Moving incision for covert breast-conserving surgery may prevent early wound complications in brachytherapy-based partial-breast irradiation

Preliminary report on ultrashort perioperative partial-breast irradiation with multicatheter interstitial brachytherapy for early-stage breast cancer

PURPOSE

Perioperative partial-breast irradiation (PBI) with multicatheter interstitial brachytherapy (MIB) is less invasive and more convenient than postoperative one. This study aimed to compare ultrashort perioperative MIB-PBI (uPBI) and conventional perioperative MIB-PBI (cPBI) performed during the same period of time.

METHODS

Inclusion criteria of the study were patients aged ≥ 40 years and those with T0-2 (≤ 3 cm), N0-mi, and negative margins on mammography. The locoregional recurrence (LRR) and toxicity rates were compared between uPBI at a dose of 25.2 Gy in four fractions and cPBI at a dose of 32 Gy in eight fractions.

RESULTS

In total, 198 patients (151 with uPBI and 47 with cPBI) were evaluated. At a median follow-up of 20.1 months, one (0.66%) patient in the uPBI group had LRR. The 2-year ipsilateral breast tumor recurrence-free survival rates of the uPBI and cPBI groups were 98.7% and 100%, respectively. The highest toxicity grades were grade 1 in 23 (15.2%) and grade 2 in 2 (1.3%) patients in the uPBI group, and grade 1 in 8 (17.0%) and grade 2 in 1 (2.1%) patient in the cPBI group. None of the patients in the two groups presented with grade 3 and higher toxicities. The toxicity rates between the two groups did not significantly differ. Further, 22 (14.6%) patients in the uPBI group and 8 (17.0%) in the cPBI group, and 3 (2.0%) patients in the uPBI group and 1 (2.1%) in the cPBI had acute and late toxicities, respectively. The timing of toxicity development between the two groups did not significantly differ.

CONCLUSIONS

Although this preliminary report included a small sample size and had a short follow-up period, the local control and toxicity rates were similar between the uPBI and cPBI groups. Further research is warranted to investigate the ideal dose schedule of MIB-PBI.

Impact of de-escalating systemic therapy guided by 21-gene assay on locoregional recurrence after partial-breast irradiation

PURPOSE

Partial-breast irradiation (PBI) has been performed as alternative to whole-breast irradiation (WBI) in breast-conserving therapy (BCT). Recently, the 21-gene recurrence score (RS) was introduced to determine the adjuvant therapy for estrogen receptor (ER)-positive, and human epidermal growth factor receptor 2 (HER2)-negative diseases. However, the impact of RS-based systemic therapy on locoregional recurrence (LRR) following BCT with PBI remains uninvestigated.

METHODS AND MATERIALS

Patients with ER-positive, HER2-negative, and node-negative breast cancer who underwent BCT with PBI were examined during May 2012-March 2022. In addition to immunohistochemistry (IHC), RS was available to decide on adjuvant therapy.

RESULTS

In total, 431 patients were evaluated with a median followup of 48.6 months. The 4-year LRR-free survival rates were 97.3% and 96.4% in the IHC and RS cohorts, respectively (p = 0.50). Ki67 of >20% was significantly associated with LRR in the multivariate analysis (HR 4.39, p < 0.05). For patients with Ki67 > 20%, 29 of 71 (40.8%) and 46 of 59 (78.0%) patients received only endocrine therapy in the IHC and RS cohorts, respectively (p < 0.0001). For patients with Ki67 >20% who received only endocrine therapy, the 4-year LRR-free survival rates were 91.8% in the IHC cohort and 94.6% in the RS cohort (p = 0.29) CONCLUSIONS: Although the introduction of RS increased the number of patients receiving endocrine therapy alone for Ki67 >20% of disease by two times, the LRR-free survival after BCT with PBI could be maintained. However, further studies from multiple institutions with longer followup data are required.

Efficacy of digital breast tomosynthesis combined with magnetic resonance imaging in the diagnosis of early breast cancer

BACKGROUND

The incidence and mortality rate of breast cancer in China rank 120^th and 163^rd, worldwide, respectively. The incidence of breast cancer is on the rise; the risk increases with age but is slightly reduced after menopause. Early screening, diagnosis, and timely determination of the best treatment plan can ensure clinical efficacy and prognosis.

AIM

To evaluate the clinical value of magnetic resonance imaging (MRI) combined with digital breast tomosynthesis (DBT) in diagnosing early breast cancer and the effect of breast-conserving surgery by arc incision.

