Performance and Practice Guideline for the Use of Neoadjuvant Systemic Therapy in the Management of Breast Cancer

Pretreatment Axillary Nodal Volume as a Prognostic Factor for Breast Cancer

Background and Objectives: We evaluated the prognostic value of pretreatment axillary nodal volume in breast cancer patients treated with neoadjuvant systemic therapy. Methods: We retrospectively reviewed 302 breast cancer patients with biopsy-proven axillary LN involvement who received neoadjuvant systemic therapy. Axillary nodal volumes were obtained from pretreatment magnetic resonance imaging. Univariate and multivariate analyses for disease-free survival (DFS) and overall survival (OS) rates were conducted. Results: The median follow-up period was 57.0 months, and 5-year DFS and OS rates were 81.6% and 91.9%, respectively. Pretreatment axillary nodal volume ranged from 0.2 mL to 134.2 mL, and the first tertile (2.6 mL) and fifth quintile (12.0 mL) were chosen as the optimal cutoff points for survival outcomes. In the multivariate analysis, nodal volume (< 2.6 mL vs. 2.6-12.0 mL vs. ≥ 12.0 mL) was a significant prognostic factor for DFS (5-year DFS, 90.1% vs. 79.6% vs. 72.2%) and OS (5-year OS, 97.9% vs. 90.9% vs. 84.2%), whereas the N stage was not. Conclusions: In breast cancer patients treated with neoadjuvant systemic therapy, larger pretreatment axillary nodal volume was associated with poor survival outcomes.

Comprehensive analysis of HER2 Low Breast Cancer Response to Neoadjuvant Chemotherapy, a Retrospective Cohort Study

BACKGROUND

This study aimed to identify the response and survival outcomes of HER2-low patients following neoadjuvant chemotherapy (NAC).

METHOD

A retrospective cohort of patients who received NAC in the Department of Breast Surgery at Peking Union Medical College Hospital (PUMCH) from September 27, 2016, to January 23, 2024, was reviewed. Multivariate logistic regression and Cox proportional hazards models were used to identify factors associated with pathological complete response (pCR) and survival outcomes. The Kaplan-Meier method was applied to compare survival outcomes between HER2-zero and HER2-low patients.

RESULT

Four hundred and twenty-one patients meeting the inclusion criteria. The pCR rate of HER2-zero patients was significantly higher than that of HER2-low patients after adjusting for confounders (OR = 2.83, 95% CI: 1.44-5.65, adjusted P = .003). HER2-low patients demonstrated the most stable status after NAC within the hormone receptor (HR)-positive subset (80.82%) and the most unstable status within the HR-negative subset (57.69%). HER2-zero status was associated with worse disease-free survival (DFS) (HR = 1.94, 95% CI: 1.13-3.32, adjusted P = .02), but not with overall survival (OS) (HR = 1.18, 95% CI: 0.59-2.37, P = .65). HER2-zero patients had significantly worse DFS than HER2-low patients in the entire cohort (P = .014) and the HR-positive subset (P < .001). pCR could serve as a surrogate endpoint of favorable survival outcomes for HER2-zero patients, but not for HER2-low patients.

CONCLUSION

HER2-low patients might exhibit distinct characteristics compared with HER2-zero patients following NAC. Further multicenter, prospective studies are warranted to validate the conclusions of this exploratory research and assess whether HER2-low expression could serve as a new clinical subtype for evaluating NAC treatment outcomes.

Frequency and outcomes of new or suspicious MRI findings on breast MRI for patients on neoadjuvant therapy

PURPOSE

To assess the frequency and outcomes of indeterminate enhancing findings on breast MRI unrelated to the index primary tumor(s) in patients on neoadjuvant therapy (NAT).

MATERIALS AND METHODS

This retrospective review identified all diagnostic breast MRIs performed to evaluate response to NAT at our institution between 2017 and 2020. All exams with indeterminate enhancing findings (BI-RADS 3-5) unrelated to the index tumor(s) for which follow-up imaging or tissue diagnosis was recommended were included. Cases lacking a pre-treatment MRI or those with insufficient follow-up were excluded. Imaging of all post-NAT breast MRIs were re-reviewed. The electronic medical record was reviewed to evaluate patient and lesion characteristics and outcomes.

RESULTS

Between 2017 and 2020, 614/4042 (15.2%) breast MRIs were performed to evaluate response to NAT. After exclusions, 38 of these exams (6.2%) identified 42 indeterminate enhancing findings unrelated to the index tumor for which follow-up imaging (15 exams) or tissue diagnosis (23 exams) was recommended. Fifteen of 42 (35.7%) of the findings were new compared to the pre-treatment baseline MRI, 8/42 (19.0%) increased and 19/42 (45.2%) were present on pre-treatment MRI. Most findings were contralateral to the index tumor (28, 66.7%). Findings were masses (17, 40.4%), focus (15, 35.7%), and non-mass enhancement (10, 23.8%). Of the 42 findings, 19 (45.2%) underwent percutaneous biopsy, 10 (23.8%) underwent surgical biopsy or mastectomy, and 13 (31%) were followed by imaging. Thirty-seven were benign, 4 were high-risk lesions without upgrade (atypical ductal hyperplasia, atypical lobular hyperplasia, and papillomatosis with atypical ductal hyperplasia), and one (2.4%) was malignant (invasive lobular carcinoma), which was non-mass enhancement present on the pre-treatment MRI.

CONCLUSION

Indeterminate enhancing lesions unrelated to the index tumor(s) on breast MRIs performed to assess response to neoadjuvant chemotherapy are uncommon. When present, these lesions have an extremely low likelihood of malignancy, especially when new compared to the pre-treatment MRI.

CLINICAL RELEVANCE

Because incidental indeterminate enhancing lesions on breast MRI at post-NAT follow-up are rarely malignant, radiologists should be judicious in recommending follow-up or tissue diagnosis for such lesions after NAT.

Comparison of Risk Stratification by CanAssist Breast Test Performed on Core Needle Biopsies Versus Surgical Specimens in Hormone Receptor-Positive, Her2-Negative Early Breast Cancer

Introduction Core needle biopsies (CNB) are being increasingly utilized for biomarker, prognostic, and predictive testing in breast cancer (BC). CanAssist Breast (CAB) is a prognostic test performed to assess the 'risk of breast cancer recurrence' in early-stage hormone receptor-positive, Her2-negative BC patients. CAB segregates tumors as 'low risk' or 'high risk' for distant recurrence. Risk assessment done by CAB aids in planning and making adjuvant chemotherapy or hormone therapy decisions. CAB is typically performed on surgical specimens (SS). However, performing it on CNB does offer additional insights into tumor biology leading to different strategies for treatment planning; hence, we aimed to compare the risk stratification performance of CAB using CNB versus SS. Method We analyzed 103 paired formalin-fixed paraffin-embedded CNB and SS samples from hormone receptor-positive, Her2-negative early BC tissue samples submitted for performing CAB at OncoStem Diagnostics between November 2021 and September 2023. Concordance on 'risk categories' of CAB performed on CNB versus SS was reported using overall percentage agreement and Pearson correlation coefficient. Results We found excellent overall concordance of 92.2% for CAB risk stratification between paired CNB and SS tumor samples with a strong Pearson correlation coefficient of r= 0.8351 (p< 0.0001) when either SS or CNB was used as the gold standard. In prognostic testing patients with a 'low risk' of recurrence may avoid chemotherapy and hence it is crucial to assess the accuracy of CAB in the low-risk category. Additionally, in a real-world scenario, it is more likely that CAB will be performed on CNB first. Conclusion CAB when performed on CNB samples showed high concordance with SS thus demonstrating that CNB was a suitable sample for the CanAssist Breast test. The accuracy in the low-risk category is 97.5%, which ensures that physicians can reliably use prognostic information by testing CNB to guide adjuvant therapy decisions.

