgical antireflux treatment. Patients and methods. From February 2009 to December 2011, 15 patients with a median age of 46.3 years (range 32– 68 years) underwent transoral fundoplication at three centres. After a median of 54 months (15–122 months) following their primary surgery, all patients were on continuous medication for GERD symptoms. Transoral fundoplication was performed using the EsophyX^® or Plicator™ device. The scoring of symptoms, as well as the impact on quality of life (QOL), was evaluated with the GERD health-related quality of life (GERD-HRQL) questionnaire for typical GERD symptoms, the SF-36 questionnaire for general health status as well as the GERD Symptom Score. Results. The median duration of the procedure was 42 min (range 30–70 min), and all patients could be discharged on the following day. The mean GERD-HRQL score at baseline during continuous proton pump inhibitor (PPI) medication was 13.4 (±2.1) and showed a statistically significant decrease to 5.7 (±1.3) at 12 months’ follow-up (P < 0.001). In accordance with this, SF-36 evaluation showed a significant improvement in physical status at 12 months’ follow-up (mean value of 50 ± 7.8 at baseline vs. 53 ± 5.2 at 12 months’ follow-up; P < 0.001). Additionally, symptom scoring improved significantly in all parameters. Twelve (80%) patients were completely off GERD medication at the last follow-up. Conclusion. In this small group of patients with recurrent GERD following previous surgical treatment, transoral fundoplication has shown to be an effective tool to reduce symptoms and to improve QOL without the need for redo surgery, which is associated with an increased risk of morbidity.

Background. The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. Methods. The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. Results. Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32.6%) underwent emergency surgery at accrual. After a mean follow-up of 10.7 years, rates of recurrence (17.2% vs. 5.8%; P < 0.001) and emergency surgery (6.9% vs. 1.3%; P = 0.021) were higher in medically treated patients than in those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1% and disease-related mortality was zero in this group. The disease-related mortality rate was 0.6% among patients who had surgical treatment. Conclusion. Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Background. Although stapled transanal rectal resection (STARR) has become an important surgical option in the treatment of obstructive defecation syndrome, objective data about parameters that predict its success or failure are not yet available. Methods. Medical history, clinical and radiomorphological data were obtained prospectively from a multi-institutional STARR registry. Predictive factors for postoperative constipation (Cleveland Clinic Constipation Score, CCS) and incontinence (Cleveland Clinic Incontinence Score, CCIS) were identified using univariable and multivariable analysis. Results. Data were obtained for 181 of 201 patients in the STARR registry, with completed median follow-up of 19.4 (range 12–41) months. Although the CCS decreased significantly overall [from mean (SD) 16.3 (4.9) to 6.7 (4.1); P < 0.001], 31 patients (17.1%) complained about persisting constipation. CCIS levels remained unchanged overall, but 16 patients (8.8% ) had new-onset faecal incontinence. Multivariable analysis revealed that rectocele (β = −0.302, P < 0.001) and intussusception (β = −0.392, P < 0.001) were independent predictors of low CCS, and intussusception (β = −0.216, P = 0.001) and enterocele (β = −0.171, P = 0.012) were independent predictors of low CCIS. In contrast, small rectal diameter (β = −0.293, P < 0.001), low squeeze pressure (β = −0.188, P = 0.005) and increased pelvic floor descent at rest (β = 0.264, P < 0.001) predicted high CCIS. Conclusion. Factors for a favourable outcome after STARR included rectocele, intussusception and enterocele, whereas small rectal diameter, low sphincter pressure and increased pelvic floor descent were unfavourable. These findings should be integrated into the therapy algorithm for STARR.