Role of specimen radiography in patients treated with skin-sparing mastectomy for ductal carcinoma in situ of the breast

Prophylactic mastectomy for the prevention of breast cancer: Review of the literature

The high incidence and recurrence rate of breast cancer has influenced multiple strategies such as early detection with imaging, chemoprevention and surgical interventions that serve as preventive measures for women at high risk. Prophylactic mastectomy is one of the growing strategies of breast cancer risk reduction that is of a special importance for breast cancer gene mutation carriers. Women with personal history of cancerous breast lesions may consider ipsilateral or contralateral mastectomy as well. Existing data showed that mastectomy effectively reduces breast cancer risk. However, careful risk estimation is necessary to wisely select individuals who will benefit from preventing breast cancer.

Multidisciplinary Intraoperative Assessment of Breast Specimens Reduces Number of Positive Margins

BACKGROUND

Successful breast-conserving surgery requires achieving negative margins. At our institution, the whole surgical specimen is imaged and then serially sectioned with repeat imaging. A multidisciplinary discussion then determines need for excision of additional margins. The goal of this study was to determine the benefit of each component of this approach in reducing the number of positive margin.

METHODS

This single-institution, prospective study included ten breast surgical oncologists who were surveyed to ascertain whether they would have taken additional margins based their review of whole specimen images (WSI) and review of serially sectioned images (SSI). These results were compared with the multidisciplinary decisions (MDD) and pathology results. Margin status was defined using consensus guidelines.

RESULTS

One hundred surveys were completed. Margins on the original specimen were positive or close in 21%. After WSI, surgeons reported that they would have taken additional margins in 26 cases, reducing the number of positive/close margins from 21 to 13% (p < 0.001). After SSI, 52 would have taken additional margins; however, the number of positive/close margins remained 13%. MDD resulted in additional margins taken in 56 cases, reducing the number of positive/close margins to 7% (p < 0.001 compared with SSI).

CONCLUSIONS

While surgeon review of specimen radiographs can decrease the number of positive or close margins from 21 to 13%, more rigorous multidisciplinary, intraoperative margin assessment reduces the number of close or positive margins to 7%.

What is the evidence behind conservative mastectomies?

INTRODUCTION

Besides the diffusion of breast reconstructive techniques, several "conservative" approaches in mastectomy have been developed, in order to perform an immediate reconstruction with better aesthetic results: the skin-sparing mastectomy (SSM), the nipple-areola complex (NAC)-sparing mastectomy (NSM) and the skin-reducing mastectomy (SRM). During the last decade, SSMs and NSMs have gained widespread acceptance and are currently considered standard treatment for early breast cancer. We would like to investigate the evidence behind this radical shift towards conservative mastectomies, where there has been a renewed interest worldwide.

METHODS

We reviewed English literature by consulting the following databases: Medline, Embase, Cochrane Register of Controlled Trials, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal and Clinicaltrials.gov. The objective is to include any randomized controlled trial (RCT) comparing a "conservative mastectomy" technique to breast conservative surgery or modified radical mastectomy (MRM) for the treatment of early-stage breast cancer. In the absence of randomized trials, we took into account prospective cohorts and retrospective series for a narrative description of available evidence.

RESULTS

Our review included 58 studies [19 prospective cohorts (34%) and 39 retrospective series (66%)] considering NSM and immediate reconstruction and ten studies [1 prospective cohort (10%) and 9 (90%) retrospective series] considering SSM and immediate reconstruction. In the NSM group, 29 studies reported data about complication rates and 42 studies presented data on NAC partial or complete necrosis. In the NSM group 45 studies and all the studies in the SSM group presented data on local and NAC recurrence.

CONCLUSIONS

In order to achieve higher levels of evidence, RCTs comparing conservative mastectomies to traditional mastectomy and breast conservative surgery would be desirable. However we can conclude that conservative mastectomies offer the psychological advantages of good cosmetics and maintenance of woman body image without compromising the oncological safety of mastectomy.

Clinical evaluation of a mobile digital specimen radiography system for intraoperative specimen verification

OBJECTIVE

Use of mobile digital specimen radiography systems expedites intraoperative verification of excised breast specimens. The purpose of this study was to evaluate the performance of a such a system for verifying targets.

MATERIALS AND METHODS

A retrospective review included 100 consecutive pairs of breast specimen radiographs. Specimens were imaged in the operating room with a mobile digital specimen radiography system and then with a conventional digital mammography system in the radiology department. Two expert reviewers independently scored each image for image quality on a 3-point scale and confidence in target visualization on a 5-point scale. A target was considered confidently verified only if both reviewers declared the target to be confidently detected.

RESULTS

The 100 specimens contained a total of 174 targets, including 85 clips (49%), 53 calcifications (30%), 35 masses (20%), and one architectural distortion (1%). Although a significantly higher percentage of mobile digital specimen radiographs were considered poor quality by at least one reviewer (25%) compared with conventional digital mammograms (1%), 169 targets (97%), were confidently verified with mobile specimen radiography; 172 targets (98%) were verified with conventional digital mammography. Three faint masses were not confidently verified with mobile specimen radiography, and conventional digital mammography was needed for confirmation. One faint mass and one architectural distortion were not confidently verified with either method.