Association of Neoadjuvant Chemotherapy With Postoperative Outcomes in Immediate Prepectoral Prosthetic Breast Reconstruction

PURPOSE

Neoadjuvant chemotherapy (NACT) followed by total mastectomy and immediate reconstruction has become an important strategy in the treatment of breast cancer. Although the safety of subpectoral implant-based breast reconstruction with NACT has been extensively evaluated, the safety in prepectoral reconstruction has not been clearly elucidated. We aimed to evaluate the association of NACT with immediate prepectoral breast reconstruction outcomes.

METHODS

A retrospective review of patients who underwent total mastectomy and immediate implant-based prepectoral breast reconstruction between May and December 2021 was conducted. Patients were categorized into 2 groups: those receiving NACT and those not receiving it. Postoperative complication rates were compared between the 2 groups. The independent association between NACT and the complication profiles was evaluated. Propensity score matching was also conducted.

RESULTS

We analyzed 343 cases, including 85 who received NACT treatment and 258 who did not. Compared with the non-NACT group, the NACT group was younger, had a higher body mass index, and a higher rate of adjuvant radiotherapy. There were no differences in the rates of overall complications or type of complication between the 2 groups. In the multivariable logistic analyses, NACT did not show a significant association with the development of adverse outcomes. Similar results were observed in propensity score matching analyses.

CONCLUSIONS

Our results suggest that receiving NACT may not have a significant detrimental effect on the postoperative outcomes of immediate prepectoral prosthetic reconstructions. Conducting prepectoral implant-based reconstruction in the setting of NACT might be safe and provide acceptable outcomes.

Impact of residual microcalcifcations on prognosis after neoadjuvant chemotherapy in breast cancer patients

BACKGROUND

Residual microcalcifications after neoadjuvant chemotherapy (NAC) are challenging for deciding extent of surgery and questionable for impact on prognosis. We investigated changes in the extent and patterns of microcalcifications before and after NAC and correlated them with pathologic response. We also compared prognosis of patients depending on presence of residual microcalcifications after NAC.

METHODS

A total of 323 patients with invasive breast carcinoma treated with neoadjuvant chemotherapy at Kangbuk Samsung Hospital and Samsung Medical center from March 2015 to September 2018 were included. Patients were divided into four groups according to pathologic response and residual microcalcifications. Non-pCRw/mic group was defined as breast non-pCR with residual microcalcifications. Non-pCRw/o mic group was breast non-pCR without residual microcalcifications. pCRw/mic group was breast pCR with residual microcalcifications. pCRw/o mic group was breast pCR without residual microcalcifications. The first aim of this study is to investigate changes in the extent and patterns of microcalcifications before and after NAC and to correlate them with pathologic response. The second aim is to evaluate oncologic outcomes of residual microcalcifications according to pathologic response after NAC.

RESULTS

There were no statistical differences in the extent, morphology, and distribution of microcalcifications according to pathologic response and subtype after NAC (all p > 0.05). With a median follow-up time of 71 months, compared to pCRw/o mic group, the hazard ratios (95% confidence intervals) for regional recurrence were 5.190 (1.160-23.190) in non-pCRw/mic group and 5.970 (1.840-19.380) in non-pCRw/o mic group. Compared to pCRw/o mic group, the hazard ratios (95% CI) for distant metastasis were 8.520 (2.130-34.090) in non-pCRw/mic group, 9.120 (2.850-29.200) in non-pCRw/o mic group. Compared to pCRw/o mic, the hazard ratio (95% CI) for distant metastasis in pCRw/mic group was 2.240 (0.230-21.500) without statistical significance (p = 0.486).

CONCLUSIONS

Regardless of residual microcalcifications, patients who achieved pCR showed favorable long term outcome compared to non-pCR group.

Oncologic Outcomes of Immediate Breast Reconstruction in the Setting of Neoadjuvant Chemotherapy: A Long-term Follow-up Study of a Matched Cohort

PURPOSE

Despite the increasing use of immediate breast reconstruction (IBR), its oncologic safety in the setting of neoadjuvant chemotherapy (NACT) needs to be comprehensively clarified in breast cancer management. The objective of the present study was to analyze the oncologic safety of IBR following NACT.

METHODS

In total, 587 patients with breast cancer who underwent a total mastectomy (TM) with IBR after NACT between 2008 and 2017 at a single institution were retrospectively reviewed. The reviewed patients with IBR following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) were matched 1:3 to patients who underwent TM alone after NACT. Matching variables included age, clinical T and N stages before NACT, response to NACT, pathologic T and N stages, and molecular subtypes.

RESULTS

After propensity score matching, 95 patients who underwent IBR following SSM/NSM after NACT (IBR group) and 228 patients who underwent TM alone after NACT (TM group) were selected. The median follow-up period was 73 (range, 5-181) months after matching. After matching, there were no significant differences between the two groups in 5-year locoregional recurrence-free survival (88.8% vs. 91.2%, p = 0.516), disease-free survival (67.3% vs. 76.6%, p = 0.099), distant metastasis-free survival (71.9% vs. 81.9%, p = 0.057), or overall survival (84.1% vs. 91.5, p = 0.061) rates. In multivariate analyses, conducting IBR was not associated with increased risks for locoregional recurrence, any recurrence, distant metastasis, or overall death.

CONCLUSION

Our findings suggest that IBR following SSM/NSM elicits comparable long-term oncologic outcomes to those of TM alone in the setting of NACT.

Reducing the Risk of Needle Tract Seeding or Tumor Cell Dissemination during Needle Biopsy Procedures

PURPOSE

Many women fear that breast needle biopsies increase the risk of cancer spread. The purpose of this review article is to discuss the breast cancer literature regarding the risk of needle-biopsy-induced cancer cell displacement and its impact on local and regional recurrence and breast cancer survival.

METHODS

A literature review is performed to discuss the risks and mitigation of needle-biopsy-induced cancer cell displacement.

