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Sasada S, Nagura N, Shimo A, Ogiya A, Saiga M, Seki H, Mori H, Kondo N, Ishitobi M, Narui K, Nogi H, Yamauchi C, Sakurai T, Shien T. Impact of radiation therapy for breast cancer with involved surgical margin after immediate breast reconstruction: A multi-institutional observational study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108360. [PMID: 38669780 DOI: 10.1016/j.ejso.2024.108360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/26/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Involved surgical margins are risk factors for local recurrence and re-excision is often difficult, particularly in patients with breast cancer undergoing immediate breast reconstruction (IBR). However, the magnitude of the effect of radiation therapy on preventing local recurrence for breast cancers with involved margins has not been sufficiently assessed. MATERIALS AND METHODS We retrospectively assessed sites of involved surgical margins and local recurrence after mastectomy with IBR in patients with early breast cancer between 2008 and 2016. The effect of postoperative radiation therapy was evaluated in patients with involved margins, adjusted for nuclear grade, lymphatic invasion, surgical procedures, and primary systemic therapy. RESULTS A total of 274 (5.8 %) out of 4726 patients who underwent mastectomy with IBR had involved surgical margins: 133, 68, 88, and 26 had involvement of the skin, deep margin, lateral margins, and nipple, respectively (including duplicates). Radiation therapy was administered to 54 patients with involved margins. In patients with involved margins, 7-year cumulative incidences of local recurrence were 1.9 % and 12.6 % with and without radiation therapy, respectively (adjusted hazard ratio, 0.17; 95 % CI, 0.04-0.80). Local recurrence occurred in 28 patients, and the sites were skin, subcutaneous tissue, muscle, and nipple-areola complex in 7, 17, 1, and 3 patients, respectively. Among them, 23 (82.1 %) were associated with involved margin sites. CONCLUSIONS Radiation therapy meaningfully reduced the incidence of local recurrence in patients with breast cancer with margin involvement after mastectomy with IBR. Most local recurrences occurred at involved margin-related sites.
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Affiliation(s)
- Shinsuke Sasada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.
| | - Naomi Nagura
- Department of Breast Surgical Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Ayaka Shimo
- Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kanagawa, Japan; Department of Breast and Endocrine Surgery, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Akiko Ogiya
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Breast Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Miho Saiga
- Department of Plastic and Reconstructive Surgery, Okayama University Hospital, Okayama, Japan
| | - Hirohito Seki
- Department of Breast Surgery, Saitama Medical Center, Saitama, Japan; Department of Breast Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoto Kondo
- Department of Breast Surgery, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Makoto Ishitobi
- Department of Breast Surgery, Mie University School of Medicine, Mie, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Medical Center, Yokohama City University, Kanagawa, Japan
| | - Hiroko Nogi
- Department of Breast and Endocrine Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Shiga, Japan
| | | | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
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van Hemert A, van Loevezijn AA, Bosman A, Vlahu CA, Loo CE, Peeters MJTFDV, van Duijnhoven FH, van der Ploeg IMC. Breast surgery after neoadjuvant chemotherapy in patients with lobular carcinoma: surgical and oncologic outcome. Breast Cancer Res Treat 2024; 204:497-507. [PMID: 38189904 DOI: 10.1007/s10549-023-07192-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/19/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Breast cancer patients with invasive lobular carcinoma (ILC) have an increased risk of positive margins after surgery and often show little response to neoadjuvant chemotherapy (NAC). We aimed to investigate surgical outcomes in patients with ILC treated with NAC. METHODS In this retrospective cohort study, all breast cancer patients with ILC treated with NAC who underwent surgery at the Netherlands Cancer Institute from 2010 to 2019 were selected. Patients with mixed type ILC in pre-NAC biopsies were excluded if the lobular component was not confirmed in the surgical specimen. Main outcomes were tumor-positive margins and re-excision rate. Associations between baseline characteristics and tumor-positive margins were assessed, as were complications, locoregional recurrence rate (LRR), recurrence-free survival (RFS), and overall survival (OS). RESULTS We included 191 patients. After NAC, 107 (56%) patients had breast conserving surgery (BCS) and 84 (44%) patients underwent mastectomy. Tumor-positive margins were observed in 67 (35%) patients. Fifty five (51%) had BCS and 12 (14%) underwent mastectomy (p value < 0.001). Re-excision was performed in 35 (33%) patients with BCS and in 4 (5%) patients with mastectomy. Definitive surgery was mastectomy in 107 (56%) patients and BCS in 84 (44%) patients. Tumor-positive margins were associated with cT ≥ 3 status (OR 4.62, 95% CI 1.26-16.98, p value 0.021) in the BCS group. Five-year LRR (4.7%), RFS (81%), and OS (93%) were not affected by type of surgery after NAC. CONCLUSION Although 33% of ILC breast cancer patients undergoing BCS after NAC required re-excision for positive resection margins, it is considered safe given that five-year RFS remained excellent and LRR and OS did not differ by extent of surgery.
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Affiliation(s)
- Annemiek van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Anne Bosman
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Surgery, NoordWest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
| | - Carmen A Vlahu
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Iris M C van der Ploeg
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Honma N, Yoshida M, Kinowaki K, Horii R, Katsurada Y, Murata Y, Shimizu A, Tanabe Y, Yamauchi C, Yamamoto Y, Iwata H, Saji S. The Japanese breast cancer society clinical practice guidelines for pathological diagnosis of breast cancer, 2022 edition. Breast Cancer 2024; 31:8-15. [PMID: 37934318 PMCID: PMC10764572 DOI: 10.1007/s12282-023-01518-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/18/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Naoko Honma
- Department of Pathology, Faculty of Medicine, Toho University, 5-21-16 Omori-Nishi, Ota-Ku, Tokyo, 143-8540, Japan.
| | - Masayuki Yoshida
- Department of Diagnostic Pathology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Keiichi Kinowaki
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Rie Horii
- Department of Pathology, Saitama Cancer Center, 780 Komuro, Ina, Kita-Adachi-Gun, Saitama, 362-0806, Japan
| | - Yuka Katsurada
- Pathology and Laboratory Medicine, National Defense Medical College, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Yuya Murata
- Department of Pathology, NHO Tokyo Medical Center, 2-5-1, Higashigaoka, Meguro-Ku, Tokyo, 152-0021, Japan
| | - Ai Shimizu
- Department of Surgical Pathology, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-Ku, Sapporo, 060-8648, Japan
| | - Yuko Tanabe
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, 4-1-1 KyomachiShiga Prefecture, Otsu City, 520-8577, Japan
| | - Yutaka Yamamoto
- Department of Breast and Endocrine Surgery, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-Ku, Nagoya, 464-8681, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
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Cheun JH, Kim HK, Lee HB, Han W, Moon HG. Residual Risk of Ipsilateral Tumor Recurrence in Patients Who Achieved Clear Lumpectomy Margins After Repeated Resection. J Breast Cancer 2023; 26:558-571. [PMID: 37985383 PMCID: PMC10761757 DOI: 10.4048/jbc.2023.26.e46] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE Patients with breast cancer with positive lumpectomy margins have a two-fold increased risk of ipsilateral breast tumor recurrence (IBTR). This can be the result of either technically incomplete resection or the biological characteristics of the tumor that lead to a positive margin. We hypothesized that if achieving negative margins by re-excision nullifies the IBTR risk, then the increased risk is mainly attributed to the technical incompleteness of the initial surgeries. Thus, we investigated IBTR rates in patients with breast cancer who achieved clear margins after re-excision. METHODS We retrospectively reviewed patients who underwent breast lumpectomy for invasive breast cancer between 2004 and 2018 at a single institution, and investigated IBTR events. RESULTS Among 5,598 patients, 793 achieved clear margins after re-excision of their initial positive margins. During the median follow-up period of 76.4 months, 121 (2.2%) patients experienced IBTR. Patients who underwent re-excision to achieve negative margin experienced significantly higher IBTR rates compared to those achieving clear margin at first lumpectomy (10-year IBTR rate: 5.3% vs. 2.6% [25 vs. 84 events]; unadjusted p = 0.031, hazard ratio, 1.61, 95% confidence interval [CI], 1.04-2.48; adjusted p = 0.030, hazard ratio, 1.69, 95% CI, 1.05-2.72). This difference was more evident in patients aged < 50 years and those with delayed IBTR. Additionally, no statistically significant differences were observed in the spatial distribution of IBTR locations. CONCLUSION Patients who underwent re-excision for initial positive margins had an increased risk of IBTR, even after achieving a final negative margin, compared to patients with negative margins initially. This increased risk of IBTR is mostly observed in young patients and delayed cases.