CONCLUSION

Mobile digital specimen radiography allows high diagnostic confidence for verification of target excision in breast specimens across target types, despite lower image quality. Substituting this modality for conventional digital mammography can eliminate delays associated with specimen transport, potentially decreasing surgical duration and increasing operating room throughput.

Determinants of optimal mastectomy skin flap thickness

Background

There is a limited evidence base to guide surgeons on the ideal thickness of skin flaps during mastectomy. Here the literature relevant to optimizing mastectomy skin flap thickness is reviewed, including anatomical studies, oncological considerations, factors affecting viability, and the impact of surgical technique and adjuvant therapies.

Methods

A MEDLINE search was performed using the search terms ‘mastectomy’ and ‘skin flap’ or ‘flap thickness’. Titles and abstracts from peer-reviewed publications were screened for relevance.

Results

A subcutaneous layer of variable thickness that contains minimal breast epithelium lies between the dermis and breast tissue. The thickness of this layer may vary within and between breasts, and does not appear to be associated with obesity or age. The existence of a distinct layer of superficial fascia in the breast remains controversial and may be present in only up to 56 per cent of patients. When present, it may not be visible macroscopically, and can contain islands of breast tissue. As skin flap necrosis occurs in approximately 5 per cent of patients, a balance must be sought between removing all breast tissue at mastectomy and leaving reliably viable skin flaps.

Conclusion

The variable and unpredictable thickness of the breast subcutaneous layer means that a single specific universal thickness for mastectomy skin flaps cannot be recommended. It may be that the plane between the subdermal fat and breast parenchyma is a reasonable guide for mastectomy flap thickness, but this may not always correspond to a subcutaneous fascial layer.

Impact of margin status on local recurrence after mastectomy for ductal carcinoma in situ

PURPOSE

To examine the rate of local recurrence according to the margin status for patients with pure ductal carcinoma in situ (DCIS) treated by mastectomy.

METHODS AND MATERIALS

One hundred forty-five consecutive women who underwent mastectomy with or without radiation therapy for DCIS from 1998 to 2005 were included in this retrospective analysis. Only patients with pure DCIS were eligible; patients with microinvasion were excluded. The primary endpoint was local recurrence, defined as recurrence on the chest wall; regional and distant recurrences were secondary endpoints. Outcomes were analyzed according to margin status (positive, close (≤2 mm), or negative), location of the closest margin (superficial, deep, or both), nuclear grade, necrosis, receptor status, type of mastectomy, and receipt of hormonal therapy.

RESULTS

The primary cohort consisted of 142 patients who did not receive postmastectomy radiation therapy (PMRT). For those patients, the median follow-up time was 7.6 years (range, 0.6-13.0 years). Twenty-one patients (15%) had a positive margin, and 23 patients (16%) had a close (≤2 mm) margin. The deep margin was close in 14 patients and positive in 6 patients. The superficial margin was close in 13 patients and positive in 19 patients. One patient experienced an isolated invasive chest wall recurrence, and 1 patient had simultaneous chest wall, regional nodal, and distant metastases. The crude rates of chest wall recurrence were 2/142 (1.4%) for all patients, 1/21 (4.8%) for those with positive margins, 1/23 (4.3%) for those with close margins, and 0/98 for patients with negative margins. PMRT was given as part of the initial treatment to 3 patients, 1 of whom had an isolated chest wall recurrence.

CONCLUSIONS

Mastectomy for pure DCIS resulted in a low rate of local or distant recurrences. Even with positive or close mastectomy margins, the rates of chest wall recurrences were so low that PMRT is likely not warranted.

Oncologic safety of skin-sparing and nipple-sparing mastectomy: a discussion and review of the literature

Breast conservation therapy has been the cornerstone of the surgical treatment of breast cancer for the last 20 years; however, recently, the use of mastectomy has been increasing. Mastectomy is one of the most frequently performed breast operations, and with novel surgical techniques, preservation of the skin envelope and/or the nipple-areolar complex is commonly performed. The goal of this paper is to review the literature on skin-sparing mastectomy and nipple-sparing mastectomy and to evaluate the oncologic safety of these techniques. In addition, this paper will discuss the oncologic importance of margin status and type of mastectomy as it pertains to risk of local recurrence and relative need for adjuvant therapy.

Role and efficacy of intraoperative evaluation of resection adequacy in conservative breast surgery

In the present study we considered the histology of 51 patients who have undergone breast conservative surgery and the related 54 re-excisions that were performed in the same surgical procedure or in delayed procedures, in order to evaluate the role of intraoperative re-excisions in completing tumor removal. In 13% of the cases the re excision obtained the resection of the target lesion. In this study, the occurrence of residual neoplastic lesions in intraoperative re-excisions (24%) is lower than in delayed re-excisions (62%; P = .03). The residual lesions that we could find with definitive histology of re excision specimens are related with lesions with ill defined profile. In 77% of the cases of re excision with tumoral residual the lesion was close to the new resection margin, thus the re-excisions couldn't achieve an adequate ablation of the neoplasm. Invasive or preinvasive nature of the main lesion resected for each case and the approach to the evaluation of the first resection specimen adequacy (surgical or radiological) don't affect the rate of tumoral residual in intraoperative re-excisions. In conclusion, our data are consistent with a low efficacy of intraoperative re excision in obtaining a complete removal of the tumor; intraoperative radiologic evaluation of the first resection specimen is however imperative in defining the effective removal of the target lesion.