RESULTS

Needle-biopsy-induced cancer cell displacement is a common event. The risk is influenced by the biopsy technique and the breast cancer type. Evidence suggests that the risk of needle-biopsy-induced cancer cell displacement may potentially increase the odds of local recurrence but has no impact on regional recurrence and long-term survival.

CONCLUSIONS

Technical modifications of needle biopsy procedures can reduce the risk of breast needle-biopsy-induced cancer cell displacement and potentially reduce the risk of local recurrence, especially in patients for whom whole breast radiation is to be omitted.

Value of ultrasound in assessing response to neoadjuvant chemotherapy in breast cancer

AIM

To analyse the utility of ultrasound in assessing response to neoadjuvant chemotherapy (NAC) and predicting residual cancer burden (RCB) index and pathological complete response (pCR) MATERIALS AND METHODS: This was a retrospective study with 417 patients over 7 years. The difference in longest diameter (LD) of the index lesion from baseline to end, baseline to mid, and mid to end was evaluated with respect to RCB class using logistic regression and ordered logistic regression.

RESULTS

Change in LD measurements from baseline to end, baseline to mid, and mid to end of chemotherapy as a predictor of RCB class show a negative relationship with a statistically significant association. This would suggest that a smaller change in LD measurements would be associated with an eventual higher RCB class. Change in LD measurements from baseline to end and baseline to mid chemotherapy as a predictor of pCR class show a negative relationship with a statistically significant association (p<0.05). This similarly indicates an inversely proportional relationship between changes in LD measurements and RCB class 0 for baseline to end and baseline to mid.

CONCLUSION

This study has shown significance in reducing LD measurements on ultrasound as a predictor of PCR and RCB class. This adds weight to the current practice of using ultrasound at the start, mid and end of chemotherapy cycles to monitor NACT responses.

Breast Cancer Cryoablation in the Multidisciplinary Setting: Practical Guidelines for Patients and Physicians

Breast cancer cryoablation has emerged as a minimally invasive alternative to lumpectomy for treating early-stage breast cancer. However, no consensus exists on what should be considered the standard of care for the multidisciplinary management of patients treated with breast cancer cryoablation. In lieu of national guidelines, this review of the literature provides a multidisciplinary framework and an evidence-based discussion of the integration of "standard of care practices" in the comprehensive management of breast cancer cryoablation patients.

Short-Term Outcomes Following Breast Cancer Surgery With and Without Neoadjuvant Chemotherapy: A Nationwide Administrative Database Study in Japan

PURPOSE

Although neoadjuvant chemotherapy (NAC) has become common for breast cancer, its impact on short-term surgical outcomes and the feasible chemotherapy-surgery interval remain unclear. Using a Japanese nationwide database, this study investigated the impact of NAC on short-term outcomes following breast cancer surgery.

METHODS

In this study of 11,722 patients with NAC and 120,538 patients without NAC who underwent surgery for stage 0-III breast cancer July 2010-March 2017, to cancel out site-specific effects, we generated a 1:4 matched-pair cohort matched for age, institution, and fiscal year of admission. We then conducted multivariable analyses adjusting for potential confounders to compare postoperative complications, duration of anesthesia, and total hospitalization costs. Additionally, we conducted three sensitivity analyses for patients with a short interval from NAC to surgery, patients receiving a particular NAC regimen, and patients undergoing a particular surgical procedure.

RESULTS

In total, the occurrence of postoperative complications was 6.0%, and the median interval from NAC to surgery was 31 (interquartile range, 24-39) days. The two groups did not differ significantly in terms of complications (odds ratio, 0.95; 95% confidence interval, 0.88-1.04), including local and general complications. NAC was significantly associated with shorter duration of anesthesia and lower total hospitalization costs. The sensitivity analyses showed similar results.

CONCLUSIONS

Our matched-pair cohort analyses revealed no significant differences in postoperative complications between patients with and without NAC for breast cancer, regardless of the interval, regimen, and surgical procedure. Patients can safely receive surgery and NAC without a lengthened interval.

The Effect of Neoadjuvant Chemotherapy on Safety Outcomes Following Immediate Breast Reconstruction

BACKGROUND

Mastectomy and immediate breast reconstruction (MIBR) are becoming an increasingly popular option for women with breast cancer. However, MIBR is associated with a higher risk of postoperative complications compared to mastectomy alone, which may delay adjuvant cancer therapy. The main objective of this retrospective cohort study was to investigate oncologic outcomes in MIBR patients with and without neoadjuvant chemotherapy (NACT).

METHODS

A 6-year retrospective study of breast cancer patients treated with MIBR was conducted from January 2013 to May 2019. The primary outcome was a delay in adjuvant radiochemotherapy. Secondary outcomes included postoperative complications and locoregional recurrences.

RESULTS

Of 1832 patients reviewed, 300 (7.1%) were included. The cohort consisted of 277 (92%) MIBR patients without NACT and 23 (7.7%) with NACT. There was significantly more N1 and N2 tumor node status in the non-NACT group compared to the NACT group (p<0.001). The overall complication rates were similar in the NACT group compared to non-NACT (37.5% versus 21.7%, p=0.148). The rates of major and minor complications were also similar between NACT and non-NACT groups (Major: 29.6% versus 21.7%, p=0.823) and (Minor: 26.7% versus 8.70%, p =0.0970). The rates of locoregional recurrence (p=1.00), time to adjuvant therapy (p=0.629), and rates of delay (p=0.305) was also similar between groups. Overall survival was significantly lower in the NACT group compared to non-NACT (98.2% versus 82.6%, p<0.001).

CONCLUSIONS

There was no difference in complication rates, or timing to adjuvant therapy, among MIBR patients with and without NACT. However, MIBR patients who received NACT had worse overall survival than MIBR patients without NACT.

Differences in sensitivity to neoadjuvant chemotherapy among invasive lobular and ductal carcinoma of the breast and implications on surgery-A systematic review and meta-analysis

Meta-analysis of >87,000 patients demonstrates that patients with invasive lobular carcinoma of the breast are far less likely to achieve pCR of the breast or axilla compared to their ductal counterparts, receive less BCS and more frequently return positive margins.

BACKGROUND

Neoadjuvant chemotherapy (NACT) facilitates tumour downstaging, increases breast conserving surgery (BCS) and assesses tumour chemosensitivity. Despite clinicopathological differences in Invasive Ductal Carcinoma (IDC) and Invasive Lobular Carcinoma (ILC), decision making surrounding the use NACT does not take account of histological differences.

AIM

To determine the impact NACT on pathological complete response (pCR), breast conserving surgery (BCS), margin status and axillary pCR in ILC and IDC.

METHODS

A systematic review was performed in accordance with the PRISMA guidelines. Studies reporting outcomes among ILC and IDCs following NACT were identified. Dichotomous variables were pooled as odds ratios (ORs) with 95% confidence intervals_(CI) using the Mantel-Haenszel method. P-values <0.05 were statistically significant.

