Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute

The Postoperative Breast: Imaging Findings and Diagnostic Pitfalls After Breast-Conserving Surgery and Oncoplastic Breast Surgery

Breast surgery is the cornerstone of treatment for early breast cancer. Historically, mastectomy and conventional breast-conserving surgery (BCS) were the main surgical techniques for treatment. Now, oncoplastic breast surgery (OBS), introduced in the 1990s, allows for a combination of BCS and reconstructive surgery to excise the cancer while preserving or enhancing the contour of the breast, leading to improved aesthetic results. Although imaging after conventional lumpectomy demonstrates typical postsurgical changes with known evolution patterns over time, OBS procedures show postsurgical changes/fat necrosis in locations other than the lumpectomy site. The purpose of this article is to familiarize radiologists with various types of surgical techniques for removal of breast cancer and to distinguish benign postoperative imaging findings from suspicious findings that warrant further work-up.

Immediate Symmetrization of the Contralateral Breast in Breast Reconstruction-Revision, Complications, and Satisfaction: A Systematic Review

Background

It is desirable to achieve breast symmetry after unilateral surgery for breast tumors. Thus, contralateral balancing is often required, but it is still debated whether symmetrization surgery should be performed alongside reconstruction or as a delayed procedure. Therefore, we aimed to compare revision rates, complication rates, and satisfaction levels between those who underwent immediate versus delayed symmetrization.

Methods

A systematic review was designed to summarize the revision surgery rates, complication rates, and satisfaction levels of patients who underwent contralateral breast symmetrization at the same time as breast reconstruction. We included articles published between 2010 and 2022 in databases such as PubMed, MEDLINE, and Embase.

Results

Most studies showed no difference or lower revision rates for immediate symmetrization, except for one study where immediate symmetrization had a revision rate twice that of delayed symmetrization. There were no significant differences in complication rates between the two groups. Regarding satisfaction levels, most studies showed that the immediate group had higher scores regardless of statistical significance; however, breast-related satisfaction was significantly higher in the immediate group than in the delayed group.

Conclusion

This systematic review demonstrates that immediate symmetrization surgery does not increase revision surgery and complication rates or decrease satisfaction levels.

Additional occult cancers identified on staging breast MRI: imaging appearances and pathologic characteristics

INTRODUCTION

Breast magnetic resonance imaging (MRI) is increasingly being used for staging of patients with breast cancer due to its high sensitivity in detecting additional cancers (ACs). However, the clinical impact of diagnosing and treating these cancers remains unclear.

METHODS

A retrospective study was undertaken of patients with newly diagnosed breast cancer who underwent staging MRI at The American University of Beirut Medical Centre (AUBMC) between 2012 and 2020. Pathology reports and breast MRI examinations were reviewed. Eighteen breast cancer patients with 19 pathology-proven index cancers (ICs) and 19 pathology-proven MRI-detected ACs were included. Chi-square and Fisher's exact tests for categorical variables and Wilcoxon signed rank test for numerical variables were used to compare ICs to ACs.

RESULTS

The ICs consisted of four ductal carcinoma in situ (DCIS), 13 invasive ductal carcinomas (IDC), of which five with associated DCIS, and two invasive lobular carcinomas, (ILC) of which one with associated DCIS. ACs comprised 12 DCIS, five IDC, two with associated DCIS and two ILC, one with associated DCIS. Interval cancers were more frequently invasive whereas ACs were more frequently in situ (P = 0.021). ACs were more frequently nuclear grade 2 (P = 0.009). There was no statistically significant difference between ICs and ACs in lesion type (P = 0.062), shape (P = 0.073), initial enhancement (P = 1), delayed enhancement (P = 0.732), hormonal receptor profile (P = 0.68) and Ki67 (P = 0.388). Among ACs, ten (53%) were larger than 10 mm of which five (26%) were invasive cancers, and five (26%) were larger than the ICs.

CONCLUSIONS

ACs detected by breast MRI were more likely to be in situ and to show a nuclear grade 2. Although not reaching statistical significance, some ACs tend to be clinically significant by their type, size or nuclear grade. The impact on clinical management remains to be determined.

Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance)

PURPOSE

Breast-conserving therapy (BCT) is the preferred treatment for unifocal breast cancer (BC). The oncologic safety of BCT for multiple ipsilateral breast cancer (MIBC) has not been demonstrated in a prospective study. ACOSOG Z11102 (Alliance) is a phase II, single-arm, prospective trial designed to evaluate oncologic outcomes in patients undergoing BCT for MIBC.

PATIENTS AND METHODS

Women age 40 years and older with two to three foci of biopsy-proven cN0-1 BC were eligible. Patients underwent lumpectomies with negative margins followed by whole breast radiation with boost to all lumpectomy beds. The primary end point was cumulative incidence of local recurrence (LR) at 5 years with an a priori rate of clinical acceptability of <8%.

RESULTS

Among 270 women enrolled between November 2012 and August 2016, there were 204 eligible patients who underwent protocol-directed BCT. The median age was 61 years (range, 40-87 years). At a median follow-up of 66.4 months (range, 1.3-90.6 months), six patients developed LR for an estimated 5-year cumulative incidence of LR of 3.1% (95% CI, 1.3 to 6.4). Patient age, number of sites of preoperative biopsy-proven BC, estrogen receptor status and human epidermal growth factor receptor 2 status, and pathologic T and N categories were not associated with LR risk. Exploratory analysis showed that the 5-year LR rate in patients without preoperative magnetic resonance imaging (MRI; n = 15) was 22.6% compared with 1.7% in patients with a preoperative MRI (n = 189; P = .002).

CONCLUSION

The Z11102 clinical trial demonstrates that breast-conserving surgery with adjuvant radiation that includes lumpectomy site boosts yields an acceptably low 5-year LR rate for MIBC. This evidence supports BCT as a reasonable surgical option for women with two to three ipsilateral foci, particularly among patients with disease evaluated with preoperative breast MRI.