Local control of ductal carcinoma in situ based on tumor and patient characteristics: the surgeon's perspective

Ductal carcinoma in situ (DCIS) is a disease whose manifestations are largely confined to in-breast pathology. Management strategies therefore focus on various combinations of local therapy: mastectomy, lumpectomy alone, and lumpectomy followed by breast irradiation. Although DCIS does not carry an inherent risk of distant organ metastasis, optimal local control is essential because any in-breast or chest wall recurrence may occur as an invasive lesion. Local recurrence has been reported following breast-conserving surgery as well as mastectomy. Breast radiation is therefore generally recommended following breast-conserving surgery, and in selected circumstances, mastectomy may be the preferred treatment strategy. This article reviews the surgical and associated clinicopathologic issues related to initial biopsy and perioperative planning that should be considered for all DCIS cases to optimize local control.

Inadequate margins of excision when undergoing mastectomy for breast cancer: which patients are at risk?

BACKGROUND

We analyzed the margin status and risk factors for inadequate margins among patients who underwent skin-sparing mastectomies (SSM) and traditional total mastectomies (TM).

MATERIALS AND METHODS

Patients undergoing mastectomies from 2003 to 2009 were included. Margins of excision were considered positive if carcinoma was at an inked margin and were considered close if such disease was within 2 mm of an inked margin.

RESULTS

A total of 426 patients were identified. The mean age was 60 years and 90% were white. Mean tumor size was 2.6 cm and 44% had multiple ipsilateral carcinomas. Of 426 patients, 177 (42%) underwent SSM with reconstruction and 249 (58%) TM. The rate of positive or close margins on the initial specimen was 29% for SSM vs. 12% for TM (P < 0.01), and the rate of reoperation for margins was 7% for SSM vs. 2% for TM (P < 0.01). Logistic regression analysis revealed that independent risk factors for initial close or positive margins included SSM (odds ratio 2.36, 95% confidence interval [95% CI] 1.05-5.30), multiple ipsilateral tumors (OR 2.12, 95% CI 1.05-4.24), and upper-inner quadrant location (OR 2.58, 95% CI 1.07-6.19). Mean follow-up time was 28 months, and the local recurrence rate was 0.9%. Local recurrence rates were not different for those undergoing SSM (1.1%) vs. TM (0.8%, P = NS).

CONCLUSIONS

Mastectomy patients undergoing SSM, with multiple ipsilateral tumors, and/or upper-inner quadrant disease are at significantly higher risk for inadequate margins of excision. These patients warrant more vigilant intraoperative attention to margin status to ensure adequate margins at the end of the first operation.

Oncological outcome and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction: a prospective observational study

BACKGROUND

The management of early breast cancer (BC) with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on level-1 evidence. In this study, the oncological outcome, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated.

METHODS

137 SSMs with IBR (10 bilateral) were undertaken in 127 consecutive women, using the LD flap plus implant (n = 85), LD flap alone (n = 1) or implant alone (n = 51), for early BC (n = 130) or prophylaxis (n = 7). Nipple reconstruction was performed in 69 patients, using the trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n = 1) and Monocryl mesh (n = 1). Thirty patients underwent contra-lateral procedures to enhance symmetry, including 19 augmentations and 11 mastopexy/reduction mammoplasties. A linear visual analogue scale was used to assess patient satisfaction with surgical outcome, ranging from 0 (not satisfied) to 10 (most satisfied).

RESULTS

After a median follow-up of 36 months (range = 6-101 months) there were no local recurrences. Overall breast cancer specific survival was 99.2%, 8 patients developed distant disease and 1 died of metastatic BC. There were no cases of partial or total LD flap loss. Morbidities included infection, requiring implant removal in 2 patients and 1 patient developed marginal ischaemia of the skin envelope. Chemotherapy was delayed in 1 patient due to infection. Significant capsule formation, requiring capsulotomy, was observed in 85% of patients who had either post-mastectomy radiotherapy (PMR) or prior radiotherapy (RT) compared with 13% for those who had not received RT. The outcome questionnaire was completed by 82 (64.6%) of 127 patients with a median satisfaction score of 9 (range = 5-10).

CONCLUSION

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically safe for T(is), T1 and T2 tumours without extensive skin involvement.

Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction

INTRODUCTION

The management of early breast cancer with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on evidence from randomised controlled trials. The purpose of this study is to evaluate the oncological safety, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis.