RESULTS

40 studies including 87,303 (7596 ILC [8.7%]and 79,708 IDC [91.3%]) patients were available for analysis. Mean age at diagnosis was 54.9 vs. 50.9 years for ILC and IDC, respectively. IDCs were significantly more likely to achieve pCR (22.1% v 7.4%, OR: 3.03 [95% CI 2.5-3.68] p < 0.00001), axillary pCR (23.6% vs. 13.4%, OR: 2.01 [95% CI 1.77-2.28] p < 0.00001) and receive BCS (45.7% vs. 33.3%, OR 2.14 [95% CI 1.87-2.45] p < 0.00001) versus ILCs. ILCs were significantly more likely to have positive margins at the time of surgery (36% vs 13.5%, OR 4.84 [95% CI 2.88-8.15] p < 0.00001).

CONCLUSION

This is the largest study comparing the impact of NACT among ILC and IDC with respect to pCR and BCS. ILC has different outcomes to IDC following NACT and incorporate it into treatment decisions and future clinical guidelines.

MRI Radiomics for Assessment of Molecular Subtype, Pathological Complete Response, and Residual Cancer Burden in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy

RATIONALE AND OBJECTIVES

There are limited data on pretreatment imaging features that can predict response to neoadjuvant chemotherapy (NAC). To extract volumetric pretreatment MRI radiomics features and assess corresponding associations with breast cancer molecular subtypes, pathological complete response (pCR), and residual cancer burden (RCB) in patients treated with NAC.

MATERIALS AND METHODS

In this IRB-approved study, clinical and pretreatment MRI data from patients with biopsy-proven breast cancer who received NAC between September 2009 and July 2016 were retrospectively analyzed. Tumors were manually identified and semi-automatically segmented on first postcontrast images. Morphological and three-dimensional textural features were computed, including unfiltered and filtered image data, with spatial scaling factors (SSF) of 2, 4, and 6 mm. Wilcoxon rank-sum tests and area under the receiver operating characteristic curve were used for statistical analysis.

RESULTS

Two hundred and fifty nine patients with unilateral breast cancer, including 73 (28.2%) HER2+, 112 (43.2%) luminal, and 74 (28.6%) triple negative breast cancers (TNBC), were included. There was a significant difference in the median volume (p = 0.008), median longest axial tumor diameter (p = 0.009), and median longest volumetric diameter (p = 0.01) among tumor subtypes. There was also a significant difference in minimum signal intensity and entropy among the tumor subtypes with SSF = 4 mm (p = 0.009 and p = 0.02 respectively) and SSF = 6 mm (p = 0.007 and p < 0.001 respectively). Additionally, sphericity (p = 0.04) in HER2+ tumors and entropy with SSF = 2, 4, 6 mm (p = 0.004, 0.02, 0.047 respectively) in luminal tumors were significantly associated with pCR. Multiple features demonstrated significant association (p < 0.05) with pCR in TNBC and with RCB in luminal tumors and TNBC, with standard deviation of intensity with SSF = 6 mm achieving the highest AUC (AUC = 0.734) for pCR in TNBC.

CONCLUSION

MRI radiomics features are associated with different molecular subtypes of breast cancer, pCR, and RCB. These features may be noninvasive imaging biomarkers to identify cancer subtype and predict response to NAC.

Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy

BACKGROUND

The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST.

SUMMARY

In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach.

KEY MESSAGES

Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.

Gradual adoption of needle biopsy for breast lesions in a rural state

Background

Minimally invasive breast biopsy (MIBB) is the standard of care for the diagnosis of breast cancer, with consensus guidelines suggesting MIBB goals of 90% of total biopsies. In a previous study of patients in the rural state of Vermont, USA (population size of 640,000), rural breast cancer patients had open biopsies 42% of the time compared to 29% of urban breast cancer patients. The aim of this study was to assess overall population‐based biopsy trends in Vermont.

Methods

The Vermont Breast Cancer Surveillance System (VBCSS) was used to identify women receiving MIBB and excisional breast biopsies in Vermont. Patient zip code at the time of initial biopsy was used to determine the patient residence rurality by rural–urban commuting area codes (RUCA 2.0™).

Results

There were 9122 diagnostic episodes from 1999 to 2018. MIBB was the initial biopsy method in 7524 (82.5%) cases, while surgical excision was the initial biopsy method in 1598 (17.5%) cases. A linear trend fit estimated an increase of 1.3% per year (p < 0.001, 95% CI 1.1%–1.5%) in the fraction of patients undergoing MIBB. Patients living in rural areas were less likely to receive MIBB (78.5%) than those living in urban areas (94.9%), p < 0.001. Multivariate analysis showed that urban patients and those patients in the years 2014–2018 were more likely to receive MIBB (OR 5.00, 95% CI 4.13–6.05 [p < 0.05] and OR 4.41, 95%CI 3.68–5.28 [p < 0.05], respectively). The rate of MIBB for rural patients increased and met the 90% quality standard in 2013 and ultimately matched urban patient rates of MIBB in 2018.

Conclusions

For the first time, we show that MIBB usage is above 90% in the state of Vermont and that there no longer exist disparities in breast biopsies between urban and rural patients or rural/urban facilities in the state, overall.

Pathologic response of ductal carcinoma in situ to neoadjuvant systemic treatment in HER2-positive breast cancer

Purpose

The presence of extensive ductal carcinoma in situ (DCIS) adjacent to HER2-positive invasive breast cancer (IBC) is often a contra-indication for breast-conserving surgery, even in case of excellent treatment response of the invasive component. Data on the response of DCIS to neoadjuvant systemic treatment (NST) are limited. Therefore, we estimated the response of adjacent DCIS to NST-containing HER2-blockade in HER2-positive breast cancer patients and assessed the association of clinicopathological and radiological factors with response.

Methods

Pre-NST biopsies were examined to determine presence of DCIS in all women with HER2-positive IBC treated with trastuzumab-containing NST ± pertuzumab between 2004 and 2017 in a comprehensive cancer center. When present, multiple DCIS factors, including grade, calcifications, necrosis, hormone receptor, and Ki-67 expression, were scored. Associations of clinicopathological and radiological factors with complete response were assessed using logistic regression models.

Results

Adjacent DCIS, observed in 138/316 patients with HER2-positive IBC, was eradicated after NST in 46% of patients. Absence of calcifications suspicious for malignancy on pre-NST mammography (odds ratio (OR) 3.75; 95% confidence interval (95% CI) 1.72–8.17), treatment with dual HER2-blockade (OR 2.36; 95% CI 1.17–4.75), a (near) complete response on MRI (OR 3.55; 95% CI 1.31–9.64), and absence of calcifications (OR 3.19; 95% CI 1.34–7.60) and Ki-67 > 20% in DCIS (OR 2.74; 95% CI 1.09–6.89) on pre-NST biopsy were significantly associated with DCIS response.