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Affiliation(s)
- Jong-Ho Cheun
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hong-Kyu Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong-Gon Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Genomic Medicine Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea.
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Björnström M, Niinikoski L, Arlan K, Meretoja TJ, Ståhls A, Hukkinen K. Vacuum-assisted excision of small breast cancers under ultrasound guidance. Eur J Radiol 2023; 167:111049. [PMID: 37611442 DOI: 10.1016/j.ejrad.2023.111049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The purpose of this study was to evaluate if it is possible to completely remove small breast cancer tumours with vacuum-assisted excision (VAE) under ultrasound guidance. METHODS Women ≥ 50 years old with a biopsy proven invasive cancer ≤ 10 mm were selected between October 2021 and November 2021 based on referrals and enrolled in this prospective study. The patients underwent VAE within six weeks following biopsy to remove the tumour. After the tumour was excised and the biopsy cavities margins were shaved, a radioactive seed was inserted into the biopsy cavity. The VAE excision cavity and surrounding tissue were surgically excised. Preliminary VAE results were evaluated after ten patients. For the study to proceed at least 80 % of the breast cancer tumours had to be completely removed by VAE. RESULTS The tumours median size in mammography was 8.5 mm (6-9 mm) and in ultrasound 6.5 mm (4-9 mm). The shape of the lesion was round in three (30 %), oval in two (20 %) and irregular in five (50 %) patients. None of the tumours were completely removed in the first VAE specimen, meaning that there was invasive cancer or ductal carcinoma in situ (DCIS) in the "shaved margins" and/or the surgical specimen. In five (50 %) cases, the surgical specimen was free of invasive cancer and DCIS. CONCLUSIONS None of the small invasive breast cancers were completely excised with VAE under ultrasound guidance, therefore it is not a reliable method to remove small breast cancers.
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Affiliation(s)
- Michaela Björnström
- HUH Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
| | - Laura Niinikoski
- Department of Breast Surgery, Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
| | - Kirill Arlan
- HUH Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
| | - Tuomo J Meretoja
- Department of Breast Surgery, Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
| | - Anders Ståhls
- HUH Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
| | - Katja Hukkinen
- HUH Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O Box 263, 00029 HUS, Finland.
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Valadares CN, Couto HL, Soares AN, Toppa PH, Ricardo BP, McIntosh SA, Sharma N, Resende V. Potential role of vacuum-assisted procedures in resecting breast cancers and highlighting selection criteria to support future trials. Front Oncol 2023; 13:1239574. [PMID: 37810980 PMCID: PMC10552518 DOI: 10.3389/fonc.2023.1239574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose The purpose of this study was to evaluate the role of vacuum-assisted biopsy (VAB) in resecting breast cancers. Methods Retrospective database analysis of 116 cancers [both invasive breast cancers (IC) and ductal carcinoma in situ (DCIS)] diagnosed by VAB submitted to standard surgical treatment with complete histological data from VAB and surgery. Excision following VAB was defined as complete resection (CR) if there was no residual tumor in the surgical specimen, minimal residual disease (MRD) if residual tumor ≤ 3 mm, gross residual disease (GRD) if residual tumor > 3 mm, and upgrade from DCIS on VAB to IC. CR and MRD were combined as potentially resected percutaneously (PRP). GRD and those with upgrade to IC were determined not eligible for percutaneous resection (NPR). Factors predictive of PRP were evaluated. Results Mean age was 55.6 years (20-91; SD: 12,27). CR was seen in 29 of 116 cases (25%), MRD in 18 of 116 cases (15.5%), GRD in 64 of 116 cases (55.2%), and five of 116 cases (4.3%) were upgraded from DCIS to IC, and those groups combined represented 47 cases of PRP (40.5%) and 69 (59,5%) of NPR. For 77 tumors ≤ 10 mm, 45 (58.5%) were PRP. Multivariate analysis reveals significance for enlarged VAB (EVAB) (p = 0.008, OR: 4.4, 95% CI), low/intermediate nuclear grade (p < 0.001, OR: 12.5, 95% CI) and final tumor size (T) ≤ 10 mm (p = 0.001, OR: 50.1, 95% CI) for PRP. Conclusions This study showed that lesions completely excised with VAB that were cancer could have been treated with VAB rather than surgery but tumor selection in terms of subtype and size is important.
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Affiliation(s)
- C. N. Valadares
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Mastologia, Rio de janeiro, Brazil
| | - H. L. Couto
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Sociedade Brasileira de Mastologia, Rio de janeiro, Brazil
| | - A. N. Soares
- Faculdade Santa Casa de Belo Horizonte, Minas Gerais, Brazil
| | - P. H. Toppa
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - B. P. Ricardo
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - S. A. McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen’s University Belfast, Belfast, United Kingdom
| | - N. Sharma
- Breast Unit, Leeds Teaching Hospital NHS Trust, St James Hospital, Leeds, United Kingdom
| | - V. Resende
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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7
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Hamersma DT, Schreuder K, Geleijnse G, Heeg E, Cellamare M, Lobbes MBI, Mureau MAM, Koppert LB, Skjerven H, Nygård JF, Groothuis-Oudshoorn CGM, Siesling S. Comparing quality of breast cancer care in the Netherlands and Norway by federated propensity score analytics. Breast Cancer Res Treat 2023; 201:247-256. [PMID: 37355527 PMCID: PMC10361850 DOI: 10.1007/s10549-023-06986-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/24/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE The aim of the study was to benchmark and compare breast cancer care quality indicators (QIs) between Norway and the Netherlands using federated analytics preventing transfer of patient-level data. METHODS Breast cancer patients (2017-2018) were retrieved from the Netherlands Cancer Registry and the Cancer Registry of Norway. Five European Society of Breast Cancer Specialists (EUSOMA) QIs were assessed: two on magnetic resonance imaging (MRI), two on surgical approaches, and one on postoperative radiotherapy. The QI outcomes were calculated using 'Vantage 6' federated Propensity Score Stratification (PSS). Likelihood of receiving a treatment was expressed in odds ratios (OR). RESULTS In total, 39,163 patients were included (32,786 from the Netherlands and 6377 from Norway). PSS scores were comparable to the crude outcomes of the QIs. The Netherlands scored higher on the QI 'proportions of patients preoperatively examined with breast MRI' [37% vs.17.5%; OR 2.8 (95% CI 2.7-2.9)], the 'proportions of patients receiving primary systemic therapy examined with breast MRI' [83.3% vs. 70.8%; OR 2.3 (95% CI 1.3-3.3)], and 'proportion of patients receiving a single breast operation' [95.2% vs. 91.5%; OR 1.8 (95% CI 1.4-2.2)]. Country scores for 'immediate breast reconstruction' and 'postoperative radiotherapy after breast-conserving surgery' were comparable. The EUSOMA standard was achieved in both countries for 4/5 indicators. CONCLUSION Both countries achieved high scores on the QIs. Differences were observed in the use of MRI and proportion of patients receiving single surgery. The federated approach supports future possibilities on benchmark QIs without transfer of privacy-sensitive data.