METHODS

Eighty-three consecutive women underwent 93 SSMs with IBR (10 bilateral), using the LD flap plus implant (n=55) or implant alone (n=38), indications included early breast cancer and prophylaxis due to BRCA-1 gene mutation. Nipple reconstruction was performed in 38 patients, using the trefoil local flap technique, nipple sharing or Monocryl mesh. Twenty-three underwent contra-lateral surgery in order to optimise symmetry, including 15 augmentations and eight mastopexy/reduction mammoplasties. Patient satisfaction with the outcome of surgery was assessed on a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied).

RESULTS

There was no local recurrence (LR) after a median follow-up of 34 months (range=3-79 months). Overall survival was 98.8%, three patients developed distant disease and one patient died of metastatic breast cancer. No case of partial or total LD flap loss was observed. Morbidities included infection, requiring implant removal in two patients and one patient developed marginal ischaemia of the skin envelope. Significant capsule formation, requiring capsulotomy, was observed in 87% of patients who had either PMR or prior RT compared with 13% for those who did not have RT. Sixty-one (73.5%) of 83 patients completed the questionnaire with a median and mean satisfaction scores of 10.0 and 9.3, respectively (range=6-10).

CONCLUSION

SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically adequate for T(is), T1 and T2 tumours without extensive skin involvement.

Oncological and aesthetic considerations of skin-sparing mastectomy

AIM

To review the oncological safety and aesthetic value of skin-sparing mastectomy (SSM) for invasive breast cancer (IBC) and ductal carcinoma in-situ (DCIS). Controversies including the impact of radiotherapy (RT) on immediate breast reconstruction (IBR), preservation of the nipple-areola complex (NAC) and the role of endoscopic mastectomy are also considered.

METHODS

Literature review facilitated by Medline and PubMed databases.

RESULTS

SSM is an oncologically safe technique in selected cases, including IBC <5 cm, multi-centric tumours, DCIS and prophylactic risk-reduction surgery. The high risk of local recurrence (LR) excludes inflammatory breast cancers and tumours with extensive involvement of the skin. SSM can facilitate IBR and is associated with an excellent aesthetic result. Prior breast irradiation or the need for post-mastectomy radiotherapy (PMR) do not preclude SSM, however the cosmetic outcome may be affected. Nipple/areola preservation is possible for remote tumours, employing a frozen section protocol for the retro-areolar tissue. There is limited data available for endoscopic mastectomy and superiority over conventional SSM has not been established.

CONCLUSION

In appropriately selected cases SSM is oncologically adequate. There are several patient centred advantages over conventional mastectomy, including aesthetic outcome and the avoidance of multiple staged procedures. Despite widespread uptake into surgical practice, validation of these techniques from randomised controlled trials is lacking.

Local Recurrence of Ductal Carcinoma in Situ after Skin-Sparing Mastectomy

BACKGROUND

The incidence of local recurrence (LR) after conventional total mastectomy for ductal carcinoma in situ (DCIS) ranges from 1% to 3%. Skin-sparing mastectomy (SSM) preserves the native skin envelope to facilitate immediate breast reconstruction. Because DCIS is generally not clinically apparent, there is a potential for inadequate excision when SSM is performed. Risk factors for local recurrence after SSM for DCIS are examined.

STUDY DESIGN

A retrospective review of 223 consecutive patients with DCIS treated by SSM and immediate reconstruction was performed. Age younger than 50 years, tumor size > 40 mm, high tumor grade, tumor necrosis, surgical margins < 1 mm, type of biopsy (excisional versus core), and SSM type were examined as risk factors for recurrence.

RESULTS

Mean followup was 82.3 months (range 4.9 to 123.2 months). Recurrences developed in 11 patients (5.1%), including: local (n = 7; 3.3%), regional (n = 2; 0.9%), and distant (n = 2; 0.9%). All seven local recurrences were detected by physical examination. No patients received adjuvant radiation therapy. Two of 19 patients with surgical margins < 1 mm developed LR (10.5%). Univariate analysis showed high tumor grade (p = .019) to influence LR.

CONCLUSIONS

The incidence of local recurrence of DCIS after SSM is similar to conventional total mastectomy. Reexcision of close margins should be performed if possible and adjuvant radiation therapy should be considered.

Role for intraoperative margin assessment in patients undergoing breast-conserving surgery

BACKGROUND

Positive/close margins are associated with higher in-breast failure rates after breast-conserving surgery (BCS). We investigated whether intraoperative margin assessment aids in obtaining negative margins, and to evaluate the local control thus achieved.

METHODS

Between 1994 and 1996, 264 patients underwent BCS for stages 0-III breast cancer [invasive, n = 200; ductal carcinoma in situ (DCIS), n = 64]. Intraoperative margin assessment included gross tissue inspection, specimen radiography, with or without frozen section.