Conclusions

As DCIS can respond to NST containing HER2-blockade, the presence of extensive DCIS in HER2-positive breast cancer before NST should not always indicate a mastectomy. The predictive factors we found could be helpful when considering breast-conserving surgery in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06235-2.

Approaching Neoadjuvant Therapy in the Management of Early-Stage Breast Cancer

Neoadjuvant therapy is integral to the treatment of early-stage breast cancer. Goals of treatment include surgical downstaging of the tumor, rendering inoperable tumors resectable, and de-escalating axillary surgery in those with clinically positive nodes. Additionally, response to treatment provides important prognostic information regarding risk of recurrence and guides future adjuvant treatment. Although chemotherapy serves as the backbone of neoadjuvant treatment, an increased understanding of the tumor's clinical course as well as its molecular and genetic make-up aids in individualizing treatment and developing novel agents. This review summarizes current clinical approaches and the future direction to the management of breast cancer patients in the neoadjuvant setting.

Frequency and Outcomes of New Suspicious Lesions on Breast MRI in the Setting of Neoadjuvant Therapy

OBJECTIVE. The purpose of this article was to determine the frequency and outcomes of new suspicious findings on breast MRI after initiation of neoadjuvant therapy. MATERIALS AND METHODS. A retrospective database review identified all breast MRI examinations performed to assess response to neoadjuvant therapy between 2010 and 2018. Cases with new suspicious lesions assessed as BI-RADS 4 or 5 and found after the initiation of neoadjuvant treatment were included. Cases with no pretreatment MRI, cases in which the suspicious lesion was present on the baseline MRI but remained suspicious, and cases with insufficient follow-up were excluded. Radiologic, pathologic, and surgical reports were reviewed. Malignant outcomes were determined by pathologic examination. Benignity was established by pathologic examination, follow-up imaging, or both. A total of 419 breast MRI examinations in 297 women were performed to assess response to neoadjuvant therapy. After exclusions, 23 MRI examinations (5.5%) with new suspicious findings, all assessed as BI-RADS 4, comprised the final cohort. RESULTS. Of the 23 lesions, 13 new suspicious findings (56.5%) were contralateral to the known malignancy, nine (39.1%) were ipsilateral, and one (4.3%) involved the bilateral breasts. Lesion types included mass (16, 69.6%), nonmass enhancement (5, 21.7%) and focus (2, 8.7%). None of the new suspicious findings were malignant. CONCLUSION. New suspicious findings occurred in 5.5% of breast MRI examinations performed to monitor response to neoadjuvant therapy, and none of these new lesions were malignant. Our findings suggest that new lesions that arise in the setting of neoadjuvant therapy are highly unlikely to represent a new site of malignancy, particularly if the index malignancy shows treatment response. Larger studies are needed to confirm whether biopsy may be safely averted in this scenario.

Lack of Standardization in the Processing and Reporting of Post-Neoadjuvant Breast Cancer Specimens

CONTEXT.—

The use of neoadjuvant therapy in the management of early-stage invasive breast cancer is increasing. Residual Cancer Burden and other similar tools use pathologic characteristics of post-neoadjuvant therapy breast tumors to determine long-term outcome. However, there are no standardized guidelines for the pathologic evaluation of these specimens in the routine clinical setting.

OBJECTIVE.—

To assess current practices among Canadian pathologists and pathology assistants with regard to the processing and reporting of post-neoadjuvant therapy breast specimens.

DESIGN.—

An electronic survey was distributed to pathologists and pathology assistants across Canada.

RESULTS.—

Sixty-three responses were obtained. A total of 48% (15 of 31) of surveyed pathologists reported familiarity with the Residual Cancer Burden tool. A total of 40% (25 of 63) of respondents reported a lack of routine use of specimen photography, and 35% (22 of 63) reported a lack of routine use of grossing diagrams. There was significant variation with respect to tumor bed sampling; the most common method was to submit 1 block per centimeter of tumor (20 of 63; 32%). There was also significant variation in the method of measuring residual tumor; the most common method was to measure the largest cross-section of residual tumor (16 of 32; 50%).

CONCLUSIONS.—

There is a need for standardization of the evaluation of post-neoadjuvant therapy breast specimens in the routine clinical setting in Canada. We recommend the routine use of specimen mapping, submitting the largest cross section of tumor bed in toto, reporting tumor size as per American Joint Committee on Cancer and Residual Cancer Burden guidelines, and routinely including measurements of residual tumor cellularity and in situ disease in the final pathology report as per Residual Cancer Burden guidelines.

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Background

There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting.

Methods

In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias.

Results

A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching.

Conclusion

A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.

Isolation and identification of adipose-derived stromal/stem cells from breast cancer patients after exposure neoadjuvant chemotherapy

BACKGROUND

With recent research advances, adipose-derived stromal/stem cells (ASCs) have been demonstrated to facilitate the survival of fat grafts and thus are increasingly used for reconstructive procedures following surgery for breast cancer. Unfortunately, in patients, following radiation and chemotherapy for breast cancer suggest that these cancer treatment therapies may limit stem cell cellular functions important for soft tissue wound healing. For clinical translation to patients that have undergone cancer treatment, it is necessary to understand the effects of these therapies on the ASC's ability to improve fat graft survival in clinical practice.

AIM

To investigate whether the impact on ASCs function capacity and recovery in cancer patients may be due to the chemotherapy.

METHODS

ASCs were isolated from the cancerous side and noncancerous side of the breast from the same patients with receiving neoadjuvant chemotherapy (NAC) or not-receiving NAC. ASCs were in vitro treated with 5-fluorouracil (5-FU), doxorubicin (DXR), and cyclophosphamide (Cytoxan) at various concentrations. The stem cells yield, cell viability, and proliferation rates were measured by growth curves and MTT assays. Differentiation capacity for adipogenesis was determined by qPCR analysis of the specific gene markers and histological staining.

RESULTS

No significant differences were observed between the yield of ASCs in patients receiving NAC treatment and not-receiving NAC. ASCs yield from the cancerous side of the breast showed lower than the noncancerous side of the breast in both patients receiving NAC and not-receiving NAC. The proliferation rates of ASCs from patients didn't differ much before and after NAC upon in vitro culture, and these cells appeared to retain the capacity to acquire adipocyte traits simile to the ASCs from patients not-receiving NAC. After cessation and washout of the drugs for another a week of culturing, ASCs showed a slow recovery of cell growth capacity in 5-FU-treated groups but was not observed in ASCs treated with DXR groups.

CONCLUSION

Neoadjuvant therapies do not affect the functioning capacity of ASCs. ASCs may hold great potential to serve as a cell source for fat grafting and reconstruction in patients undergoing chemotherapy.