The no-vertical scar technique for oncoplastic breast reconstruction

INTRODUCTION

Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri‑areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction.

METHODS

Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation.

RESULTS

Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required.

CONCLUSION

The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

A prospective analysis of two studies that used the 5-mm interval slices and 5-mm margin-free method for ipsilateral breast tumor recurrence after breast-conserving surgery without radiotherapy

BACKGROUND

Breast-conserving surgery with radiotherapy is one of standard treatments for early breast cancer. However, it is regarded as an option to treat elderly patients with small hormone receptor-positive breast cancer with breast-conserving surgery and hormone therapy without radiotherapy. We conducted two sequential prospective studies to examine the feasibility of breast-conserving surgery without radiotherapy since 2002 and present the results.

PATIENTS AND METHODS

Primary female breast cancer patients who fulfilled the strict eligibility criteria were prospectively enrolled in two sequential studies named WORTH 1 and 2. The surgical materials were sliced in 5-mm intervals and all slices were examined microscopically. Postoperative radiotherapy was not allowed, but tamoxifen or anastrozole was administered for 5 years. Ipsilateral breast tumor recurrence (IBTR)-free survival was the primary outcome.

RESULTS

The data of the two studies were combined (N = 321). The median follow-up period for IBTR was 94 months (4-192 months). Only three patients were treated with adjuvant chemotherapy. The 5- and 10-year IBTR-free rates were 97.0% and 90.5%, respectively. The age at operation and PR status affected IBTR rates independently. When we calculated IBTR-free rates of patients who were 65 years of age or older at the time of surgery and had PR-positive tumors, the 5- and 10-year IBTR rates were both 98.4%.

CONCLUSIONS

 Our "5-mm-thick slice and 5-mm free-margin" method may be effective to select patients who can be treated by breast-conserving surgery and hormone therapy without radiotherapy.

Comparison of Clinical Outcomes Between Low- and High-Risk Groups of Early Breast Cancer Patients Treated with Intraoperative Radiotherapy in Addition to External Beam Radiation: A Multi-Centre Prospective Study

BACKGROUND

There is a paucity of data on the use of intraoperative radiotherapy (IORT) with low-energy X-rays in Malaysian women with early breast cancer. The aim of this study is to evaluate the clinical, cosmetic, and patient-reported outcomes in low- and high-risk early breast cancer patients treated with breast conserving surgery (BCS) and IORT.

METHODOLOGY

Patients suitable for BCS who were treated with IORT between January 2016 and June 2019 from three centres were analysed. They were divided into low-risk and high-risk groups based on the risk of recurrence according to the TARGeted Intraoperative radioTherapy (TARGIT) A and B study criteria. Outcomes of interest included local recurrence, wound complications, and radiation toxicity, with a subset analysed for cosmetic and patient-reported outcomes.

RESULTS

Within a median follow-up of 31 months, there were 104 and 211 patients in the low- and high-risk groups, respectively. No significant difference was observed in local recurrence rates (low-risk, 1.0% vs. high-risk, 1.4%; p = 1.000). Both cohorts exhibited low frequencies of severe wound complications ranging between 1.4 and 1.9%. No major radiation toxicities were reported in either group. In the subgroup analysis, low-risk patients had significantly better mean scores in the subscales of inframammary fold and scar. Based on the BREAST-Q patient-reported outcomes questionnaire, seven out of nine parameters were scored similarly between both groups with no significant difference.

CONCLUSION

This study showed that the use of IORT in both low- and high-risk early breast cancers is efficacious and safe with low recurrence rates and an acceptable toxicity profile.

Robotic Stereotactic Body Radiation Therapy for the Adjuvant Treatment of Early-Stage Breast Cancer: Outcomes of a Large Single-Institution Study

Purpose

Advancements in breast radiation therapy offer innumerable benefits to patients and the health care system. Despite promising outcomes, clinicians remain hesitant about long-term side effects and disease control with accelerated partial breast radiation therapy (APBI). Herein, we review the long-term outcomes of patients with early-stage breast cancer treated with adjuvant stereotactic partial breast irradiation (SAPBI).

Methods and Materials

This retrospective study examined outcomes of patients who received diagnoses of early-stage breast cancer treated with adjuvant robotic SAPBI. All patients were eligible for standard ABPI and underwent lumpectomy, followed by fiducial placement in preparation for SAPBI. Using fiducial and respiratory tracking to maintain a precise dose distribution throughout the course of treatment, patients received 30 Gy in 5 fractions on consecutive days. Follow-up occurred at routine intervals to evaluate disease control, toxicity, and cosmesis. Toxicity and cosmesis were characterized using the Common Terminology Criteria for Adverse Events version 5.0 and Harvard Cosmesis Scale, respectively.

Results

Patients (N = 50) were a median age of 68.5 years at the time of treatment. The median tumor size was 7.2 mm, 60% had an invasive cell type, and 90% were estrogen receptor positive, progesterone receptor positive, or both. Patients (n = 49) were followed for a median of 4.68 years for disease control and 1.25 years for cosmesis and toxicity. One patient experienced local recurrence, 1 patient experienced grade 3+ late toxicity, and 44 patients demonstrated excellent cosmesis.

Conclusions

To our knowledge, this is the largest retrospective analysis with the longest follow-up time for disease control among patients with early breast cancer treated with robotic SAPBI. With follow-up time for cosmesis and toxicity comparable to that of previous studies, results of the present cohort advance our understanding of the excellent disease control, excellent cosmesis, and limited toxicity that can be achieved by treating select patients with early-stage breast cancer with robotic SAPBI.