RESULTS

Ninety-two patients (46%) with invasive cancer and 24 (38%) with DCIS had positive/close margins on the permanent section analysis of their initial surgical specimens. Fifty-eight patients (29%) with invasive cancer and six (9%) with DCIS had initial positive/close margins, and were rendered margin-negative by intraoperative analysis and immediate re-excision. Final margins on permanent pathology were positive/close in 52 patients (20%): 34 patients (17%) with invasive cancer and 18 patients (28%) with DCIS. By multivariate analysis, excisional biopsy for diagnosis, larger tumor size, and multifocality were associated with final positive/close margins. Of these 52 patients, 23 underwent a second operation to achieve widely negative margins (13 completion mastectomies, 10 re-excisions). The 5-year ipsilateral breast recurrence-free survival rates after BCS and radiation were 99% for invasive cancer (n = 167) and 100% for DCIS (n = 27).

CONCLUSIONS

Intraoperative assessment of margins assisted in identifying positive/close margins and allowed over a quarter of the patients to be rendered margin-negative with intraoperative re-excision at their original operation. This approach resulted in excellent local control in patients treated with BCS and radiation.

Immediate Breast Reconstruction (IBR) With Direct, Anatomic, Extra-Projection Prosthesis

There are different methods described until now for immediate breast reconstruction. Despite the use of autologous flaps considered by many authors, implants are considered as an option by others. A prospective study of 102 clinical cases was designed, including a 1-year follow-up in which glands were reconstructed by immediate breast reconstruction (IBR) with direct, extra projection, anatomic prostheses located in a submuscular pocket after a skin-sparing mastectomy. The prosthesis coverage was made by the muscle in its upper two thirds and by using the skin from the mastectomy in its lower third. The cosmetic results obtained were evaluated according to the volume, form, and symmetry achieved using a linear numeric analogical score. This evaluation had an averaged value of 2.79 +/- 0.8 in our scale from poor (0) to excellent result (4). The overall rate of complications was 15.7% of the cases, with seroma being the most frequent. In conclusion, this preliminary study demonstrates that immediate breast reconstruction with a direct, extra projection, anatomic prosthesis is a good alternative. Nevertheless, more long-term studies with a higher number of patients and using an SF-36 for patient satisfaction are needed to confirm these results.

Breast specimen radiography: can it predict margin status of excised breast carcinoma?

RATIONALE AND OBJECTIVES

This study examined the value of intraoperative specimen radiography (SR) in determining margin status of excised breast lesions. Of interest was the concordance between the radiologic and histopathologic interpretation of margins. We investigated the influence of in situ disease and of one versus two radiologic views on this concordance.

MATERIALS AND METHODS

Our study consisted of 112 women who underwent breast conservation therapy (BCT) during 2002. Margins were examined with one- or two-view SR. Margins were histologically positive if malignant cells resided < or = 1 mm from the specimen edge. The McNemar's test was used to determine concordance between SR and histopathology (HP). Because surgeons excised extra tissue in cases of positive radiologic margins, we believe that a change in margin status occurred in which true positives became false positives. Accordingly, we analyzed our data with multiple iterations in which, one by one, false positives were considered true positives.

RESULTS

Concordance between SR and HP reached statistical significance after 5/17 false positives were considered true positives. Data excluding DCIS reached significance after 6 of 6 false positives were considered true positives. One- and two-view SR reached significance when 2 of 8 and 7 of 9 false positives, respectively, were considered true positives.

CONCLUSION

In conclusion, our study suggests that SR can aid in margin assessment for patients undergoing BCT. We did not find that concordance between SR and HP is higher in cases of purely invasive disease. Concordance was higher in one-view SR in comparison to two-view. A larger sample size should be analyzed before recommending against using two views.

Specimen radiography as predictor of resection margin status in non-palpable breast lesions

AIM

This study aimed to evaluate the role of specimen radiography in predicting margin status for non-palpable breast malignancies.

METHODS

We retrospectively reviewed the clinical and pathological data together with specimen radiographs of 164 women with ductal carcinoma in situ, who were referred to our centre between January 1997 and December 2000. In all cases microcalcifications were discovered on mammography. Lesions were localized preoperatively using a guide-wire. Specimen radiography findings and clinicopathological data were correlated with pathological findings.

RESULTS

Findings comprised 122 pure ductal carcinomas in situ (74%) and 42 mixed carcinomas, both infiltrating and in situ (26%). On the specimen radiographs, the lesions were close (<1mm) to one edge of the lumpectomy in 34 (21%) cases. Histologically, there were 103 positive resection margins (<1mm, 63%) and only 61 negative margins (> or =1mm, 37%). On univariate analysis, factors associated with positive resection margins were found to be distance from microcalcifications to edge of lesion on specimen radiographs, and radiological multifocality. On multivariate analysis (logistic regression), a radiological margin <5mm and multifocality were the only risk factors for close histological margins. Radiological margins were not associated with surgical findings.

CONCLUSION

Our results demonstrate that there is a correlation between specimen radiographs and histological results. The clinical relevance of this should be evaluated in a prospective study.

Nipple sparing subcutaneous mastectomy: sixty-six months follow-up

AIM

Validation of oncological and reconstructive efficacy of nipple sparing subcutaneous mastectomy.