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Affiliation(s)
- Dave T Hamersma
- Faculty Science & Technology, Health Sciences, University of Twente, Enschede, The Netherlands
| | - Kay Schreuder
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht/Eindhoven/Enschede, The Netherlands
| | - Gijs Geleijnse
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht/Eindhoven/Enschede, The Netherlands
| | - Erik Heeg
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht/Eindhoven/Enschede, The Netherlands
- Department of Plastic & Reconstructive Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Matteo Cellamare
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht/Eindhoven/Enschede, The Netherlands
| | - Marc B I Lobbes
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Marc A M Mureau
- Department of Plastic & Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Helle Skjerven
- Section for Breast and Endocrine Surgery Department, Vestre Viken Hospital Trust, Drammen, Norway
- Department of Registry Informatics, Cancer Registry of Norway, Oslo, Norway
| | - Jan F Nygård
- Department of Registry Informatics, Cancer Registry of Norway, Oslo, Norway
- Machine Learning Group, The Arctic University of Norway, Tromsø, Norway
| | | | - Sabine Siesling
- Faculty Science & Technology, Health Sciences, University of Twente, Enschede, The Netherlands.
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht/Eindhoven/Enschede, The Netherlands.
- Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Hallenweg 5, 7522 NH, Enschede, The Netherlands.
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van Loevezijn AA, Geluk CS, van den Berg MJ, van Werkhoven ED, Vrancken Peeters MJTFD, van Duijnhoven FH, Hoornweg MJ. Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases. Breast Cancer Res Treat 2023; 198:295-307. [PMID: 36690822 DOI: 10.1007/s10549-022-06841-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS. METHODS We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes. RESULTS Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively. CONCLUSION Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charissa S Geluk
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marieke J van den Berg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marije J Hoornweg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Cysteine Cathepsins in Breast Cancer: Promising Targets for Fluorescence-Guided Surgery. Mol Imaging Biol 2023; 25:58-73. [PMID: 36002710 PMCID: PMC9971096 DOI: 10.1007/s11307-022-01768-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/24/2022]
Abstract
The majority of breast cancer patients is treated with breast-conserving surgery (BCS) combined with adjuvant radiation therapy. Up to 40% of patients has a tumor-positive resection margin after BCS, which necessitates re-resection or additional boost radiation. Cathepsin-targeted near-infrared fluorescence imaging during BCS could be used to detect residual cancer in the surgical cavity and guide additional resection, thereby preventing tumor-positive resection margins and associated mutilating treatments. The cysteine cathepsins are a family of proteases that play a major role in normal cellular physiology and neoplastic transformation. In breast cancer, the increased enzymatic activity and aberrant localization of many of the cysteine cathepsins drive tumor progression, proliferation, invasion, and metastasis. The upregulation of cysteine cathepsins in breast cancer cells indicates their potential as a target for intraoperative fluorescence imaging. This review provides a summary of the current knowledge on the role and expression of the most important cysteine cathepsins in breast cancer to better understand their potential as a target for fluorescence-guided surgery (FGS). In addition, it gives an overview of the cathepsin-targeted fluorescent probes that have been investigated preclinically and in breast cancer patients. The current review underscores that cysteine cathepsins are highly suitable molecular targets for FGS because of favorable expression and activity patterns in virtually all breast cancer subtypes. This is confirmed by cathepsin-targeted fluorescent probes that have been shown to facilitate in vivo breast cancer visualization and tumor resection in mouse models and breast cancer patients. These findings indicate that cathepsin-targeted FGS has potential to improve treatment outcomes in breast cancer patients.
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Simpson D, Allan J, McFall B. Radiological Underestimation of Tumor Size Influences the Success Rate of Re-Excision after Breast-conserving Surgery. Eur J Breast Health 2021; 17:363-370. [PMID: 34651116 DOI: 10.4274/ejbh.galenos.2021.2021-4-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
Objective Failure to achieve adequate margins after breast-conserving surgery often leads to re-excision, either by repeat breast-conserving surgery (BCS) or by mastectomy. Despite the high frequency of this problem, the success rate of achieving adequate margins by repeat BCS is not well documented. The objective of this study was to determine the success rate of repeat BCS and identify the factors influencing that rate. Materials and Methods A retrospective review was performed of all women undergoing repeat BCS for inadequate margins after initial BCS in our breast unit between 2013 and 2019. Univariate and multivariate analyses were carried out to identify the factors influencing how often adequate margins were achieved after repeat BCS. Results One hundred fifty-four patients underwent repeat BCS after initially inadequate margins, of which adequate margins were achieved in 82%. Patients with successful repeat BCS had smaller tumors, had less underestimation of tumor size on imaging, and were less likely to have had cavity shaves taken at their initial BCS. A tumor size more than 50% larger than predicted by imaging was independently associated with failure of repeat BCS in multivariate analysis (odds ratio: 3.6, 95% CI: 1.41-9.20, p = 0.007). Underestimation of tumor size by imaging was commoner and more extensive in patients with larger tumors and those with ductal carcinoma in situ. Conclusion Re-excision by cavity shaves has a high success rate and should be offered to all patients who are deemed suitable for the procedure. Patients whose tumors are more than 50% larger than predicted by imaging should be counseled about the higher risk of failure.
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Affiliation(s)
- Duncan Simpson
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Jennifer Allan
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Brendan McFall
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
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11
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Akrami M, Hosseinpour H, Ghoddusi Johari M, Shariat M, Zangouri V, Tahmasebi S, Keumarsi Z, Hosseinpour A, Talei A. Occurrence of residual disease in specimens of re-excision surgery in patients with positive margins of primary quadrantectomy. Breast J 2021; 27:797-803. [PMID: 34402559 DOI: 10.1111/tbj.14281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
Performing a re-intervention following a positive margin after primary lumpectomy in patients with breast cancer entails several disadvantages such as additional costs and postponing the follow-up treatments. In the present study, we sought to measure the incidence rate of residual disease in specimens taken from breast cancer patients who had positive margins after quadrantectomy and also compare the clinical and pathological factors between patients with and without a residual disease after the secondary surgery. All of the medical records of patients undergoing quadrantectomy from December 1994 to December 2019 were collected from Shiraz Breast Cancer Registry (SBCR). Patients were divided into two subgroups of patients with and without residual disease from the secondary surgery and also with and without positive margin from the first operation. Two groups were compared in terms of all clinicopathological factors. The records of 4843 patients undergoing quadrantectomy were reviewed, of which 132 (2.3%) had involved margins. Of these, 112 patients underwent a secondary surgery and 28 had residual disease (25%). No clinicopathological factor was correlated with presence of residual cancer. Also, bigger tumor size (p < 0.001) and the presence of in situ component (p < 0.001) were associated with positive margin and hence the need for a re-excision surgery. These results revealed that the significant rate of residual disease in the specimens of the secondary surgery indicates that a re-operation (either re-excision or simple mastectomy) cannot be omitted after obtaining a positive margin from the primary quadrantectomy.
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Affiliation(s)
- Majid Akrami
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Mehdi Shariat
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Zangouri
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigheh Tahmasebi
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Keumarsi
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Hosseinpour
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdolrasoul Talei
- Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Simpson DJ, Allan J, McFall B. Factors predicting residual disease on re-excision after breast conserving surgery. Surgeon 2021; 20:e149-e157. [PMID: 34326010 DOI: 10.1016/j.surge.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/12/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Breast conserving surgery is the standard of care for early breast cancer, however in a quarter of patients, satisfactory margins are not achieved, usually leading to re-excision. Residual disease is found in less than half of these re-excisions, leading to increased morbidity, poorer cosmesis and increased cost, possibly with no oncological benefit. Our study aimed to identify a group of patients with unsatisfactory margins but a low risk of residual disease, who may be able to avoid re-excision. METHODS AND MATERIALS All patients from our unit undergoing re-excision for unsatisfactory margins after breast conserving surgery between January 2013 and October 2019 were identified. Pathological factors predicting residual disease were investigated using univariable and multivariable analysis. RESULTS 220 patients were included. 90 (41 %) had residual disease. Residual disease was more likely in those having mastectomy than cavity shaves (61 % vs 32 %, p < 0.0001). Residual disease increased in a linear fashion with number of involved margins and with increasing tumour size. Tumour size <20 mm (p = 0.045), a pathological to radiological tumour size ratio less than 1.5 (p < 0.0001) and disease-free cavity shaves taken at initial surgery (p = 0.041) were all independent predictors of a low chance of residual disease on multivariable analysis. Patients with all three factors had a 14 % chance of residual disease. CONCLUSIONS More than half of patients undergo potentially unnecessary re-excision, and patients with small, radiologically obvious tumours are less likely to have residual disease. The decision on re-excision should include these factors in addition to the margin status.