CAIX is a predictor of pathological complete response and is associated with higher survival in locally advanced breast cancer submitted to neoadjuvant chemotherapy

BACKGROUND

Locally advanced breast cancer often undergoes neoadjuvant chemotherapy (NAC), which allows in vivo evaluation of the therapeutic response. The determination of the pathological complete response (pCR) is one way to evaluate the response to neoadjuvant chemotherapy. However, the rate of pCR differs significantly between molecular subtypes and the cause is not yet determined. Recently, the metabolic reprogramming of cancer cells and its implications for tumor growth and dissemination has gained increasing prominence and could contribute to a better understanding of NAC. Thus, this study proposed to evaluate the expression of metabolism-related proteins and its association with pCR and survival rates.

METHODS

The expression of monocarboxylate transporters 1 and 4 (MCT1 and MCT4, respectively), cluster of differentiation 147 (CD147), glucose transporter-1 (GLUT1) and carbonic anhydrase IX (CAIX) was analyzed in 196 locally advanced breast cancer samples prior to NAC. The results were associated with clinical-pathological characteristics, occurrence of pCR, disease-free survival (DFS), disease-specific survival (DSS) and overall survival (OS).

RESULTS

The occurrence of pCR was higher in the group of patients whith tumors expressing GLUT1 and CAIX than in the group without expression (27.8% versus 13.1%, p = 0.030 and 46.2% versus 13.5%, p = 0.007, respectively). Together with regional lymph nodes staging and mitotic staging, CAIX expression was considered an independent predictor of pCR. In addition, CAIX expression was associated with DFS and DSS (p = 0.005 and p = 0.012, respectively).

CONCLUSIONS

CAIX expression was a predictor of pCR and was associated with higher DFS and DSS in locally advanced breast cancer patients subjected to NAC.

A dual-tuned multichannel bilateral RF coil for 1 H/23 Na breast MRI at 7 T

PURPOSE

Sodium MRI has shown promise for monitoring neoadjuvant chemotherapy response in breast cancer. The purpose of this work was to build a dual-tuned bilateral proton/sodium breast coil for 7T MRI that provides sufficient SNR to enable sodium breast imaging in less than 10 minutes.

METHODS

The proton/sodium coil consists of 2 shielded unilateral units: 1 for each breast. Each unit consists of 3 nested layers: (1) a 3-loop solenoid for sodium excitation, (2) a 3-loop solenoid for proton excitation and signal reception, and (3) a 4-channel receive array for sodium signal reception. Benchmark measurements were performed in phantoms with and without the sodium receive array insert. In vivo images were acquired on a healthy volunteer.

RESULTS

The sodium receive array boosted 1.5 to 3 times the SNR compared with the solenoid. Proton SNR loss due to residual interaction with the sodium array was less than 10%. The coil enabled sodium imaging in vivo with 2.8-mm isotropic nominal resolution (~5-mm real resolution) in 9:36 minutes.

CONCLUSION

The coil design that we propose addresses challenges associated with sodium's low SNR from a hardware perspective and offers the opportunity to investigate noninvasively breast tumor metabolism as a function of sodium concentration in patients undergoing neoadjuvant chemotherapy.

Tailored axillary surgery with or without axillary lymph node dissection followed by radiotherapy in patients with clinically node-positive breast cancer (TAXIS): study protocol for a multicenter, randomized phase-III trial

Background

Complete lymph node removal through conventional axillary dissection (ALND) has been standard treatment for breast cancer patients for almost a century. In the 1990s, however, and in parallel with the advent of the sentinel lymph node (SLN) procedure, ALND came under increasing scrutiny due to its association with significant patient morbidity. Several studies have since provided evidence to suggest omission of ALND, often in favor of axillary radiation, in selected clinically node-negative, SLN-positive patients, thus supporting the current trend in clinical practice. Clinically node-positive patients, by contrast, continue to undergo ALND in many cases, if only for the lack of studies re-assessing the indication for ALND in these patients. Hence, there is a need for a clinical trial to evaluate the optimal treatment for clinically node-positive breast cancer patients in terms of surgery and radiotherapy. The TAXIS trial is designed to fill this gap by examining in particular the value of tailored axillary surgery (TAS), a new technique for selectively removing positive lymph nodes.

Methods

In this international, multicenter, phase-III, non-inferiority, randomized controlled trial (RCT), including 34 study sites from four different countries, we plan to randomize 1500 patients to either receive TAS followed by ALND and regional nodal irradiation excluding the dissected axilla, or receive TAS followed by regional nodal irradiation including the full axilla. All patients undergo adjuvant whole-breast irradiation after breast-conserving surgery and chest-wall irradiation after mastectomy. The main objective of the trial is to test the hypothesis that treatment with TAS and axillary radiotherapy is non-inferior to ALND in terms of disease-free survival of clinically node-positive breast cancer patients in the era of effective systemic therapy and extended regional nodal irradiation. The trial was activated on 31 July 2018 and the first patient was randomized on 7 August 2018.

Discussion

Designed to test the hypothesis that TAS is non-inferior to ALND in terms of curing patients and preventing recurrences, yet is significantly superior in reducing patient morbidity, this trial may establish a new worldwide treatment standard in breast cancer surgery. If found to be non-inferior to standard treatment, TAS may significantly contribute to reduce morbidity in breast cancer patients by avoiding surgical overtreatment.

Trial registration

ClinicalTrials.gov, ID: NCT03513614. Registered on 1 May 2018.

www.kofam.ch, ID: NCT03513614. Registered on 17 June 2018.

EudraCT No.: 2018–000372-14.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3021-9) contains supplementary material, which is available to authorized users.

Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts' experiences in the Netherlands

PURPOSE

To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer.

METHODS

Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC.

RESULTS

A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%).

CONCLUSION

This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making.

Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit

INTRODUCTION

NAC has led to an increase in breast conserving surgery (BCS) worldwide. This study aims to analyse trends in the use of neoadjuvant chemotherapy (NAC) and the impact on surgical outcomes.

METHODS

We reviewed all records of cT1-4N0-3M0 breast cancer patients diagnosed between July 2011 and June 2016 who have been registered in the Dutch National Breast Cancer Audit (NBCA) (N = 57.177). The surgical outcomes of 'BCS after NAC' were compared with 'primary BCS', using a multivariable logistic regression model.

RESULTS

Between 2011 and 2016, the use of NAC increased from 9% to 18% and 'BCS after NAC' (N = 4170) increased from 43% to 57%. We observed an involved invasive margin rate (IMR) of 6,7% and a re-excision rate of 6,6%. As compared to 'primary BCS', the IMR of 'BCS after NAC' is higher for cT1 (12,3% versus 8,3%; p < 0.005), equal for cT2 (14% versus 14%; p = 0.046) and lower for cT3 breast cancer (28,3% versus 31%; p < 0.005). Prognostic factors associated with IMR for both 'primary BCS' as for 'BCS after NAC' are: lobular invasive breast cancer and a hormone receptor positive receptor status (all p < 0,005).