METHODS

We enrolled 50 patients on behalf of Humanitas Centro Catanese di Oncologia fulfilling appropriate reconstructive and oncological criteria to undergo nipple sparing subcutaneous mastectomy. We preferably selected women with medium size-small breast affected by early stage breast cancer peripherally located with intra-operative negative frozen section of the major ducts.

RESULTS

fourty-six patients were alive after a mean follow-up of 5.5 years. We observed a single case of local recurrence in the nipple successfully treated with local excision. Five patients presented metastatic disease. One is currently alive, 4 died because of progressive disease.

CONCLUSIONS

Our study supports other findings regarding safety and efficacy of nipple sparing subcutaneous mastectomy for selected patients.

Oncological considerations of skin-sparing mastectomy

Aim

To review evidence concerning the oncological safety of performing skin-sparing mastectomy (SSM) for invasive breast cancer and ductal carcinoma in situ (DCIS). Furthermore, the evidence concerning RT in relation to SSM and the possibility of nipple preservation was considered.

Methods

Literature review facilitated by Medline and PubMed databases.

Findings

Despite the lack of randomised controlled trials, SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for early breast cancer. Compared to non-skin-sparing mastectomy (NSSM), SSM seems to be oncologically safe in patients undergoing mastectomy for invasive tumours smaller than 5 cm, multicentric tumours, DCIS or risk-reduction. However, the technique should be avoided in patients with inflammatory breast cancer or in those with extensive tumour involvement of the skin in view of the high risk of local recurrence. SSM with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumour is not close to the nipple and a frozen section protocol for the retro-areolar tissue is followed. Although radiotherapy (RT) does not represent a contraindication to SSM, the latter should be used with caution if postoperative RT is likely, since it detracts from the final cosmetic outcome.

Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome

BACKGROUND

Skin-sparing mastectomy (SSM) followed by immediate reconstruction has been advocated as an effective treatment option for patients with early-stage breast carcinoma. It minimizes deformity and improves cosmesis through preservation of the natural skin envelope of the breast. The purpose of this study was to evaluate postoperative morbidity, patients' satisfaction, and oncological safety for SSM and immediate breast reconstruction (IBR) with a latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis in patients with operable breast cancer.

METHODS

Twenty-one consecutive patients with operable breast cancer undergoing 25 SSM and immediate reconstruction with an LD flap plus implant (n = 14) or implant alone (n = 11) were retrospectively studied (from 2001 through 2005). The median patients' age was 44 years (range, 30-68). Patient satisfaction with the outcome of surgery was assessed using a detailed questionnaire including a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied). Eight of 20 (40%) patients required adjuvant chemotherapy, and only 2 patients required post-mastectomy radiation. Reconstruction of the nipple-areola complex was performed in 7 patients (33%) using the trefoil local flap technique. Contralateral procedures to achieve symmetry were performed in 6 (28%) patients (5 augmentations and 1 reduction mammoplasty).

RESULTS

Histological analysis showed pure ductal carcinoma in situ (DCIS) in 4 patients and invasive carcinoma (+/- DCIS) in 20 cases, of which 5 (25%) were node positive. One prophylactic mastectomy in a BRCA-2 carrier was negative for malignancy. Tumor size ranged from 5 to 90 mm. The surgical margins were clear in all cases. There was no delay in time to commencement of adjuvant therapies. After a mean follow-up period of 13.5 months (range, 5-46 months), none of the patients developed locoregional recurrence. Only 1 patient (5%) developed systemic recurrence (bony metastases). Overall survival was 100%. The incidence of flap necrosis/loss, implant loss, wound infection, or hematoma requiring surgical evacuation was 0%, 0%, 0%, and 0%, respectively. Capsule formation requiring capsulotomy was observed in 3 of 21 patients (14%). The median patient satisfaction score was 10 (range, 6-10).

CONCLUSION

SSM and IBR for operable breast cancer is associated with a high level of patient satisfaction and low morbidity. The procedure seems to be oncologically safe, even in patients with high-risk (T3 or node-positive) carcinoma. The latter needs to be confirmed with greater numbers of patients and longer follow-up.

Skin-sparing mastectomy

Background

Skin-sparing mastectomy (SSM) is a new technique being used in a variety of clinical settings. This article reviews the published data on SSM to establish its current role in clinical practice.

Methods

A Medline search was carried out using the key words ‘skin-sparing mastectomy’ to identify English-language articles published between 1990 and 2004 and further material referenced in these publications.

Results

SSM is most commonly used for surgical prophylaxis and to treat in situ and early invasive disease in patients who request immediate breast reconstruction. SSM and non-SSM result in similar surgical and oncological outcomes, but skin flap ischaemia is more common after SSM and is associated with a range of risk factors, including smoking.

Conclusion

SSM has become an established procedure in breast surgery, but there is a lack of prospective data on which to make evidence-based decisions about its use in individual patients.

Skin-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy while preserving the natural skin envelope of the breast. It facilitates immediate breast reconstruction using an implant or myocutaneous flap, resulting in excellent cosmesis.

DATA SOURCES

A PubMed database literature search was performed.