Association of Surgical Margin Status with Oncologic Outcome in Patients Treated with Breast-Conserving Surgery

We aimed to compare the prognosis of patients with close resection margins after breast-conserving surgery (BCS) with that of patients with negative margins and identified predictors of residual disease. A total of 542 patients with breast cancer who underwent BCS between 2003 and 2019 were selected and divided into the close margin (114 patients) and negative margin (428 patients) groups. The median follow-up period was 72 (interquartile range, 42-113) months. Most patients received radiation therapy (RTx) and systemic therapy according to their stage and molecular subtype. The 10-year locoregional recurrence-free survival rates of the close and negative margin groups were 88.2% and 95.5%, respectively (p = 0.001). Multivariable analysis showed that adjuvant RTx and margin status after definitive surgery were significantly associated with locoregional recurrence. Of the 57 patients who underwent re-excision, 34 (59.6%) had residual disease. Multivariable analysis revealed that a histological type of positive or close margins and multifocality were independent predictive factors for residual disease. Although the current guidelines suggest that no ink on tumor is an adequate margin after BCS, a close resection margin may be associated with locoregional failure. The treatment strategy for close resection margins after BCS should be based on individual clinicopathological features.

Breast-conserving surgery versus mastectomy for older women with triple-negative breast cancer: population-based study

Purpose: To assess whether the poor prognosis of triple-negative breast cancer (TNBC) necessitates a more aggressive surgical approach. Methods: We examined the association of: breast-conserving surgery (BCS); BCS plus radiotherapy; mastectomy; and mastectomy plus radiotherapy with overall and breast cancer-specific survival of stage I-III TNBC patients aged 66 years and older. We used unweighted and inverse probability of treatment weighted Cox proportional hazards regression and the Fine and Gray sub-distribution model. Results: Among 4333 women, individuals who were selected for BCS, mastectomy or mastectomy plus radiotherapy had lower adjusted overall and breast cancer-specific survival compared with women who had BCS plus radiotherapy. Conclusion: In this population-based study, women with TNBC treated with BCS plus radiotherapy have a better prognosis than those treated with BCS, mastectomy or mastectomy plus radiotherapy. Given the poor prognosis of TNBC and selection bias inherent in observational studies, these findings should be confirmed in further studies such as randomized clinical trials.

The theory of tumor ecosystem

Cancer cells can be conceived as “living organisms” interacting with cellular or non‐cellular components in the host internal environment, not only the local tumor microenvironment but also the distant organ niches, as well as the immune, nervous and endocrine systems, to construct a self‐sustainable tumor ecosystem. With increasing evidence for the systemic tumor‐host interplay, we predict that a new era of cancer therapy targeting the ecosystemic vulnerability of human malignancies has come. Revolving around the tumor ecosystem scoped as different hierarchies of primary, regional, distal and systemic onco‐spheres, we comprehensively review the tumor‐host interaction among cancer cells and their local microenvironment, distant organ niches, immune, nervous and endocrine systems, highlighting material and energy flow with tumor ecological homeostasis as an internal driving force. We also substantiate the knowledge of visualizing, modelling and subtyping this dynamically intertwined network with recent technological advances, and discuss ecologically rational strategies for more effective cancer therapies.

Outcomes of Breast-Conserving Surgery Plus Radiation vs Mastectomy for All Subtypes of Early-Stage Breast Cancer: Analysis of More Than 200,000 Women

BACKGROUND

Recent large retrospective studies suggest that breast-conserving therapy (BCT) plus radiation yielded better outcomes than mastectomy (MST) for women with early-stage breast cancer (ESBC). Whether this is applicable to the different subtypes is unknown. We hypothesize that BCT yielded better outcomes than MST, regardless of subtypes of ESBC.

STUDY DESIGN

Data on women diagnosed with first primary stage I to II breast cancer between 2010 and 2017 who underwent either BCT or MST were from the population-based 18 Surveillance, Epidemiology, and End Results cancer registries. The Kaplan-Meier method was used to estimate unadjusted 5-year overall survival and cause-specific survival. Univariable and multivariable Cox proportional regression models were used to determine the impact of surgical approaches on the hazard ratios adjusted for relevant demographic and clinical variables for molecular subtype (luminal A, luminal B, triple-negative, and HER2 enriched).

RESULTS

Of the 214,128 patients with breast cancer, 41.6% received MST. For the different subtypes, BCT yielded better 5-year overall survival and cause-specific survival than MST. After adjusting for demographic and clinical factors, the risk of overall survival and cause-specific survival was still statistically significantly higher among MST recipients than BCT recipients for all subtypes.

CONCLUSIONS

BCT yielded better survival rates than mastectomy for women with all subtypes of ESBC. The role of mastectomy for women with ESBC should be reassessed in future clinical trials.

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia

PURPOSE

Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS).

METHODS

The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received.

RESULTS

Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001).

CONCLUSION

Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

Determinants of Breast-Conserving Therapy in Early-Stage Breast Cancer Patients: A Nationwide Study

INTRODUCTION

Evidence from previous studies and treatment guidelines suggested that breast-conserving therapy (BCT) is the treatment of choice for early-stage breast cancer. However, in the last decades, surgeons have noticed a high percentage of mastectomies done in this population. The aim of this study is to explore the factors associated with not choosing BCT among eligible patients with early-stage breast cancer.

MATERIALS AND METHODS

This study uses a retrospective cohort design. Demographic and clinical characteristics derived from The Taiwan Cancer Registry Database, the National Health Insurance Database and the Death File Database from January 1, 2004 to December 31, 2014. Patients were followed until December 31, 2015. To explore the associated factors related to BCT, we used univariate and multivariate logistic regression analysis.

RESULTS

A total sample of 25,967 stage I breast cancer patients was included. Among them, 12,191 underwent BCT and 13,776 underwent mastectomy as their primary treatment. The logistic regression analysis reveals that age, pay-for-performance (P4P) program participation, number of affected lymph nodes, tumor size and location, were determinants of BCT. Interestingly enough, histological type did not reach the significance level.

CONCLUSION

This study shows that personal and clinical characteristics influence the treatment choice in stage 1 breast cancer patients.

Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy

Background and purpose

Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material.

Materials and methods

Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications.

Results

251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications.

Conclusions

The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.