CONCLUSION

The use of NAC and the incidence of 'BCS after NAC' increased exponentially in time for all stages of invasive breast cancer in the Netherlands. This nationwide data confirms that 'BCS after NAC' compared to 'primary BCS' leads to equal surgical outcomes for cT2 and improved surgical outcomes for cT3 breast cancer. These promising results encourage current developments towards de-escalation of surgical treatment.

Pretreatment MRI features associated with diagnostic accuracy of post-treatment MRI after neoadjuvant chemotherapy

AIM

To investigate whether pretreatment magnetic resonance imaging (MRI) features are associated with diagnostic accuracy of post-treatment MRI for predicting pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in patients with breast cancer.

MATERIALS AND METHODS

From January 2005 and December 2016, 221 consecutive patients (mean age, 50 years; range, 20-81 years) who had undergone NAC, breast MRI before and after NAC, and surgery for invasive breast cancer were enrolled. Pretreatment and post-treatment MRI images were reviewed. Radiological complete response (rCR) was defined as the absence of both early and late enhancement on MRI after NAC. The association of pretreatment MRI features and post-treatment MRI diagnostic accuracy was assessed by using logistic regression analysis.

RESULTS

Among 221 patients, 60 (27.1%) underwent pCR after NAC. The diagnostic accuracy of post-treatment MRI was 84.2% (186/221). False-positive diagnosis occurred in 21 cases and false-negative diagnosis occurred in 14 cases. Of pretreatment features, the presence of peritumoural oedema (odds ratio, 3; 95% confidence interval [CI]: 1.1, 8.0; p=0.03) and HER2 (human epidermal growth factor receptor 2)-positive status (odds ratio, 3.4; 95% CI: 1.2, 9.9; p=0.02) were significantly associated with false-positive MRI results. Dense fibroglandular tissue (odds ratio, 10.8; 95% CI: 1.1, 105.2; p=0.04), presence of rim enhancement (odds ratio, 7.5; 95% CI: 1.2, 38.3; p=0.02) and oestrogen receptor (ER)-positive status (odds ratio, 6.3; 95% CI: 1.2, 32.5; p=0.03) were significantly associated with false-negative MRI results.

CONCLUSION

Pretreatment MRI features and cancer subtypes may be associated with diagnostic accuracy of post-treatment MRI after NAC in patients with breast cancer.

Patients' experiences with decisions on timing of chemotherapy for breast cancer

INTRODUCTION

Despite potential advantages, application of chemotherapy in the neo-adjuvant (NAC) instead of adjuvant (AC) setting for breast cancer (BC) patients varies among hospitals. The aim of this study was to gain insight in patients' experiences with decisions on the timing of chemotherapy for stage II and III BC.

MATERIALS AND METHODS

A 35-item online questionnaire was distributed among female patients (age>18) treated with either NAC or AC for clinical stage II/III invasive BC in 2013-2014 in the Netherlands. Outcome measures were the experienced exchange of information on the possible choice between both options and patients' involvement in the final decision on chemotherapy timing. Chemotherapy treatment experience was measured with the Cancer Therapy Satisfaction Questionnaire (CTSQ).

RESULTS

Of 805 invited patients, 49% responded (179 NAC, 215 AC). NAC-treated patients were younger and more often treated in teaching/academic hospitals and high-volume hospitals. Information on the possibility of NAC was given to a minority of AC-treated patients (AC, stage II:14%, stage III: 31%). Information on pros and cons of both NAC and AC was rated sufficient in about three fourth of respondents. Respondents not always felt having a choice in the timing of chemotherapy (stage II: 54% NAC vs 36% AC; stage III: 26% NAC, 54% AC).

CONCLUSION

The need to make a treatment decision on NAC was found to be made explicit in only a small number of adjuvant treated patients, in particular in BC stage II. Less than half of the respondents felt they had a real choice.

Radiology as the Point of Cancer Patient and Care Team Engagement: Applying the 4R Model at a Patient's Breast Cancer Care Initiation

Radiologists aspire to improve patient experience and engagement, as part of the Triple Aim of health reform. Patient engagement requires active partnerships among health providers and patients, and rigorous teamwork provides a mechanism for this. Patient and care team engagement are crucial at the time of cancer diagnosis and care initiation but are complicated by the necessity to orchestrate many interdependent consultations and care events in a short time. Radiology often serves as the patient entry point into the cancer care system, especially for breast cancer. It is uniquely positioned to play the value-adding role of facilitating patient and team engagement during cancer care initiation. The 4R approach (Right Information and Right Care to the Right Patient at the Right Time), previously proposed for optimizing teamwork and care delivery during cancer treatment, could be applied at the time of diagnosis. The 4R approach considers care for every patient with cancer as a project, using project management to plan and manage care interdependencies, assign clear responsibilities, and designate a quarterback function. The authors propose that radiology assume the quarterback function during breast cancer care initiation, developing the care initiation sequence, as a project care plan for newly diagnosed patients, and engaging patients and their care teams in timely, coordinated activities. After initial consultations and treatment plan development, the quarterback function is transitioned to surgery or medical oncology. This model provides radiologists with opportunities to offer value-added services and solidifies radiology's relevance in the evolving health care environment. To implement 4R at cancer care initiation, it will be necessary to change the radiology practice model to incorporate patient interaction and teamwork, develop 4R content and local adaption approaches, and enrich radiology training with relevant clinical knowledge, patient interaction competence, and teamwork skill set.

Surgical Outcomes for Mastectomy Patients Receiving Neoadjuvant Chemotherapy: A Propensity-Matched Analysis

Objective:

To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching.

Background:

Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence.

Methods:

Data from American College of Surgeons National Surgical Quality Improvement Program (2006–2012) were used to identify females with invasive breast cancer undergoing planned mastectomy. Surgical cases categorized as clean and undergoing no secondary procedures unrelated to mastectomy were included. A 1:1 matched propensity analysis was performed using neoadjuvant chemotherapy within 30 days of surgery as treatment. A total of 12 preoperative variables were used with additional procedure matching: bilateral mastectomy, nodal surgery, tissue, and/or implant. Outcomes examined were 4 wound occurrences, sepsis, and unplanned return to the operating room.

Results:

We identified 31,130 patient procedures with 2488 (7.5%) receiving chemotherapy. We matched 2411 cases, with probability of treatment being 0.005 to 0.470 in both cohorts. Superficial wound complication was the most common wound event, 2.24% in neoadjuvant-treated versus 2.45% in those that were not (P = 0.627). The rate of return to the operating room was 5.7% in the neoadjuvant group versus 5.2% in those that were not (P = 0.445). The rate of sepsis was 0.37% in the neoadjuvant group versus 0.46% in those that were not (P = 0.654).

Conclusions:

This large, matched cohort study, controlled for preoperative risk factors and most importantly for the surgical procedure performed, demonstrates that breast cancer patients receiving neoadjuvant chemotherapy have no increased risk for surgical morbidity.

Do Calcifications Seen on Mammography After Neoadjuvant Chemotherapy for Breast Cancer Always Need to Be Excised?