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Affiliation(s)
- Duncan James Simpson
- Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, BT41 2RL, United Kingdom.
| | - Jennifer Allan
- Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, BT41 2RL, United Kingdom.
| | - Brendan McFall
- Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, BT41 2RL, United Kingdom.
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13
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DeStefano LM, Coffua L, Wilson E, Tchou J, Shulman LN, Feldman M, Brooks A, Sataloff D, Fisher CS. Risk factors for the presence of residual disease in women after partial mastectomy for invasive breast cancer: A single institution experience. Surg Oncol 2021; 37:101608. [PMID: 34077835 DOI: 10.1016/j.suronc.2021.101608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 04/28/2021] [Accepted: 05/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND We hypothesize that in addition to specimen margin widths other clinical variables may help predict the presence of residual disease in the lumpectomy bed. METHODS Patients with Stage I-III invasive breast cancer (BC) who underwent partial mastectomy (PM) and re-excision from July 2010-June 2015 were retrospectively reviewed. Bivariate analyses were conducted using two-sample t-tests for continuous variables and Fisher's Exact tests for categorical variables. A multivariate logistic regression was then performed on significant bivariate analyses variables. RESULTS ne-hundred and eighty-four patients were included in our analysis; 47% had residual disease on re-excision, while 53% had no residual disease. Tumor and nodal stage, operation type, type of disease present at margin, and number of positive margins were significantly associated with residual disease. On multivariate logistic regression, DCIS alone at the margin (p = 0.02), operation type (PM with cavity margins) (p = 0.003), and number of positive margins (3 or more) (p < 0.001) remained predictive of residual disease at re-excision. CONCLUSION Based on a more comprehensive review of the initial pathology, there are additional factors that can help predict the likelihood of finding residual disease and help guide the surgeon in the decision for re-excision.
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Affiliation(s)
- Lauren M DeStefano
- Department of Surgery, Division of Surgical Oncology. Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Lauren Coffua
- Department of Surgery, Crozer-Chester Medical Center, Upland, PA, USA
| | - Elise Wilson
- Department of Gynecology-Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Julia Tchou
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Department of Medicine, Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Feldman
- Department of Pathology and Laboratory Medicine, Division of Surgical Pathology. Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | - Ari Brooks
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Dahlia Sataloff
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carla S Fisher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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14
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McIntosh SA. Surgery for Good Prognosis Breast Cancers. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00414-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Purpose of Review
The introduction of mammographic screening programmes has resulted increasing numbers of women with small breast cancers with biologically favourable characteristics. Many of these cancers may represent overdiagnosis, with a resulting treatment burden for women and healthcare costs for providers. Here, current surgical approaches to the treatment of such tumours are reviewed, together with alternative approaches to their management.
Recent Findings
The surgical treatment of small, screen-detected breast cancers with biologically favourable characteristics has been extrapolated from the management of symptomatic breast cancers. There is no prospective randomised evidence for conventional open surgery compared with other approaches in this setting. A number of minimally invasive techniques, most notable vacuum-assisted excision, have been described for the management of these tumours, but at present, there is a lack of high-quality evidence to support their routine use. There are currently ongoing randomised trials evaluating risk-adapted surgical and minimally invasive approaches to the management of good prognosis disease.
Summary
It is possible that the surgical treatment of good prognosis screen-detected breast cancers may be de-escalated. However, high-quality evidence from ongoing prospective randomised trials will be required in order to change clinical practice.
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Gommers JJJ, Duijm LEM, Bult P, Strobbe LJA, Kuipers TP, Hooijen MJH, Mann RM, Voogd AC. The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study. Ann Surg Oncol 2021; 28:5929-5938. [PMID: 33796997 PMCID: PMC8460561 DOI: 10.1245/s10434-021-09868-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 01/10/2023]
Abstract
Background This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS). Methods Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008–2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved. Results Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33–0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68–4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03–1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07–12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69–7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01–3.40) were independently associated with positive resection margins after BCS. Conclusions Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.
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Affiliation(s)
- Jessie J J Gommers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Toon P Kuipers
- Department of Radiology, Bernhoven Hospital, Uden, The Netherlands
| | | | - Ritse M Mann
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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van de Voort EMF, Struik GM, Birnie E, Moelker A, Verhoef C, Klem TMAL. Thermal Ablation as an Alternative for Surgical Resection of Small (≤ 2 cm) Breast Cancers: A Meta-Analysis. Clin Breast Cancer 2021; 21:e715-e730. [PMID: 33840627 DOI: 10.1016/j.clbc.2021.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 02/23/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022]
Abstract
Women with early-stage breast cancer have an excellent prognosis with current therapy, but could presumably be treated less invasively, without the need for surgery. The primary goal of this meta-analysis was to examine whether thermal ablation is an effective method to treat early-stage breast cancer. Studies reporting on complete ablation rate after thermal ablation as a treatment of small breast cancers (≤ 2 cm) were included. Methodologic quality of included studies was assessed using MINORS criteria. Complete ablation rates are given as proportions, and meta-regression and subgroup analyses were performed. The overall complete ablation rate in 1266 patients was 86% and was highest after radiofrequency ablation (RFA) (92%). Local recurrence rates varied from 0% to 3%, with a median follow-up of 15 to 61 months. Overall, complication rates were low (5%-18% across techniques) and were highest after high-intensity focused ultrasound ablation and lowest after cryoablation. Cosmetic outcome was good to excellent in at least 85% of patients but was reported infrequently and long-term results of cosmetic outcome after thermal ablation and radiotherapy are still lacking. Thermal ablation techniques treating early-stage breast cancer (≤ 2 cm) are safe and effective based on complete ablation rate and short-term local recurrence rates. Especially, RFA, microwave ablation, and cryoablation are promising techniques as an alternative to surgical resection without jeopardizing current treatment effectiveness or safety. Owing to great heterogeneity in the included studies, a formal recommendation on the best technique is not possible. These findings warrant the design of large randomized controlled trials comparing thermal ablation and breast-conserving surgery in the treatment of T1 breast cancer.
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Affiliation(s)
| | - Gerson M Struik
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Statistics and Education, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Interventional Radiology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
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Monib S, Anis K, Habashy H. Routine cavity shaves following breast conserving surgery; friend or foe? Surg Oncol 2021; 37:101521. [PMID: 33548588 DOI: 10.1016/j.suronc.2021.101521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/30/2020] [Accepted: 01/24/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Radial margin status is considered one of the most important prognostic predictor for patients undergoing breast-conserving surgery (BCT), not only related to regional recurrence but also to 5y survival, especially in patients with invasive disease. AIM While our primary aim was to evaluate whether doing routine radial cavity shaves following at the time of primary conservative breast surgery will decrease the need for a second operation or not, our secondary aim was to assess time added to the operation to resect and mark the radial shaves, as well as patients' satisfaction with the results. MATERIAL AND METHODS We have conducted a case series prospective analysis, including158 patients who underwent breast-conserving surgery looking into the histological status of resection margins and radial shaves, added time taken to take and mark the shaves as well as patients' satisfaction. RESULTS 158 female breast cancer patients have been included in our analysis, the mean age was 56 years; total number of lesions was 160. While 89.3% of lesions were palpable, 10.6% were not requiring wire-guided localisation. Mean tumour size was 24 mm SD 7, final histology revealed that 86.8% lesion was invasive ductal carcinoma, 5.6% invasive lobular carcinoma, 1.2% medullary carcinoma. 12.4% had invasive disease as well as DCIS, and 1.8% had DCIS only with no invasive disease. Mean preoperative breast volume was 723 ml, Mean wide local excision specimen weight was 73 g, and mean shave weight was 1.6 g. Total number of radial margins was 640, 81.8% was clear, 14.6% was close, and 3.4% was involved. Total number of shaves was 640 out of which 98.7% was clear 0.7% was close and 0.4% was involved. Out of the 160 lesions, 3.7% required a second procedure to clear margins, out of which 2.5% had re-excision for close or involved single shaves each while 1.2% had mastectomy due to close or involved two shaves each. Average time utilised in resection of radial shaves and marking was 7 min 0.6% of patients developed a haematoma, 1.8% had a Seroma, and 1.2% had wound infection. Mean hospital stay was 1day SD 1. CONCLUSION Routine radial cavity shaves not only ensure microscopic clearance, reduce the need for re-excision with no significant added operating time but also has no impact on patients' satisfaction.