Oncological Safety, Surgical Outcome, and Patient Satisfaction of Oncoplastic Breast-Conserving Surgery With Contralateral Balancing Reduction Mammoplasty

Introduction

Oncoplastic breast-conserving surgery (OBCS) is considered a cornerstone in the management of locally invasive breast cancer. We evaluated patient-reported outcomes of OBCS with contralateral balancing breast reduction mammoplasty and reviewed its oncologic outcomes and complications.

Methods

This is mixed method study design using retrospective chart review and prospective cohort study. Patient demographics were reviewed. Outcome measures included clinicopathologic characteristics, complications, margin status, local recurrence, tumor histopathologies, duration of follow-up, patient satisfaction, self-esteem, event-related stress, and quality of life.

Results

A total of 48 patients were included in this study. Complete excision with negative margins was obtained in 42 (87.5%) patients, positive margins in 6 (12.5%) patients, all who had re-excision with repeat lumpectomy. Thirteen patients developed minor complications, defined as being managed as an outpatient. No patients developed major complications requiring inpatient admission. These complications did not delay commencement of chemotherapy or radiotherapy. Postsurgery BREAST-Q^TM26 scores demonstrated no statistical difference in satisfaction with breasts, nipples, and sexual well-being. There was high satisfaction with overall outcome with average score of 80.8%. For the Rosenberg self-esteem scale, the results were similar for 3- and 12-month post-operative indicating maintenance of normal self-esteem post-operatively. The Impact of Events Scale showed statistically significant difference at 12-month post-operative (25.1) when compared with preoperative scores indicating that patients had lower event-related stress. There was no significant change in Hospital Anxiety and Depression Scale.

Conclusion

Our study has shown that the patient who undergo OBCS have high patient-reported outcomes with acceptable oncologic outcomes and complication rates.

Breast Cancer Surgery: New Issues

Since ancient times, breast cancer treatment has crucially relied on surgeons and clinicians making great efforts to find increasingly conservative approaches to cure the tumor. In the Halstedian era (mid-late 19th century), the predominant practice consisted of the radical and disfiguring removal of the breast, much to the detriment of women's psycho-physical well-being. Thanks to enlightened scientists such as Professor Umberto Veronesi, breast cancer surgery has since impressively progressed and adopted a much more conservative approach. Over the last three decades, a better understanding of tumor biology and of its significant biomarkers has made the assessment of genetic and molecular profiles increasingly important. At the same time, neo-adjuvant treatments have been introduced, and great improvements in genetics, imaging technologies and in both oncological and reconstructive surgical techniques have been made. The future of breast cancer management must now rest on an ever more precise and targeted type of surgery that, through an increasingly multidisciplinary and personalized approach, can ensure oncological radicality while offering the best possible quality of life.

Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials

PURPOSE/OBJECTIVE

The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials.

MATERIAL AND METHODS

We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes.

RESULTS

For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively).

CONCLUSION

Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.

MRI-Derived Tumour-to-Breast Volume Is Associated with the Extent of Breast Surgery

The tumour-to-breast volume ratio (TBVR) is a metric that may help surgical decision making. In this retrospective Ethics-Committee–approved study, we assessed the correlation between magnetic resonance imaging (MRI)-derived TBVR and the performed surgery. The TBVR was obtained using a fully manual method for the segmentation of the tumour volume (TV) and a growing region semiautomatic method for the segmentation of the whole breast volume (WBV). Two specifically-trained residents (R1 and R2) independently segmented T1-weighted datasets of 51 cancer cases in 51 patients (median age 57 years). The intraobserver and interobserver TBVR reproducibility were calculated. Mann-Whitney U, Spearman correlations, and Bland-Altman statistics were used. Breast-conserving surgery (BCS) was performed in 31/51 cases (61%); mastectomy was performed in 20/51 cases (39%). The median TBVR was 2.08‰ (interquartile range 0.70–9.13‰) for Reader 1, and 2.28‰ (interquartile range 0.71–9.61‰) for Reader 2, with an 84% inter-reader reproducibility. The median segmentation times were 54 s for the WBV and 141 s for the TV. Significantly-lower TBVR values were observed in the breast-conserving surgery group (median 1.14‰, interquartile range 0.49–2.55‰) than in the mastectomy group (median 10.52‰, interquartile range 2.42–14.73‰) for both readers (p < 0.001). Large scale prospective studies are needed in order to validate MRI-derived TBVR as a predictor of the type of breast surgery.

Oncoplastic partial breast reconstruction: concepts and techniques

Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.

10-Year Survival after Breast-Conserving Surgery Compared with Mastectomy in Louisiana Women with Early-Stage Breast Cancer: A Population-Based Study

BACKGROUND

Louisiana has the third highest breast cancer mortality in the US, despite ranking 30th in incidence. Whether surgical approach contributes to such a poor outcome is unknown. We compared outcomes of breast-conserving surgery plus radiation (BCT) vs mastectomy (MST) for Louisiana women with early-stage breast cancer.

STUDY DESIGN

Data on women diagnosed with Stage I-II breast cancer from 2004 to 2016 were analyzed from the Louisiana Tumor Registry. Overall survival (OS) and breast cancer-specific survival (CSS) were compared between BCT and MST. Kaplan-Meier method and log-rank test were used to compare survival curves, and logistic regression was used to examine the association of sociodemographic and clinical factors with the type of breast cancer surgery. Values of p < 0.05 were considered significant.

RESULTS

Of the 18,260 patients, 9,968 patients (54.6%) had BCT and 8,292 patients (45.4%) had MST. Compared with BCT, the MST group tended to be underinsured/Medicare/Medicaid, more impoverished, had higher stage 2 disease, were more likely to reside in rural regions, travel ≥25 miles to radiation treatment facility, be treated at low volume centers, and have T3, node positive, and poorly differentiated tumors. Ten-year OS and CSS were significantly better among those who had BCT (OS: 80.0%; 95% CI: 79.0%-81.1%; CSS: 92.7%; 95% CI: 92.1%-93.4%) than those having MST (OS: 69.3%; 95% CI: 68.0%-70.5%; CSS: 88.8%:95% CI: 87.9%-89.7%) (p < 0.05). Even after controlling for sociodemographic and clinical variables, MST was associated with a 28.6% increased risk of death from all causes (hazard ratio [HR]:1.286; 95% CI:1.197-1.380) and a 29.8% increased risk of breast-cancer specific death (HR:1.298; 95% CI: 1.150-1.465).