CONCLUSIONS

Skin-sparing mastectomy is an oncologically safe technique in selected cases; T1/T2, multicentric tumors, ductal carcinoma in situ, and prophylactic mastectomies are particularly suited to this technique. Further research is required to confirm oncologic safety in T3 tumors. In selected cases, the nipple-areola complex can be preserved. A modification of skin-sparing mastectomy includes the removal of the nipple while preserving the areola. The balance of evidence suggests that skin-sparing mastectomy does not increase the risk of locoregional recurrence. Furthermore, it does not delay adjuvant therapies. Contraindications to skin-sparing mastectomy approaches include inflammatory breast cancer and extensive skin involvement by tumor. Preoperative and postoperative radiotherapy are not a contraindication to skin-sparing mastectomy.

Skin-Sparing and Nipple-Sparing Mastectomy: Preoperative, Intraoperative, and Postoperative Considerations

The last several decades have witnessed significant advances in the surgical management of breast cancer. Although many have embraced breast conservation as the procedure of choice, some patients will still opt for mastectomy for a variety of reasons. Recently, the concept of skin sparing mastectomy and immediate breast reconstruction has emerged as an option that provides excellent cosmetic results while being oncologically safe. However, this surgical approach must be considered within a multidisciplinary context, and there are a number of perioperative issues that need to be considered. In addition, newer techniques, which spare the nipple and/or areola, warrant further examination.

The use of skin sparing mastectomy in the treatment of breast cancer: The Emory experience

INTRODUCTION

Long-term follow-up of the use of skin sparing mastectomy (SSM) in the treatment of breast cancer is presented to determine the impact of local recurrence (LR) on survival.

METHODS

565 cases of breast cancer were treated by SSM and IBR from 1/1/1989-12/31/1998. The AJCC pathological staging was Stage 0 175 (31%), Stage I 135 (23.9%), Stage II 173 (30.6%), Stage III 54 (9.6%), Stage IV 8 (1.4%), recurrent 20 (3.5%). Forty-one patients received postoperative adjuvant radiation therapy.

RESULTS

Thirty-one patients developed a LR during the follow-up including five who received adjuvant radiation. The distribution of LR stratified by cancer stage was Stage 0 1 (3.2%), Stage I 5 (16.1%), Stage II 17 (54.8%), Stage III 6 (19.4%), and recurrent 2 (6.5%). The overall LR was 5.5%. Isolated LRs were treated with surgical resection and radiation therapy if not previously administered. Twenty-four patients (77.4%) developed a systemic relapse and 7 (22.6%) patients remained free of recurrent disease at a mean follow-up of 78.1 months. The cancer stage of those remaining disease free was Stage 0 1, Stage I 4, and Stage II 2.

CONCLUSIONS

LR of breast cancer after SSM is not always associated with systemic relapse.

Skin-sparing mastectomy

BACKGROUND

Skin-sparing mastectomy (SSM) is a variation of modified radical mastectomy (MRM) optimized for reconstruction. The authors attempted to determine SSM attitudes and biases within different specialties and countries throughout the world.

METHODS

The authors polled 11,485 individuals via e-mail, including members of surgical, medical, and breast oncology societies, about SSM. Respondents were directed to a survey website where data were directly entered into a database.

RESULTS

Among 1027 respondents, 19 said their knowledge was insufficient to attempt the survey. Surveys were completed by 1008 respondents (8.8%) from 52 countries, comprising 436 (43.3%) surgeons, 376 (37.3%) medical oncologists, 146 (14.5%) radiation oncologists, and 50 (5.0%) individuals from other fields. Of the respondents, 61.9% stated that SSMs are performed at their institution. However 19.1% of these believed that SSM leaves the nipple and areola intact. This perception was higher outside the U.S. (P < 0.0001). Despite knowledge by 77.8% that SSM does not have a higher local disease recurrence rate than MRM, 25.3% of these individuals did not believe the literature. This was most prevalent among radiation oncologists (48.5%), as was the belief that SSM is contraindicated in patients with ductal carcinoma in situ and invasive breast carcinoma (23.3%).

CONCLUSIONS

Despite a developing body of literature, there was variation in opinion among specialties and a lack of understanding of SSM. Many physicians were not familiar with the literature. Among those who were, skepticism was highest among radiation oncologists. Although these results were indicative of only those responding, education about SSM is needed across specialties and in other countries if the procedure is to be widely accepted.

Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery

BACKGROUND

Reported rates of reexcision for margin control after breast-conserving surgery for ductal carcinoma in situ (DCIS) range from 48% to 59%. The optimal technique for intraoperative margin assessment in patients with DCIS has yet to be defined. We sought to determine whether intraoperative multidisciplinary evaluation using gross tissue assessment and sectioned-specimen radiography reduces the need for reoperation for margin control in DCIS.

METHODS

A prospectively compiled database was used to identify patients who had DCIS diagnosed by core needle biopsy and were treated with breast-conserving surgery at our institution between July 1999 and July 2002. All patients had intraoperative gross margin assessment and specimen radiography of both the whole and sliced specimen for calcifications.