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Affiliation(s)
- Sherif Monib
- St Albans Hospital Breast Unit, West Hertfordshire Hospitals NHS Trust, UK.
| | - Karim Anis
- St Albans Hospital Breast Unit, West Hertfordshire Hospitals NHS Trust, UK
| | - Hany Habashy
- General Surgery Department, Fayoum University Hospital, Fayoum, Egypt
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18
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Retrospective Review of Preoperative Radiofrequency Tag Localization of Breast Lesions in 848 Patients. AJR Am J Roentgenol 2020; 217:605-612. [PMID: 33084384 DOI: 10.2214/ajr.20.24374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND. Advantages of radiofrequency tags for preoperative breast lesion localization include decoupling of tag placement from surgical schedules and improved patient comfort. OBJECTIVE. The purpose of this study was to evaluate the feasibility of a preoperative localization radiofrequency tag system for breast lesions requiring surgical excision. METHODS. The cohort for this retrospective study included consecutive patients who underwent image-guided needle localization with radiofrequency tags before surgical excision from July 12, 2018, to July 31, 2019. Images and medical records were reviewed to evaluate the pathologic diagnoses serving as indications for tag placement, imaging guidance for tag placement, number of tags placed, and target lesion type. Tag placement technical accuracy rate (defined as deployment of the tag within 1 cm of the edge of the target), success (defined as technical accuracy without complication), and surgical margin and reexcision status were evaluated. RESULTS. A total of 1013 tags were placed under imaging guidance in 848 patients (mean age, 60 years; range, 23-96 years) and 847 subsequently underwent surgical excision. Tags were most commonly placed for invasive carcinoma (537/1013, 53.0%), ductal carcinoma in situ (138/1013, 13.6%), and high-risk lesions (289/1013, 28.5%). A total of 673 (66.4%) tags were deployed under mammographic guidance, whereas 340 (33.6%) were placed under sonographic guidance. Two or more tags were placed in 149 of 848 patients (17.6%). Targeted lesion types primarily included masses (448/1013, 44.2%), biopsy clip markers (331/1013, 32.7%), and calcifications (155/1013, 15.3%). Technical accuracy of placement was achieved in 1004 (99.1%) tags. Of the nine inaccurate tag placements, seven (77.8%) required an additional tag or wire placement. Seven (0.7%) biopsy clip markers were displaced within the breast or removed by the tag device during placement. No complications were reported intraoperatively. Therefore, success was achieved in 997 (98.4%) tags. Tags were successfully retrieved in all 847 patients who underwent surgery. Of the 568 patients with a preoperative diagnosis of carcinoma, 86 (15.1%) had positive or close surgical margins requiring surgical reexcision. CONCLUSION. Preoperative image-guided localization with radiofrequency tags is a safe and feasible technique for breast lesions requiring surgery. CLINICAL IMPACT. Radiofrequency tag localization is an acceptable alternative to needle or wire localization, offering the potential for improved patient workflow and experience.
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Sanderink WBG, Strobbe LJA, Bult P, Schlooz-Vries MS, Lardenoije S, Venderink DJ, Sechopoulos I, Karssemeijer N, Vreuls W, Mann RM. Minimally invasive breast cancer excision using the breast lesion excision system under ultrasound guidance. Breast Cancer Res Treat 2020; 184:37-43. [PMID: 32737712 PMCID: PMC7568696 DOI: 10.1007/s10549-020-05814-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/15/2020] [Indexed: 11/08/2022]
Abstract
Purpose To assess the feasibility of completely excising small breast cancers using the automated, image-guided, single-pass radiofrequency-based breast lesion excision system (BLES) under ultrasound (US) guidance. Methods From February 2018 to July 2019, 22 patients diagnosed with invasive carcinomas ≤ 15 mm at US and mammography were enrolled in this prospective, multi-center, ethics board-approved study. Patients underwent breast MRI to verify lesion size. BLES-based excision and surgery were performed during the same procedure. Histopathology findings from the BLES procedure and surgery were compared, and total excision findings were assessed. Results Of the 22 patients, ten were excluded due to the lesion being > 15 mm and/or being multifocal at MRI, and one due to scheduling issues. The remaining 11 patients underwent BLES excision. Mean diameter of excised lesions at MRI was 11.8 mm (range 8.0–13.9 mm). BLES revealed ten (90.9%) invasive carcinomas of no special type, and one (9.1%) invasive lobular carcinoma. Histopathological results were identical for the needle biopsy, BLES, and surgical specimens for all lesions. None of the BLES excisions were adequate. Margins were usually compromised on both sides of the specimen, indicating that the excised volume was too small. Margin assessment was good for all BLES specimens. One technical complication occurred (retrieval of an empty BLES basket, specimen retrieved during subsequent surgery). Conclusions BLES allows accurate diagnosis of small invasive breast carcinomas. However, BLES cannot be considered as a therapeutic device for small invasive breast carcinomas due to not achieving adequate excision.
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Affiliation(s)
- W B G Sanderink
- Department of Medical Imaging/Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - L J A Strobbe
- Department of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - P Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M S Schlooz-Vries
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Lardenoije
- Department of Medical Imaging/Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - D J Venderink
- Department of Radiology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - I Sechopoulos
- Department of Medical Imaging/Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - N Karssemeijer
- Department of Medical Imaging/Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - W Vreuls
- Department of Pathology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - R M Mann
- Department of Medical Imaging/Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands.
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Tamburelli F, Ponzone R. The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care. Ann Surg Oncol 2020; 28:340-352. [PMID: 32524463 DOI: 10.1245/s10434-020-08704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Indexed: 02/06/2023]
Abstract
Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.
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Hendriks MP, Verbeek XAAM, van Vegchel T, van der Sangen MJC, Strobbe LJA, Merkus JWS, Zonderland HM, Smorenburg CH, Jager A, Siesling S. Transformation of the National Breast Cancer Guideline Into Data-Driven Clinical Decision Trees. JCO Clin Cancer Inform 2020; 3:1-14. [PMID: 31141422 DOI: 10.1200/cci.18.00150] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The essence of guideline recommendations often is intertwined in large texts. This impedes clinical implementation and evaluation and delays timely modular revisions needed to deal with an ever-growing amount of knowledge and application of personalized medicine. The aim of this project was to model guideline recommendations as data-driven clinical decision trees (CDTs) that are clinically interpretable and suitable for implementation in decision support systems. METHODS All recommendations of the Dutch national breast cancer guideline for nonmetastatic breast cancer were translated into CDTs. CDTs were constructed by nodes, branches, and leaves that represent data items (patient and tumor characteristics [eg, T stage]), data item values (eg, T2 or less), and recommendations (eg, chemotherapy), respectively. For all data items, source of origin was identified (eg, pathology), and where applicable, data item values were defined on the basis of existing classification and coding systems (eg, TNM, Breast Imaging Reporting and Data System, Systematized Nomenclature of Medicine). All unique routes through all CDTs were counted to measure the degree of data-based personalization of recommendations. RESULTS In total, 60 CDTs were necessary to cover the whole guideline and were driven by 114 data items. Data items originated from pathology (49%), radiology (27%), clinical (12%), and multidisciplinary team (12%) reports. Of all data items, 101 (89%) could be classified by existing classification and coding systems. All 60 CDTs could be integrated in an interactive decision support app that contained 376 unique patient subpopulations. CONCLUSION By defining data items unambiguously and unequivocally and coding them to an international coding system, it was possible to present a complex guideline as systematically constructed modular data-driven CDTs that are clinically interpretable and accessible in a decision support app.