CONCLUSIONS

Surgical approach, a factor that is within the control of the surgeon, has an impact on mortality for Louisiana women with early-stage breast cancer.

Radiotherapy plays an important role in improving the survival outcome in patients with T1-2N1M0 breast cancer - a joint analysis of 4262 real world cases from two institutions

Background

To compare the survival outcomes between breast-conserving surgery (BCS) and modified radical mastectomy (MRM), and to investigate the role of radiotherapy (RT) in patients with pT1–2N1M0 breast cancer.

Methods

A total of 4262 women with T1–2N1M0 breast cancer treated at two institutions were retrospectively reviewed. A total of 3858 patients underwent MRM, and 832 (21.6%) of them received postoperative RT (MRM + RT). A total of 404 patients received BCS plus postoperative RT (BCS + RT). All patients received axillary lymph node dissection, while 3.8% of them had upfront sentinel node biopsy. The association of survival outcomes with different surgical modalities (BCS vs. MRM) and the role of RT were evaluated using multivariable proportional hazards regression and confirmed by the propensity score-matching (PSM) method.

Results

At a median follow-up of 71 months (range of 6–230 months), the 5-year overall survival (OS) rates of the BCS and MRM groups were 96.5 and 92.7%, respectively (P = .001), and the corresponding 5-year disease-free-survival (DFS) and locoregional recurrence (LRR) rates were 92.9 and 84.0%, and 2.0 and 7.0% (P = .001), respectively (P < .001). Multivariate analysis revealed that RT was an independent prognostic factor for improved OS (P = .001) and DFS (P = .009), and decreased LRR (P < .001). However, surgery procedure was not independently associated with either OS (P = .495), DFS (P = .204), or LRR (P = .996), which was confirmed by PSM analysis.

Conclusion

Postoperative radiotherapy rather than the surgery procedures was associated with superior survival outcomes in patients with T1–2N1M0 breast cancer.

Cosmetic Outcomes Following Breast-Conservation Surgery and Radiation for Multiple Ipsilateral Breast Cancer: Data from the Alliance Z11102 Study

BACKGROUND

Diagnoses of multiple ipsilateral breast cancer (MIBC) are increasing. Historically, the primary treatment for MIBC has been mastectomy due to concerns about in-breast recurrence risk and poor cosmetic outcome. The Alliance Z11102 study prospectively assessed cosmetic outcomes in women with MIBC treated with breast-conserving therapy (BCT).

PATIENTS AND METHODS

Z11102 was a multicenter trial enrolling women with two or three separate sites of biopsy-proven malignancy separated by ≥ 2 cm within the same breast. Cosmetic outcome was a planned secondary endpoint. Data were collected with a four-point cosmesis survey (1 = excellent, 4 = poor) and the BREAST-Q (scored 0-100). All patients undergoing successful breast-conserving therapy were treated with whole-breast radiation. Associations were assessed with Chi square or Fisher's exact tests as appropriate.

RESULTS

Cosmetic outcome data for 216 eligible women who completed therapy are included in this analysis. Of the 136 patients who completed the survey 2 years postoperatively, 70.6% (N = 96) felt the result was good or excellent, while 3.7% (N = 5) felt the result was poor. We found no significant differences in patient-reported cosmetic outcomes when stratifying by patient age, number of lesions (two or three), number of incisions, number of lumpectomies, or size of largest area of disease. Mean satisfaction score on the BREAST-Q was 77.2 at 6 months following whole-breast radiation and 73.7 at 3 years following surgery.

CONCLUSIONS

BCT performed for MIBC results in good or excellent cosmesis for the majority of women. From a cosmetic perspective, BCT is a valid surgical approach to women with MIBC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01556243.

Determinants of Breast-Conserving Therapy in the Asian Population: A Systematic Review

BACKGROUND

Treatment guidelines recommend breast-conserving therapy (BCT) for patients with early-stage breast cancer. However, Asian patients choose mastectomy over BCT, and the factors influencing this choice are unknown. This review aimed to identify the factors most frequently reported in the Eastern and Southeastern Asian population influencing the choice of BCT for treatment of early-stage breast cancer.

METHODS

PRISMA guidelines were followed, and PubMed and EMBASE databases were used. The literature search initially identified 4619 articles; abstract screening and full-text screening were performed on 150 and 19 articles, respectively, and 9 articles were finally included in the study.

RESULTS

Selection of BCT was associated with sociodemographic factors, such as high socioeconomic status and education level and young age at diagnosis; clinicopathological factors, such as small tumor size and mammographically detected tumors; and healthcare provider factors, such as treatment from a female doctor or from a breast specialist. However, not selecting BCT was associated with personal factors, such as fear of recurrence and avoidance of further treatment.

CONCLUSIONS

The process of making a treatment decision is complicated and involves many factors influencing patients' choice of surgery type. Exploring these factors helps to elucidate why patients do not choose BCT as their treatment option.

Oncoplastic Breast-Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use in Patients with Traditional Indications for Mastectomy?

INTRODUCTION

Traditional indications for mastectomy include multiple ipsilateral lesions and/or disease spanning ≥ 5 cm. Neoadjuvant chemotherapy increases breast conservation but does not improve survival. We hypothesized that oncoplastic breast-conserving surgery (OPS) may allow for breast conservation while providing full staging and tumor profiling information to guide systemic therapy decisions, thereby permitting more judicious chemotherapy use.

METHODS

This was an observational cohort of patients with invasive breast cancer with multiple lesions and/or disease spanning ≥ 5 cm who underwent OPS from 2012 to 2018. Clinicopathologic features, mastectomy rate, chemotherapy use, and recurrence were evaluated.