RESULTS

Four hundred two patients with DCIS were evaluated at our institution during the study period. Of these, 160 had excisional biopsy for diagnosis prior to referral, 92 had mastectomy as their initial procedure, 40 were seen for a second opinion only, and 1 patient refused surgery. The remaining 109 patients formed the study population. The median age was 55 years (range 34 to 81). The median pathologic size of DCIS was 1.2 cm (range 0.2 to 8.0 cm). Fifty-nine patients had positive (less than 1 mm) or close (less than 5 mm) margins on intraoperative assessment. Final pathology agreed with intraoperative assessment of a positive or close margin in 43 of the 59 patients (P = 0.00005). Seventy-five percent of those thought to have a positive or close margin at the time of surgery (n = 44) underwent intraoperative reexcision. Of the total 109 patients, 31 (34%) had an intraoperative reexcision that resulted in a change in margin status from positive on intraoperative evaluation to negative on final pathologic evaluation (P < 0.00001). A second procedure for margin control was necessary in only 24 patients (22%). The decision to excise additional tissue at the first surgery on the basis of intraoperative assessment resulted in significantly fewer second procedures for margin control (P = 0.029).

CONCLUSIONS

In patients with DCIS, intraoperative margin assessment by gross pathological examination and sliced specimen radiography significantly affects intraoperative decision making, and excision of further tissue on the basis of intraoperative assessment results in a substantial decrease in second procedures for margin control.

Towards optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a spectrum of heterogenous disease that accounts for approximately one fifth of all screen-detected breast cancers and is considered as a precursor of invasive breast cancer if left untreated (35-50% risk). DCIS can be treated by total mastectomy with or without immediate breast reconstruction, local excision (LE) plus adjuvant radiotherapy (RT) or LE alone. Total mastectomy is associated with low rates of local recurrence (1.4%) and breast cancer-specific mortality (0.59%). Three recent randomized controlled trials (RCTs) have demonstrated that adjuvant RT after LE of localized DCIS significantly reduces the incidence of local recurrence. However these trials did not identify any subgroups of patients where RT could be safely omitted. Retrospective studies suggest that RT can be safely omitted after adequate LE (margin width > or =1 cm) of small (< 15 mm), non-high grade DCIS not associated with necrosis. Further RCTs are required to validate these retrospective findings, with an emphasis on standardized and meticulous tissue processing and pathological evaluation. The role of adjuvant tamoxifen in the management of DCIS continues to evolve. Formal axillary dissection is not appropriate for DCIS, however, the potential role of the sentinel node biopsy (SNB) in selected high risk cases requires further evaluation. The International Breast Cancer Intervention Study (IBIS-II) trial aims to evaluate the potential role of third generation aromatase inhibitors in postmenopausal women with hormone-sensitive DCIS.Future research will focus on the relevance of gene expression profiling, proteomics, Laser therapy and mammary ductoscopy to the management of DCIS.

Local recurrence after skin-sparing mastectomy: tumor biology or surgical conservatism?

BACKGROUND

Long-term follow-up of the use of skin-sparing mastectomy (SSM) in the treatment of breast cancer is presented to determine the impact of local recurrence (LR) on survival.

METHODS

A total of 539 patients were treated for 565 cases of breast cancer by SSM and immediate breast reconstruction from January 1, 1989 to December 31, 1998. The American Joint Committee on Cancer pathological staging was stage 0 175 (31%), stage I 135 (23.9%), stage II 173 (30.6%), stage III 54 (9.6%), stage IV 8 (1.4%), and recurrent 20 (3.5%). The mean follow-up was 65.4 months (range, 23.7-86.3 months). Five patients were lost to follow-up.

RESULTS

Thirty-one patients developed a LR during the follow-up including five who received adjuvant radiation. The distribution of LR stratified by cancer stage was stage 0 1, stage I 5, stage II 17, stage III 6, and recurrent 2. The overall LR was 5.5%. Twenty-four patients (77.4%) developed a systemic relapse and 7 (22.6%) patients remained free of recurrent disease at a mean follow-up of 78.1 months. The cancer stage of those remaining disease free was stage 0 1 (100%), stage I 4 (80%), and stage II 2 (11.8%).

CONCLUSIONS

LR of breast cancer after SSM is not always associated with systemic relapse.

Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy

BACKGROUND

Patients receiving breast conservation therapy have a lifelong risk of local recurrence. To minimize this risk, surgeons have explored various approaches to examining the surgical margins of the resection specimen. If tumor cells are found at the margin, there is a high probability that residual tumor remains in the surgical cavity. This review examines published reports about standard and innovative approaches to assessing surgical margins, the clinical significance of margin size, and risk factors for positive margins.

METHODS

Published literature abstracted in Medline was reviewed using the Gateway site from the National Library of Medicine.

CONCLUSIONS

It is still not clear whether obtaining a radical margin will decrease the rate of local recurrence after breast conserving surgery. What is clear is that it is absolutely unacceptable to have tumor cells directly at the cut edge of the excised specimen, regardless of the type of post-surgical adjuvant therapy.