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Affiliation(s)
| | | | - Thijs van Vegchel
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | | | | | | | | | | | - Agnes Jager
- Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sabine Siesling
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands.,University of Twente, Enschede, the Netherlands
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22
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Burstein HJ, Curigliano G, Loibl S, Dubsky P, Gnant M, Poortmans P, Colleoni M, Denkert C, Piccart-Gebhart M, Regan M, Senn HJ, Winer EP, Thurlimann B. Estimating the benefits of therapy for early-stage breast cancer: the St. Gallen International Consensus Guidelines for the primary therapy of early breast cancer 2019. Ann Oncol 2019; 30:1541-1557. [PMID: 31373601 DOI: 10.1093/annonc/mdz235] [Citation(s) in RCA: 403] [Impact Index Per Article: 80.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The 16th St. Gallen International Breast Cancer Conference 2019 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. DESIGN Treatments were assessed in light of their intensity, duration and side-effects, estimating the magnitude of clinical benefit according to stage and biology of the disease. The Panel acknowledged that for many patients, the impact of adjuvant therapy or the adherence to specific guidelines may have modest impact on the risk of breast cancer recurrence or overall survival. For that reason, the Panel explicitly encouraged clinicians and patients to routinely discuss the magnitude of benefit for interventions as part of the development of the treatment plan. RESULTS The guidelines focus on common ductal and lobular breast cancer histologies arising in generally healthy women. Special breast cancer histologies may need different considerations, as do individual patients with other substantial health considerations. The panelists' opinions reflect different interpretation of available data and expert opinion where is lack of evidence and sociocultural factors in their environment such as availability of and access to medical service, economic resources and reimbursement issues. Panelists encourage patient participation in well-designed clinical studies whenever available. CONCLUSIONS With these caveats in mind, the St. Gallen Consensus Conference seeks to provide guidance to clinicians on appropriate treatments for early-stage breast cancer and guidance for weighing the realistic tradeoffs between treatment and toxicity so that patients and clinical teams can make well-informed decisions on the basis of an honest reckoning of the magnitude of clinical benefit.
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Affiliation(s)
- H J Burstein
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA.
| | - G Curigliano
- European Institute of Oncology, IRCCS, and University of Milano, Milan, Italy.
| | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - P Dubsky
- Brustzentrum Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - M Gnant
- Medical University Vienna, Vienna, Austria
| | - P Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France; Paris Sciences & Lettres University, Paris, France
| | - M Colleoni
- European Institute of Oncology, IRCCS, and University of Milano, Milan, Italy
| | - C Denkert
- Institut für Pathologie, Charité Universitätsmedizin, Berlin, Germany
| | - M Piccart-Gebhart
- Department of Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - M Regan
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - H-J Senn
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - E P Winer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - B Thurlimann
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
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23
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Morgan J, Potter S, Sharma N, McIntosh SA, Coles CE, Dodwell D, Elder K, Gaunt C, Lyburn ID, McIntosh SA, Morgan J, Paramasivan S, Pinder S, Pirrie S, Potter S, Rea D, Roberts T, Sharma N, Stobart H, Taylor-Phillips S, Wallis M, Wilcox M. The SMALL Trial: A Big Change for Small Breast Cancers. Clin Oncol (R Coll Radiol) 2019; 31:659-663. [PMID: 31160130 DOI: 10.1016/j.clon.2019.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/16/2019] [Accepted: 05/13/2019] [Indexed: 11/16/2022]
Affiliation(s)
- J Morgan
- University of Sheffield, FU32, The Medical School, Sheffield, UK
| | - S Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Bristol Breast Care Centre, Southmead Hospital, Bristol, UK
| | - N Sharma
- Breast Unit, St James Hospital, Leeds, UK
| | - S A McIntosh
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK.
| | | | | | - K Elder
- Western General Hospital, Edinburgh, UK
| | - C Gaunt
- CRCTU, University of Birmingham, UK
| | | | | | | | | | | | - S Pirrie
- CRCTU, University of Birmingham, UK
| | | | - D Rea
- University of Birmingham, UK
| | | | - N Sharma
- St James's University Hospital, Leeds, UK
| | - H Stobart
- Independent Cancer Patients' Voice, UK
| | | | - M Wallis
- Addenbrooke's Hospital, Cambridge, UK
| | - M Wilcox
- Independent Cancer Patients' Voice, UK
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Sorrentino L, Agozzino M, Albasini S, Bossi D, Mazzucchelli S, Vanna R, Papadopoulou O, Villani L, Corsi F. Involved margins after lumpectomy for breast cancer: Always to be re-excised? Surg Oncol 2019; 30:141-146. [PMID: 31500779 DOI: 10.1016/j.suronc.2019.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/14/2019] [Accepted: 08/05/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The oncologic benefit of upfront re-excision of involved margins after breast-conserving surgery in the context of current multimodal clinical management of breast cancer is unclear. The aim of the present study was to assess the 5-years locoregional recurrence (LRR)-free and distant metastases (DM)-free survival probabilities in patients not undergoing re-excision of positive margins after lumpectomy for breast cancer. METHODS A cohort of 104 patients with positive margins not undergoing re-excision was matched by propensity score with a cohort of 2006 control patients with clear margins after breast-conserving surgery, treated between 2008 and 2018. A multivariate survival analysis was performed accounting for all variables related to LRR and DM, including adjuvant treatments. RESULTS After adjusting for potential confounders, avoiding to re-excise a positive margin after lumpectomy had no effect on 5-years LRR-free survival probability (HR 0.98, 95%CI 0.36-2.67, p = 0.96) or 5-years DM-free survival probability (HR 0.37, 95%CI 0.08-1.61, p = 0.18). No correlation was found between occurrence of LRR and number of involved margins (HR 1.28, 95%CI 0.10-12.4, Log-rank p = 0.83), or extension of infiltrating disease (HR 1.21, 95%CI 0.20-7.40, Log-rank p = 0.83), but a trend toward higher LRR probability was found for invasive ductal (HR 6.92, 95%CI 0.7-68.8, Log-rank p = 0.10) and invasive lobular cancer (HR 12.95, 95%CI 0.79-213.6, Log-rank p = 0.07) on positive margins. CONCLUSIONS In the era of multimodal treatment of breast cancer and accurate strategies to reduce the probability of residual disease in the post-lumpectomy cavity, re-excision of positive margins might be omitted in selected patients with low-risk breast cancers.
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Affiliation(s)
- Luca Sorrentino
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, via G. B. Grassi 74, 20157, Milan, Italy
| | - Manuela Agozzino
- Pathology Unit, Istituti Clinici Scientifici Maugeri IRCCS, via S. Maugeri 10, 27100, Pavia, Italy
| | - Sara Albasini
- Surgery Department, Breast Unit, Istituti Clinici Scientifici Maugeri IRCCS, via S. Maugeri 10, 27100, Pavia, Italy
| | - Daniela Bossi
- Surgery Department, Breast Unit, Istituti Clinici Scientifici Maugeri IRCCS, via S. Maugeri 10, 27100, Pavia, Italy
| | - Serena Mazzucchelli
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, via G. B. Grassi 74, 20157, Milan, Italy
| | - Renzo Vanna
- Nanomedicine and Molecular Imaging Lab, Istituti Clinici Scientifici Maugeri IRCCS, via S. Maugeri 10, Pavia, Italy
| | - Ourania Papadopoulou
- Service of Breast Radiology, Department of Radiology, Istituti Clinici Scientifici Maugeri IRCCS, via. S. Maugeri 10, Pavia, Italy
| | - Laura Villani
- Pathology Unit, Istituti Clinici Scientifici Maugeri IRCCS, via S. Maugeri 10, 27100, Pavia, Italy
| | - Fabio Corsi
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, via G. B. Grassi 74, 20157, Milan, Italy.