RESULTS

Overall, 100 patients were identified. Average disease span was 62.8 ± 20.1 mm, with an average of 2.9 lesions (range 1-13). 'No ink on tumor' was achieved at the index operation in 80 patients; 13 patients underwent completion mastectomy to achieve adequate margins. Eighty-one patients completed radiation therapy. Breast conservation was possible in 50/58 (86%) patients who did not receive chemotherapy. Forty-two patients received chemotherapy (8 neoadjuvant, 34 adjuvant), of whom 37 (88%) achieved breast conservation. Twenty-six patients with high-risk features received adjuvant chemotherapy. Oncotype DX testing demonstrated the need for chemotherapy in an additional eight patients. After a median follow-up of 40 months, four patients had a local recurrence, including two who declined radiation therapy.

CONCLUSIONS

OPS can facilitate breast conservation in most patients with traditional indications for mastectomy. Additionally, OPS may reduce unnecessary chemotherapy, especially in patients who qualify for Oncotype DX testing. Further study evaluating long-term oncologic and cosmetic outcomes is warranted.

Prognosis of Surgical Treatment After Ipsilateral Breast Tumor Recurrence

BACKGROUND

Ipsilateral breast tumor recurrence (IBTR) was determined to be a powerful independent risk factor of distant disease and increased mortality. Although mastectomy is the standard salvage treatment for IBTR after breast conserving treatment, there is evidence that repeat breast conserving surgery (rBCS) might be a feasible alternative treatment.

MATERIALS AND METHODS

The data of patients who were diagnosed with IBTR between 1998 and 2013 were obtained from the Surveillance, Epidemiology, and End Results database. Breast cancer-specific survival (BCSS) and overall survival (OS) were calculated using the Kaplan-Meier method. The Cox proportional hazards model was used for multivariate analysis, and propensity score matching analysis was applied to compensate for the differences in some baseline characteristics.

RESULTS

A total of 475 patients (22.9%) who underwent rBCS and 1600 (77.1%) who underwent mastectomy after IBTR were included in the study. During a median follow-up of 130 mo, no significant differences were observed in BCSS and OS between the rBCS and mastectomy groups of patients before and after propensity score matching. Multivariate analysis revealed that race, the American Joint Committee on Cancer stage of the recurrent tumor, and reirradiation were independent prognostic factors for both BCSS and OS.

CONCLUSIONS

The results of our study indicate that rBCS can be a feasible alternative treatment option for patients with IBTR. Nevertheless, further studies should be conducted to identify the prognosis of patients after rBCS as well as the best candidates for a second breast conserving surgery.

Chest wall perforator flaps in partial breast reconstruction after breast conservation surgery: an additional oncoplastic surgical option

Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes.

This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy.

Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences.

CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.

The Use of Synthetic Mesh in Reconstructive, Revision, and Cosmetic Breast Surgery

BACKGROUND

Recent evidence suggests that the use of acellular dermal matrices in prosthetic breast reconstruction, revision, or augmentation may be associated with an increased risk of complications. In this article we report our results of a potential alternative, using a new long-term resorbable synthetic matrix in these cases.

METHODS

A retrospective study was performed evaluating 11 primary breast reconstructions (19 breasts), 43 secondary reconstructions (77 breasts), 3 augmentation/augmentation mastopexys (6 breasts), and 5 mastopexys (10 breasts) in 62 patients using TIGR^® Matrix Surgical Mesh.

RESULTS

Follow-up ranged from 9.4 to 26.1 months with an average follow-up of 16.5 months. Average age was 54 years. The number of patients who had prior radiation was 9 (14.5 %). Four patients (6.5 %) were smokers. Postoperative breast complications included necrosis of two flaps (1.8 %), two seromas requiring drainage (1.8 %), four infection/extrusions (3.6 %), two relapses of inframammary fold/malposition (1.8 %), and two with rippling (1.8 %). Other complications included six cases of asymmetry that required a corrective procedure. In a variety of breast surgery cases very good aesthetic results were achieved.

CONCLUSION

The long-term absorbable synthetic matrix, TIGR^® Matrix Surgical Mesh, shows potential when used as temporary reinforcement in patients undergoing breast reconstruction or breast surgery revisions and in primary aesthetic procedures, and it appears to be a viable alternative to the use of acellular dermal matrices.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Multicentre prospective observational study evaluating recommendations for mastectomy by multidisciplinary teams

BACKGROUND

Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates.

METHODS

Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected.

RESULTS

Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent).

CONCLUSION

Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.

Use of animation video in surgical decision-making for treatment of early breast cancer in Indian women

Introduction:

Surgical decision-making in early breast cancer is difficult for the patient and also for the treating clinician, especially when the patient is not completely aware of the available options. Adjuncts such as animation video with case scenarios can be helpful in this regard. We used an animation video to help in decision-making and evaluated the effect of such adjunct in Indian women with early breast cancer.

Materials and Methods:

An animation video of running time of 4 min and 11 s was shown to forty patients with early breast cancer, who filled in a patient satisfaction multimedia questionnaire at the end of the animation.

Results:

Seventeen (42.5%) patients underwent breast-conserving surgery (BCS) while the rest 23 (57.5%) patients underwent the mastectomy. All forty patients were satisfied with the animation video. The mean score of the utility of the video to improve understanding of the disorder, better organization of treatment, stimulated interest in the relations, and saved unnecessary discussion was 88.50, 88.50,88.3, and 90.3, respectively. Age and literacy status did not significantly affect the scores.

Discussion:

All the patients found the video useful and most patients made the decision on the first attempt. Patients’ perspective about BCS is influenced by the fear of recurrence, fear of multiple surgeries, complications, and also the counseling provided by the surgeon.

Conclusion:

In this situation, such animation videos provide an unbiased view on the operative procedure and help in decision-making.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

BACKGROUND

Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications.

METHODS

In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications.

RESULTS

Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05).