METHODS

This study was divided into two parts. Firstly, 110 patients with early breast cancer confirmed by pathological examination and 110 with benign breast diseases diagnosed simultaneously in Changzhi People’s Hospital of Shanxi Province and Shanxi Dayi Hospital from May 2019 to September 2020 were included in the breast cancer group and the benign group, respectively. Both groups underwent DBT and MRI examination, and the pathological results were used as the gold standard to evaluate the effectiveness of the combined application of DBT and MRI in the diagnosis of early breast cancer. Secondly, according to the operation method, 110 patients with breast cancer were divided into either a breast-conserving group (69 patients) or a modified radical mastectomy group (41 patients). The surgical effect, cosmetic effect, and quality of life of the two groups were compared.

RESULTS

Among the 110 cases of breast cancer, 66 were of invasive ductal carcinoma (60.00%), and 22 were of ductal carcinoma in situ (20.00%). Among the 110 cases of benign breast tumors, 55 were of breast fibromas (50.00%), and 27 were of breast adenosis (24.55%). The sensitivity, specificity, and area under the curve (AUC) of DBT in the differential diagnosis of benign and malignant breast tumors were 73.64%, 84.55%, and 0.791, respectively. The sensitivity, specificity, and AUC of MRI in the differential diagnosis of benign and malignant breast tumors were 84.55%, 85.45%, and 0.850, respectively. The sensitivity, specificity, and AUC of DBT combined with MRI in the differential diagnosis of benign and malignant breast tumors were 97.27%, 93.64%, and 0.955, respectively. The blood loss, operation time and hospitalization time of the breast-conserving group were significantly lower than those of the modified radical treatment group, and the difference was statistically significant (P < 0.05). After 3 mo of observation, the breast cosmetic effect of the breast-conserving group was better than that of the modified radical group, and the difference was statistically significant (P < 0.05). Before surgery, the quality-of-life scores of the breast-conserving and modified radical mastectomy groups did not differ (P > 0.05). Three months after surgery, the quality-of-life scores in both groups were higher than those before surgery (P < 0.05), and the quality-of-life score of the breast-conserving group was higher than that of the modified radical group (P < 0.05). In the observation of tumor recurrence rate two years after the operation, four patients in the breast-conserving group and one in the modified radical treatment group had a postoperative recurrence. There was no significant difference in the recurrence rate between the two groups (χ² = 0.668, P = 0.414 > 0.05).

CONCLUSION

MRI combined with DBT in diagnosing early breast cancer can significantly improve the diagnostic efficacy compared with the two alone. Breast-conserving surgery leads to better cosmetic breast effects and reduces the impact of surgery on postoperative quality of life.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

Predicting adherence of dose-volume constraints for personalized partial-breast irradiation technique

PURPOSE

Multicatheter interstitial brachytherapy (MIB) and external-beam (EB) radiotherapy are established partial-breast irradiation (PBI) techniques. Although EB-PBI is widely available, it requires extra irradiated margins for target uncertainties. We examined the impact of EB-PBI on dose-volume constraints as compared to MIB-PBI.

METHODS AND MATERIALS

Among 653 patients receiving MIB-PBI between October 2008 and April 2020, consequent 159 patients after September 2018 were examined. Clinical target volume (CTV) included the lumpectomy cavity plus 1.0 cm. Planning target volume (PTV) for EB-PBI was defined as CTV with 1.0-cm expansion. Because the ratio of PTV to breast volume (RPB) was related to cosmesis, <25% of RPB was defined as suitable for the ipsilateral breast constraints. Preoperative breast size was classified as very small (<350 cm³), small (350-699 cm³), and medium or large (≥700 cm³). According to each category, the dose-volume constraints of the organs at risk were compared between the two PBI techniques.

RESULTS

Patients including 84 very small, 59 small, and 16 moderate to large breasts were examined. Although RPB was suitable in all patients receiving MIB-PBI, it was achieved in 74 patients (46.5%) receiving EB-PBI (p < 0.0001). The suitable RPB in patients with very small, small, and moderate to large breast was 32.1%, 55.9%, and 100%, respectively (p < 0.0001). Normal-tissue constraints for the other organs could be satisfied in patients with moderate to large breasts.

CONCLUSION

Although EB-PBI may be an appropriate option for patients with moderate to large breasts, MIB-PBI could still be a crucial technique, especially for patients with small breasts.