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Song J, Zhang L, Yi H, Huang J, Zhang N, Zhong Y, Hao L, Ke Yang, Wang Z, Wang D, Yang Z. NIR-responsive nanoplatform for pre/intraoperative image-guided carcinoma surgery and photothermal ablation of residual tumor tissue. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2019; 20:102020. [DOI: 10.1016/j.nano.2019.102020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/01/2019] [Accepted: 05/10/2019] [Indexed: 12/30/2022]
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Cho WK, Choi DH, Park W, Kim H, Cha H. Is higher dose radiation necessary for positive resection margin after breast-conserving surgery for breast cancer? Breast 2019; 47:16-21. [PMID: 31265973 DOI: 10.1016/j.breast.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/11/2019] [Accepted: 06/15/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A positive resection margin after breast-conserving surgery (BCS) usually requires re-excision, which impairs cosmetic outcomes and causes considerable distress. This study aimed to evaluate the prognosis of patients with positive resection margin after BCS and the role of radiation therapy (RT) in these patients. MATERIALS AND METHODS We analyzed 297 patients who underwent BCS for breast cancer and had invasive carcinoma or ductal carcinoma in situ (DCIS) within less than 1 mm from the resection margin in Samsung Medical Center from January 2000 to June 2012. The association between RT dose and the incidence rate of ipsilateral breast tumor recurrence (IBTR) was examined. RESULTS After a median follow-up of 78 months, the incidence rate of IBTR in all patients was 4.6% after 5 years. In the multivariate analysis, the unfavorable factors associated with IBTR were age < 40 years (p = 0.019), RT dose (<60 Gy vs. > 66 Gy, p = 0.012; 60-66 Gy vs. > 66 Gy, p = 0.017), and discontinuation of hormone therapy (p = 0.001). CONCLUSIONS Among the patients with invasive carcinoma or DCIS within less than 1 mm from the resection margin, adjuvant RT with higher dose > 66Gy EQD2 might improve local control. Further prospective studies are warranted to validate the benefit and risk of a high dose boost after BCS in patients with a positive resection margin.
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Affiliation(s)
- Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyejung Cha
- Department of Radiation Oncology, Yonsei University Wonju College of Medicine, Wonju, South Korea
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27
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Kantor O, Pesce C, Kopkash K, Barrera E, Winchester DJ, Kuchta K, Yao K. Impact of the Society of Surgical Oncology-American Society for Radiation Oncology Margin Guidelines on Breast-Conserving Surgery and Mastectomy Trends. J Am Coll Surg 2019; 229:104-114. [DOI: 10.1016/j.jamcollsurg.2019.02.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/07/2019] [Accepted: 02/27/2019] [Indexed: 01/31/2023]
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28
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Schreuder K, Maduro J, Spronk P, Bijker N, Poortmans P, van Dalen T, Struikmans H, Siesling S. Variation in the Use of Boost Irradiation in Breast-Conserving Therapy in the Netherlands: The Effect of a National Guideline and Cofounding Factors. Clin Oncol (R Coll Radiol) 2019; 31:250-259. [DOI: 10.1016/j.clon.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 12/25/2022]
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29
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Houvenaeghel G, Lambaudie E, Bannier M, Rua S, Barrou J, Heinemann M, Buttarelli M, Thomassin Piana J, Cohen M. Positive or close margins: reoperation rate and second conservative resection or total mastectomy? Cancer Manag Res 2019; 11:2507-2516. [PMID: 30992681 PMCID: PMC6445211 DOI: 10.2147/cmar.s190852] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Reoperation after breast-conserving surgery (BCS) could be proposed for positive or close margins. Reoperation type, re-excision or mastectomy, depends on several factors in relation to patient's and tumor's characteristics. We have analyzed our breast cancer (BC) database in order to determine second and third attempts for BCS and mastectomy rates, as well as associated factors for type of surgery. Methods All patients with BCS between 1995 and 2017 were included. Patient's characteristics, pathologic results, and treatments were analyzed. Reoperation rate, type of reoperation, second reoperation, and associated factors of reoperation, mastectomy, and third intervention were determined. Three periods were determined: P1-P3. Results We analyzed 10,761 patients: 1,161 with ductal carcinoma in situ (DCIS) and 9,600 with invasive BC. The reoperation rate was 41.4% for DCIS and 28.0% for invasive BC. Using multivariate analysis, we identified tumor size >20 mm as being a risk factor for reoperation, whereas age >50 years, P2-3, and some localization decreased reoperation rates. For invasive BC, age >40 years, triple-negative tumors, neoadjuvant chemotherapy, and noncentral tumors decreased reoperation rates and lobular tumor, multifocal tumors, lymphovascular invasion, DCIS component, and Her2-positive tumors increased reoperation rates. For patients requiring reoperation, re-excision was performed in 48.1% (1,523/3,168) and mastectomy was required after first re-excision in 13.46% (205/1,523). For DCIS, mastectomy rates were higher for grade 2 and tumor ≥20 mm. For invasive BC, mastectomy rates were higher for lobular, multifocal, ≥20 mm, Her2-positive tumors and diffuse positive margins and lower for age >50 years and during the last period. Even if interval time between surgery and adjuvant treatments was higher for patients with reoperation, survival rates were not different between patients with and without reoperation. Conclusion A decrease in reoperation and mastectomy rates had been reported with several associated factors. A third intervention with mastectomy was required in 13.5% of patients. This information should be done in case of reoperation.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Eric Lambaudie
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Marie Bannier
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Julien Barrou
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Mellie Heinemann
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 13009 Marseille, France,
| | - Max Buttarelli
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
| | - Jeanne Thomassin Piana
- Department of Pathology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, 13009 Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, 13009 Marseille, France
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30
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Grant Y, Al-Khudairi R, St John E, Barschkett M, Cunningham D, Al-Mufti R, Hogben K, Thiruchelvam P, Hadjiminas DJ, Darzi A, Carter AW, Leff DR. Patient-level costs in margin re-excision for breast-conserving surgery. Br J Surg 2018; 106:384-394. [PMID: 30566233 DOI: 10.1002/bjs.11050] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/04/2018] [Accepted: 10/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS. METHODS The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85. RESULTS The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001). CONCLUSION The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.
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Affiliation(s)
- Y Grant
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - R Al-Khudairi
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - E St John
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - M Barschkett
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - D Cunningham
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - R Al-Mufti
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - K Hogben
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - P Thiruchelvam
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - D J Hadjiminas
- Breast Unit, Imperial College Healthcare NHS Trust, London, UK
| | - A Darzi
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - A W Carter
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - D R Leff
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK.,Breast Unit, Imperial College Healthcare NHS Trust, London, UK
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Santos IP, Barroso EM, Bakker Schut TC, Caspers PJ, van Lanschot CGF, Choi DH, van der Kamp MF, Smits RWH, van Doorn R, Verdijk RM, Noordhoek Hegt V, von der Thüsen JH, van Deurzen CHM, Koppert LB, van Leenders GJLH, Ewing-Graham PC, van Doorn HC, Dirven CMF, Busstra MB, Hardillo J, Sewnaik A, Ten Hove I, Mast H, Monserez DA, Meeuwis C, Nijsten T, Wolvius EB, Baatenburg de Jong RJ, Puppels GJ, Koljenović S. Raman spectroscopy for cancer detection and cancer surgery guidance: translation to the clinics. Analyst 2018; 142:3025-3047. [PMID: 28726868 DOI: 10.1039/c7an00957g] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Oncological applications of Raman spectroscopy have been contemplated, pursued, and developed at academic level for at least 25 years. Published studies aim to detect pre-malignant lesions, detect cancer in less invasive stages, reduce the number of unnecessary biopsies and guide surgery towards the complete removal of the tumour with adequate tumour resection margins. This review summarizes actual clinical needs in oncology that can be addressed by spontaneous Raman spectroscopy and it provides an overview over the results that have been published between 2007 and 2017. An analysis is made of the current status of translation of these results into clinical practice. Despite many promising results, most of the applications addressed in scientific studies are still far from clinical adoption and commercialization. The main hurdles are identified, which need to be overcome to ensure that in the near future we will see the first Raman spectroscopy-based solutions being used in routine oncologic diagnostic and surgical procedures.
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Affiliation(s)
- Inês P Santos
- Center for Optical Diagnostics and Therapy, Department of Dermatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Clement Z, McLeay W, Hoffmann C, Shin P, Chowdhry M, Eaton M. Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study. Breast Dis 2018; 38:7-13. [PMID: 30198861 DOI: 10.3233/bd-180339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique. METHODS This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors. RESULTS 415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01). CONCLUSION BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.