CONCLUSION

Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Extreme oncoplasty: Expanding indications for breast conservation

INTRODUCTION

Presence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described.

METHODS

This is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated.

RESULTS

One hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ± 23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50-160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy.

CONCLUSION

EOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.

Rate of Breast-Conserving Surgery vs Mastectomy in Breast Cancer: a Tertiary Care Centre Experience from South India

Worldwide, breast conservation has become increasingly accepted as the surgical management of breast cancer in clinical practice. Cancer care in India is also evolving tremendously with many cancer treatment centres following evidence-based practice hence the rates of breast conservation are expected to increase. Here, we are reporting the rate of breast-conserving surgery (BCS) at our centre. A retrospective study of 401 patients who underwent breast cancer surgery at a tertiary care centre in South India from January 2015 to August 2017 were analysed to study the rate of BCS. All early breast cancers (EBC) were offered BCS. For large operable breast cancer (LOBC) and locally advanced breast cancer (LABC), neoadjuvant chemotherapy (NACT) followed by BCS was offered to these patients who wish to conserve their breast. The mean age was 45 years. A total of 163 patients underwent BCS. Yearly, BCS rates were 38.8% in 2015, 36.7% in 2016 and 46.5% in 2017. Majority had EBC 310 (77.3%) of which 62.7% of T1 lesions (n = 51) had BCS, and 45.7% of T2 lesions (n = 258) had BCS of which 5 patients had to undergo NACT to preserve their breast whereas 100% Tis patient (n = 1) had mastectomy. Fifty patients had LOBC and only 2 (4%) patients had upfront BCS whereas 9 of them had to undergo NACT (18%). cT4 lesions had NACT followed by BCS in 2 patients. The rates of BCS have been increasing in India over the past few years. The majority of the women presented with EBC which makes them suitable for BCS.

Radioimmunoguided Breast Surgery Using Radiolabeled Antibody NR-LU-10 FAB: A Pilot Study

Aim and Background

Radioimmunoguided surgery using radiolabeled NR-LU-10 Fab was evaluated as a method of intraoperative breast cancer detection.

Methods

Breast cancer patients were injected intravenously with 125I (74 MBq) labeled NR-LU-10 Fab (5 mg) and then underwent tumor excision 2, 4 or 7 days later, during which time the gamma detector probe was used to evaluate the primary tumor for evidence of radioactive uptake.

Results

Intraoperative probing revealed tumor localization in 7 of 10 patients (70%). Gamma probe counts of the excised tumor were elevated in all patients, although high counts in surrounding nonmalignant tissue obscured the ability to detect the tumor in vivo in 3 patients. One patient with bilateral breast cancer was found to have a separate focus of occult tumor in each breast using the gamma detector probe.

Conclusions

Radiolabeled NR-LU-10 Fab possesses favorable pharmokinetics and tumor-binding ability as a targeting agent. However, binding to nonmalignant tissue limits its role in the intraoperative evaluation of tumor margins in breast cancer patients. Its role in other malignancies should be explored.

Breast Reconstruction and Radiation Therapy: An Update

With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.

Selection of oncoplastic surgical technique in Asian breast cancer patients

BACKGROUND

Oncoplastic surgery is being increasingly performed in Korean women; however, unlike Westerners, Korean women usually have small to moderate-sized breasts. To achieve better outcomes in reconstructed breasts, several factors should be considered to determine the optimal surgical method.

METHODS

A total of 108 patients who underwent oncoplastic surgery from January 2013 to December 2016 were retrospectively investigated. We used various methods, including glandular tissue reshaping, latissimus dorsi (LD) flap transposition, and reduction oncoplasty, to restore the breast volume and symmetry.

RESULTS

The mean weight of the tumor specimens was 40.46 g, and the ratio of the tumor specimen weight to breast volume was 0.12 g/mL in the patients who underwent glandular tissue reshaping (n=59). The corresponding values were 101.47 g and 0.14 g/mL, respectively, in the patients who underwent reduction oncoplasty (n=17), and 82.54 g and 0.20 g/mL, respectively, in those treated with an LD flap (n=32). Glandular tissue reshaping was mostly performed in the upper outer quadrant, and LD flap transposition was mostly performed in the lower inner quadrant. No major complications were noted. Most patients were satisfied with the aesthetic results.

CONCLUSIONS

We report satisfactory outcomes of oncoplastic surgical procedures in Korean patients. The results regarding specimen weight and the tumor-to-breast ratio of Asian patients will be a helpful reference point for determining the most appropriate oncoplastic surgical technique.

Effective use of nanocarriers as drug delivery systems for the treatment of selected tumors

Nanotechnology has recently gained increased attention for its capability to effectively diagnose and treat various tumors. Nanocarriers have been used to circumvent the problems associated with conventional antitumor drug delivery systems, including their nonspecificity, severe side effects, burst release and damaging the normal cells. Nanocarriers improve the bioavailability and therapeutic efficiency of antitumor drugs, while providing preferential accumulation at the target site. A number of nanocarriers have been developed; however, only a few of them are clinically approved for the delivery of antitumor drugs for their intended actions at the targeted sites. The present review is divided into three main parts: first part presents introduction of various nanocarriers and their relevance in the delivery of anticancer drugs, second part encompasses targeting mechanisms and surface functionalization on nanocarriers and third part covers the description of selected tumors, including breast, lungs, colorectal and pancreatic tumors, and applications of relative nanocarriers in these tumors. This review increases the understanding of tumor treatment with the promising use of nanotechnology.

