Controversies in Breast Cancer Surgery

Individualized Analysis of Nipple-Sparing Mastectomy Versus Modified Radical Mastectomy Using Deep Learning

Background

This study aimed to evaluate the impact of nipple-sparing mastectomy (NSM) and modified radical mastectomy (MRM) on individual survival outcomes and to assess the potential of neoadjuvant systemic therapy (NST) in reducing surgical intervention requirements.

Methods

To develop treatment recommendations for breast cancer patients, five machine learning models were trained. To mitigate bias in treatment allocation, advanced statistical methods, including propensity score matching (PSM) and inverse probability treatment weighting (IPTW), were applied.

Results

NSM demonstrated either superior or noninferior survival outcomes compared with MRM across all breast cancer stages, irrespective of adjustments for IPTW and PSM. Among all models and National Comprehensive Cancer Network guidelines, the Balanced Individual and Mixture Effect (BIME) for survival regression model proposed in this study showed the strongest protective effects in treatment recommendations, as evidenced by an IPTW hazard ratio of 0.39 (95% CI: 0.26-0.59), an IPTW risk difference of 19.66% (95% CI: 18.20-21.13), and an IPTW difference in restricted mean survival time of 17.77 months (95% CI: 16.37-19.21). NST independently reduced the probability of surgical intervention by 1.4% (95% CI: 0.9%-2.0%), with the greatest impact observed in patients with locally advanced breast cancer, in whom a 4.5% reduction (95% CI: 3.8%-5.2%) in surgical selection was noted.

Conclusions

The BIME model provides superior accuracy in recommending surgical approaches for breast cancer patients, leading to improved survival outcomes. These findings underscore the potential of BIME to enhance clinical decision-making. However, further investigation incorporating comprehensive prognostic evaluation is needed to optimize the surgical selection process and refine its clinical utility.

Identification of the optimal candidates to benefit from surgery and chemotherapy among elderly female breast cancer patients with bone metastases

Breast cancer is currently the most common malignant tumor affecting women's health worldwide. The rise in breast cancer metastases among patients is attributed to the inherent variability in metastatic behavior. In breast cancer, bones are the primary location for distant metastases, significantly impacting the survival rates of elderly (≥ 65) patients. The use of surgery and chemotherapy in this population is controversial. This study seeks to create a tool for forecasting overall survival (OS) in older breast cancer patients with bone metastases and to determine the optimal candidates for surgery and chemotherapy. Elderly female breast cancer patients with bone metastases from the Surveillance, Epidemiology, and End Results (SEER) database were included in this study and categorized into a training cohort and a validation cohort using R software. To identify independent predictors of OS in this population, both univariate and multivariate Cox regression analyses were conducted. Subsequently, a prognostic nomogram was created to estimate OS at 12, 24, and 36 months. The nomogram's accuracy and practical value were assessed using a calibration curve, area under the curve (AUC), and decision curve analysis (DCA). At the same time, a mortality risk classification system based on the nomogram was created to divide the population into high and low mortality risk categories, and subgroups were analyzed to determine the optimal candidates for surgery and chemotherapy. This study encompassed 2257 elderly female breast cancer patients with bone metastases, divided into 1581 participants for the training cohort and 676 for the validation cohort. Both univariate and multivariate Cox regression analyses validated those variables such as age, race, marital status, histological type, tumor grade, ER status, PR status, breast subtype, distant metastases (lung, liver, and brain), and treatment methods (surgery and chemotherapy) independently predicted OS in elderly female breast cancer patients with bone metastases (p < 0.05). Utilizing these independent predictors, a prognostic nomogram was developed to estimate OS at 12, 24, and 36 months. The calibration curves indicated that the nomogram's predictions closely matched the observed outcomes. The nomogram's AUC for forecasting OS at 12, 24, and 36 months was 0.753, 0.748, and 0.745 in the training cohort, and 0.744, 0.723, and 0.723 in the validation cohort. Additionally, the nomogram's AUC surpassed that of any individual independent predictor. DCA showed that the nomogram could achieve more net clinical benefit over a broader range of threshold probabilities. The nomogram-based risk classification system effectively sorted patients into two categories: low risk (≤ 820) and high risk (> 820). Subgroup analysis indicated that individuals classified as low-risk experienced the greatest advantage from surgery and chemotherapy (p < 0.05), whereas the high-risk group did not exhibit a statistically significant difference (p > 0.05). Drawing from the clinicopathological characteristics of elderly female breast cancer patients with bone metastases, this study developed a novel prognostic nomogram to forecast OS at 12, 24, and 36 months, enabling precise survival predictions. In addition, this study also constructed a mortality risk classification system, which can effectively help clinicians screen out the optimal candidates to benefit from surgery and chemotherapy and rationalize the allocation of medical resources.

The Five-Year Outcomes of Breast Cancer Surgical Management at the Colentina Surgical Clinic, Bucharest, Romania: A Descriptive Retrospective Analysis Between 2019 and 2023

Background: Breast cancer still represents the most commonly diagnosed cancer among women, accounting for 12.5% of all new annual cancer cases worldwide. In Romania in 2020, breast cancer was the most common, with a share of new cases of 26.9%, far behind the rates of colon cancer (11.8%) and cervix cancer (7.5%). The aim of this study is to reveal five years of experience in treating breast cancer at the Surgical Clinic of the Colentina Hospital in Bucharest, Romania. Methods: Retrospective analysis, including 68 patients admitted to our clinic between January 2019 and December 2023 undergoing modified radical mastectomy, sectorectomy, or subcutaneous mastectomy. Results: Madden-modified radical mastectomy with total excision of the axillary lymph nodes accounted for 77.94% of surgeries, with a complication rate of 13.2%, represented by lymphedema of the ipsilateral arm and prepectoral seroma. Conclusions: Continuous innovation regarding early diagnosis and treatment methods in our surgical clinic will, hopefully, contribute to improving the outcomes of our patients.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.