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Affiliation(s)
- Zackariah Clement
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - William McLeay
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Clive Hoffmann
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Peter Shin
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Munir Chowdhry
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Michael Eaton
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia.,Medical School, Flinders University, Adelaide, Australia
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A national multicenter study on 1072 DCIS patients treated with breast-conserving surgery and whole breast radiotherapy (COBCG-01 study). Radiother Oncol 2018; 131:208-214. [PMID: 30075864 DOI: 10.1016/j.radonc.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Breast-conserving surgery (BCS) and whole breast radiation (RT) with or without endocrine therapy (ET) represent the standard of care for ductal carcinoma in situ (DCIS). The use of adjuvant treatments after surgery is still controversial in this setting. We performed a retrospective multicenter analysis on a series of DCIS patients treated with BCS and adjuvant RT. MATERIALS AND METHODS We collected clinical data from nine Italian centers on 1072 women having a diagnosis of DCIS and treated between 1997 and 2012. We reported on the 5- and 10-year local recurrence (LR) rates, overall survival, and breast cancer specific survival (BCSS) employing the Kaplan-Meier method. RESULTS At a median follow-up of 8.4 years, 67 LR (6.3%) and 47 deaths (4.4%) were observed. LR rates at 5 and 10 years were 3.4% and 7.6%, respectively. BCSS rates at 5 and 10 years were 99.7% and 99.1%, respectively. At univariate regression analysis, postmenopausal state (p = 0.009), estrogen receptor (ER) (p = 0.0001) and progesterone receptor (p = 0.018) positivity and ET (p = 0.006) were inversely correlated with LR. Final surgical margins (FSM) status <1 mm was significantly correlated with higher LR (p = 0.003). At multivariate regression analysis postmenopausal state (p = 0.03), and ER positive (p = 0.045) maintained the significant favorable feature, while FSM <1 mm (p = 0.024) confirmed its negative impact on LR. CONCLUSIONS Our real-life study pointed out the significant favorable prognostic role of postmenopausal state and ER positive status on LR occurrence. FSM <1 mm was significantly correlated to a higher chance to experience LR.
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Park S, Ahn SD, Choi EK, Kim SS. The effect of escalating the boost dose for patients with involved resection margin after breast-conserving surgery. Jpn J Clin Oncol 2018; 48:272-277. [PMID: 29385496 PMCID: PMC6018944 DOI: 10.1093/jjco/hyy002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/12/2018] [Indexed: 11/28/2022] Open
Abstract
Background This study aims to investigate the impact of boost dose escalation on ipsilateral breast tumor recurrence (IBTR) in breast cancer patients with involved resection margins following breast-conserving surgery. Methods Between January 1998 and December 2010, 192 patients were treated with a boost dose of over 10 Gy for involved resection margins. We retrospectively analyzed outcomes in 192 patients who underwent whole breast irradiation of 50.4 Gy followed by a median boost dose of 15.0 Gy (range, 12–16 Gy). Boost doses of 12.5 Gy and 15 Gy were delivered to patients with carcinoma in situ and invasive carcinoma, respectively, at the positive margins. We evaluated the impact of the boost dose on the IBTR rate. Results Median follow-up duration was 6.7 years (0.4–15.6 years). The 5-year cumulative risk of IBTR as a first event was 5.0%. IBTR occurred as a first recurrence in 13 of 192 patients. In-boost-field recurrences were found in 11 patients (85%). Five patients (39%) experienced out-of boost field recurrences, and three experienced both types of recurrences. In multivariate analysis, age (<40 years), pT stage, and positive radial resection margin were prognostic factors for IBTR (P = 0.029, P = 0.024 and P = 0.035, respectively). Conclusions A median boost dose of 15 Gy might be insufficient in patients younger than 40 years, with tumor size greater than 2 cm, or with involved radial resection margins. On the other hand, in cases of positive superficial or deep margins, dose-escalated boost or re-excision may not be necessary.
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Affiliation(s)
- Sunmin Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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35
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Osborn VW, Givi B, Rineer J, Roden D, Sheth N, Lederman A, Katsoulakis E, Hu K, Schreiber D. Patterns of care and outcomes of adjuvant therapy for high-risk head and neck cancer after surgery. Head Neck 2018; 40:1254-1262. [PMID: 29451961 DOI: 10.1002/hed.25103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/20/2017] [Accepted: 01/18/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Postoperative chemoradiotherapy (CRT) is considered standard of care in patients with locally advanced head and neck cancer with positive margins and/or extracapsular extension (ECE). METHODS The National Cancer Data Base (NCDB) was queried to identify patients with squamous cell carcinoma of the head and neck with stages III to IVB disease or with positive margins and/or ECE diagnosed between 2004 and 2012 receiving postoperative radiotherapy (RT). Using univariable and multivariable logistic and Cox regression, we assessed for predictors of CRT use and covariables impacting overall survival (OS), including in a propensity-matched subset. RESULTS Of 12 224 patients, 67.1% with positive margins and/or ECE received CRT as well as 54.0% without positive margins and/or ECE. The 5-year OS was 61.6% for RT alone versus 67.4% for CRT. In the propensity-matched cohort, OS benefit persisted with CRT, including in a subset with positive margins and/or ECE but not without. CONCLUSION Postoperative CRT seems underutilized with positive margins and/or ECE and overutilized without positive margins and/or ECE. The CRT was associated with improved OS but the benefit persisted only in the subset with positive margins and/or ECE.
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Affiliation(s)
- Virginia Wedell Osborn
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,SUNY Downstate Medical Center, Brooklyn, New York
| | - Babak Givi
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,NYU Langone Medical Center, New York, New York
| | - Justin Rineer
- UF Health Cancer Center Orlando Health, Orlando, Florida
| | - Dylan Roden
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,NYU Langone Medical Center, New York, New York
| | - Niki Sheth
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,SUNY Downstate Medical Center, Brooklyn, New York
| | - Ariel Lederman
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,SUNY Downstate Medical Center, Brooklyn, New York
| | | | - Kenneth Hu
- NYU Langone Medical Center, New York, New York
| | - David Schreiber
- Department of Veterans Affairs New York Harbor Healthcare System, New York, New York.,SUNY Downstate Medical Center, Brooklyn, New York
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Vos EL, Gaal J, Verhoef C, Brouwer K, van Deurzen CHM, Koppert LB. Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence. Eur J Surg Oncol 2017; 43:1846-1854. [PMID: 28688723 DOI: 10.1016/j.ejso.2017.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision after breast conserving surgery (BCS) for invasive breast cancer (IBC) can be omitted for focally positive margins in the Netherlands, but this guideline is not routinely followed. Focally positive and extensively positive margins have rarely been studied separately and compared to negative margins regarding clinicopathological predictors, residual disease incidence, and local recurrence. METHODS All females with BCS for Tis-T3, without neo-adjuvant chemotherapy between 2005 and 2014 at one university hospital were included. Clinicopathological and follow-up information was collected from electronic patient records. Index tumor samples from all patients with re-excision were reviewed by one pathologist. Margins were classified as negative (≥2 mm width), close (<2 mm width), focally positive (≤4 mm length of tumor touching inked margin), or extensively positive (>4 mm length). RESULTS From 499 patients included, 212 (43%) had negative, 161 (32%) had close, 59 (12%) had focally positive, and 67 (13%) had extensively positive margins. Increasingly involved margins were associated with lobular type, tumor size, and adjacent DCIS in IBC patients and lesion size in purely DCIS patients. In IBC patients, 17%, 49%, and 77% had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 55%, 50%, and 70% respectively. In purely DCIS patients, 26 (65%), 13 (87%), and 16 (94%) had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 39%, 46%, and 90% respectively. CONCLUSION Incidence of residual disease after focally positive margins was not different from close margins, but was significantly higher after extensively positive margins. We recommend quantifying extent of margin involvement in all pathology reports.
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Affiliation(s)
- E L Vos
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - J Gaal
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - K Brouwer
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - C H M van Deurzen
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - L B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands.
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