Revisiting the impact of age and molecular subtype on overall survival after radiotherapy in breast cancer patients

Adjuvant radiotherapy (RT) in breast cancer (BC) is often used to eradicate remaining tumor cells following surgery with the goal of maximizing local control and increasing overall survival. The current study investigated the impact of age and BC molecular subtype on overall survival after RT using a meta-analysis of the METABRIC and TCGA BC patient cohorts. We found that RT significantly prolonged survival across the whole BC patient population. The survival benefit of RT was predominantly observed in stage II BC patients treated with breast conserving surgery. Patients were then stratified by age and molecular subtype to investigate survival rate associated with RT. An increase in survival for the luminal-A and basal BC molecular subtypes was observed after RT. Stratifying patients based on age revealed that increased survival was restricted to younger patients (≤60 years of age at diagnosis). There was a significant survival benefit of radiotherapy for younger patients with tumors of the luminal A and basal molecular subtypes. Patients with other breast tumor subtypes or older breast cancer patients did not seem to benefit effects of RT. Therefore, alternate local treatment strategies should be considered for older, luminal B, and HER2 driven BC patients.

Survival after Breast-Conserving Surgery with Whole Breast or Partial Breast Irradiation in Women with Early Stage Breast Cancer: A SEER Data-base Analysis

Randomized clinical trials have demonstrated equivalency in survival outcomes for early stage breast cancer patients treated with either mastectomy or breast-conserving surgery (BCS) with radiation. Recent, state-level data confirm comparable survival outcomes. Using Surveillance Epidemiology and End Research (SEER) data, we sought to evaluate survival outcomes among patients with early stage breast cancer treated with mastectomy, BCS with whole breast irradiation (BCS + WBI), or BCS with accelerated partial breast irradiation (BCS + APBI). Data on women 50 years or older diagnosed with a node negative invasive breast cancer (≤3 cm in size) between 1995 and 2009 were extracted from the SEER data base. Women treated with mastectomy alone or BCS with radiation were eligible for analysis. Kaplan-Meier estimates and Cox proportional hazard models were used to compare overall survival (OS) and cancer-specific survival (CSS) among the treatment groups. 150,171 women fulfilled inclusion criteria. OS was significantly improved among women treated with BCS and WBI or BCS and APBI compared to mastectomy alone. Adjusted hazard ratios for death in BCS with WBI or APBI (versus mastectomy alone) were 0.73 (95% CI: 0.71, 0.76) and 0.68 (95% CI: 0.58, 0.79), respectively. Adjusted CSS was also significantly improved in patients treated with BCS and WBI (HR 0.80, 95% CI: 0.76, 0.85) as compared to mastectomy. BCS with radiation (WBI or APBI) was associated with significantly improved OS and CSS, versus mastectomy alone. These results support the use of BCS with WBI or APBI (in well selected patients) for the treatment of breast cancer.

Surgical and Locoregional Treatment of DCIS and Early-Invasive Breast Cancer

Surgical and radiation therapy for DCIS and early stage 1 and 2 invasive breast cancer is detailed and described.

Outcomes After Mastectomy and Lumpectomy in Elderly Patients with Early-Stage Breast Cancer

INTRODUCTION

Survival in elderly patients undergoing mastectomy or lumpectomy has not been specifically analyzed.

METHODS

Patients older than 70 years of age with clinical stage I invasive breast cancer, undergoing mastectomy or lumpectomy with or without radiation, and surveyed within 3 years of their diagnosis, were identified from the Surveillance, Epidemiology, and End Results and medicare health outcomes survey-linked dataset. The primary endpoint was breast cancer-specific survival (CSS).

RESULTS

Of 1784 patients, 596 (33.4 %) underwent mastectomy, 918 (51.4 %) underwent lumpectomy with radiation, and 270 (15.1 %) underwent lumpectomy alone. Significant differences were noted in age, tumor size, American Joint Committee on Cancer (AJCC) stage, lymph node status (all p < 0.0001) and number of positive lymph nodes between the three groups (p = 0.003). On univariate analysis, CSS for patients undergoing lumpectomy with radiation [hazard ratio (HR) 0.61, 95 % confidence interval (CI) 0.43-0.85; p = 0.004] was superior to mastectomy. Older age (HR 1.3, 95 % CI 1.09-1.45; p = 0.002), two or more comorbidities (HR 1.57, 95 % CI 1.08-2.26; p = 0.02), inability to perform more than two activities of daily living (HR 1.61, 95 % CI 1.06-2.44; p = 0.03), larger tumor size (HR 2.36, 95 % CI 1.85-3.02; p < 0.0001), and positive lymph nodes (HR 2.83, 95 % CI 1.98-4.04; p < 0.0001) were associated with worse CSS. On multivariate analysis, larger tumor size (HR 1.89, 95 % CI 1.37-2.57; p < 0.0001) and positive lymph node status (HR 1.99, 95 % CI 1.36-2.9; p = 0.0004) independently predicted worse survival.

CONCLUSIONS

Elderly patients with early-stage invasive breast cancer undergoing breast conservation have better CSS than those undergoing mastectomy. After adjusting for comorbidities and functional status, survival is dependent on tumor-specific variables. Determination of lymph node status remains important in staging elderly breast cancer patients.

Acute and Chronic Complications in Breast Cancer Patients Treated with Intraoperative Radiation Therapy

INTRODUCTION

Intraoperative radiation therapy (IORT) permits the delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the complications associated with this modality of treatment using the Xoft(®) Axxent Electronic Brachytherapy (Axxent) System.

METHODS

A total of 702 patients who received IORT using the Xoft(®) Axxent System at Hoag Memorial Hospital Presbyterian between June 2010-February 2016 were accrued in an IORT data registry study. The prospective and retrospective protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months.

RESULTS

Acute complications were observed in 21 % of patients and included hematomas that required drainage, seromas requiring drainage more than 3 times, infections treated with antibiotics or surgery, necrosis requiring surgery, and erythema. Chronic complications were observed in 13 % of patients and included seromas, fibrosis, and hyperpigmentation. The majority of acute and chronic problems from IORT were mild. If grade I erythema, fibrosis, and hyperpigmentation were removed, only 32 of 702 (4.6 %) had significant complications. Our complication rates were comparable to those of the TARGIT trial.

CONCLUSIONS

IORT is a modality that safely delivers radiation therapy to patients diagnosed with breast cancer. This technique allows women who cannot (or decline to) undergo whole breast radiation to consider breast-conserving therapy rather than mastectomy.