BACKGROUND

This study aimed to determine the relationship between mammographic calcifications and magnetic resonance imaging (MRI) tumoral enhancement before and after neoadjuvant chemotherapy (NAC) and to assess the impact of these findings on surgical management.

METHODS

This Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study involved breast cancer patients who underwent NAC between 2009 and 2015. The study cohort comprised 90 patients with pre- and posttreatment MRI and mammograms demonstrating calcifications within the tumor bed either at presentation or after treatment. The data gathered included pre- and post-NAC imaging findings and post-NAC histopathology, particularly findings associated with calcifications. Comparisons were made using Fisher's exact test, with p values lower than 0.05 considered significant.

RESULTS

Complete resolution of MRI enhancement occurred for 44% of the patients, and a pathologic complete response (pCR) was achieved for 32% of the patients. No statistically significant correlation between changes in mammographic calcifications and MRI enhancement was found (p = 0.12). Resolution of enhancement was strongly correlated with pCR (p < 0.0001). The majority of the patients with pCR demonstrated complete resolution of enhancement (79%, 23/29). No statistically significant relationship was found between changes in calcifications and rates of pCR (p = 0.06). A pCR was achieved most frequently for patients with resolution of enhancement and new, increasing, or unchanged calcifications (p < 0.0001).

CONCLUSIONS

Although calcifications seen on post-NAC mammography may be associated with benign disease, loss of MRI enhancement does not predict the absence of residual tumor with sufficient accuracy to leave calcifications in place. Complete excision of tumor bed calcifications remains standard practice and a substantial limitation to NAC use for downstaging patients to be eligible for breast conservation treatment.

Chemotherapy may eradicate ductal carcinoma in situ (DCIS) but not the associated microcalcifications

INTRODUCTION

We studied the effect of neoadjuvant chemotherapy (NAC) ± trastuzumab on the ductal carcinoma in situ (DCIS) component in patients with locally advanced breast cancer who achieved pathological complete response (pCR).

METHODS

The diagnostic biopsies of 92 consecutive breast cancer patients that were treated with neoadjuvant chemotherapy (NAC) ± trastuzumab were evaluated for the presence of DCIS. Upon completion of NAC, the surgical specimens were evaluated for complete eradication of both the invasive and non-invasive cancer in the breast. The pretreatment mammograms were evaluated for the presence of microcalcifications and compared to the mammograms that were obtained upon completion of therapy prior to surgery.

RESULTS

Thirty of 92 patients (33%) had a substantial component of DCIS in the pretreatment biopsy. Thirty nine patients (42%) achieved pCR: 22 (56%) following NAC + trastuzumab, 17 (32%) following chemotherapy only. Ten of 30 patients (33%) with DCIS component achieved pCR: 4 received chemotherapy only, in 6 trastuzumab was added. Multiple microcalcifications on the pretreatment mammograms were observed in 3 of 10 patients with DCIS who achieved pCR. No reduction in the area of calcifications was observed following NAC.

CONCLUSIONS

DCIS may be completely eradicated by NAC ± trastuzumab. However, associated microcalcifications probably persist. Patients with locally advanced breast cancer with substantial DCIS may still opt for NAC and breast conservation as the DCIS component may respond and even completely disappear following NAC. Residual widespread microcalcifications after NAC do not necessarily indicate residual cancer. Larger studies are needed to direct the surgical management of these patients.

Impact of neoadjuvant therapy on eligibility for and frequency of breast conservation in stage II-III HER2-positive breast cancer: surgical results of CALGB 40601 (Alliance)

OBJECTIVE

It had been previously shown that patients who receive neoadjuvant systemic therapy (NST) are more likely to undergo breast-conserving therapy (BCT) than those who have primary surgery. However, the frequency with which patients who are not BCT-eligible prior to NST convert to BCT-eligible with treatment is unknown. To document this conversion rate in a subset of patients expected to have a high clinical response rate to NST, we studied surgical assessment and management of patients enrolled on a randomized neoadjuvant trial for stage II-III HER2-positive breast cancer (HER2 + BC)(CALGB 40601).

METHODS

The treating surgeon assessed BCT candidacy based on clinico-radiographic criteria both before and after NST. Definitive breast surgical management was at surgeon and patient discretion. We sought to determine (1) the conversion rate from BCT-ineligible to BCT-eligible (2) the percentage of BCT-eligible patients who chose breast conservation, and (3) the rate of successful BCT. We also evaluated surgeon-determined factors for BCT-ineligibility and the correlation between BCT eligibility and pathologic complete response (pCR).

RESULTS

Of 292 patients with pre- and post-NST surgical assessments, 59 % were non-BCT candidates at baseline. Of the 43 % of these patients who converted with NST, 67 % opted for BCT, with an 80 % success rate. NST increased the BCT-eligible rate from 41 to 64 %. Common factors cited for BCT-ineligibility prior to NST including tumor size (56 %) and probable poor cosmetic outcome (26 %) were reduced by 67 and 75 %, respectively, with treatment, while multicentricity, the second most common factor (33 %), fell by only 16 %. Since 23 % of the BCT-eligible patients chose mastectomy, BCT was the final surgical procedure in just 40 % of the patients. Patients considered BCT-eligible both at baseline and after NST had a pCR rate of 55 %, while patients who were BCT-ineligible prior to NST had the same pCR rate (44 %) whether they converted to BCT-eligible or not.

CONCLUSIONS

Many patients with HER2 + BC deemed ineligible for BCT at baseline can be converted to BCT-eligible with NST; excluding patients with multicentric disease substantially increases that percentage. In converted patients who opt for BCT, the success rate is similar to that of patients considered BCT-eligible at baseline. Whether a BCT-ineligible patient converts to BCT eligibility or not does not appear to affect the likelihood of achieving a pCR. Despite the efficacy of NST in this patient cohort, only 40 % of patients had successful BCT; further research into why BCT-eligible patients often opt for mastectomy is needed.

Neoadjuvant nab-paclitaxel in the treatment of breast cancer

Neoadjuvant chemotherapy has the advantage of converting unresectable breast tumors to resectable tumors and allowing more conservative surgery in some mastectomy candidates. Chemotherapy agents, including taxanes, which are recommended in the adjuvant setting, are also considered in the neoadjuvant setting. Here, we review studies of nab-paclitaxel as a neoadjuvant treatment for patients with breast cancer. PubMed and conference or congress proceedings were searched for clinical studies of nab-paclitaxel in the neoadjuvant treatment of breast cancer. We also searched ClinicalTrials.gov for ongoing trials of nab-paclitaxel as a neoadjuvant agent in breast cancer. Twenty studies of nab-paclitaxel in the neoadjuvant setting were identified. In addition to reviewing key efficacy and safety data, we discuss how each trial assessed response, focusing on pathologic complete response and residual cancer burden scoring. Safety profiles are also reviewed. nab-Paclitaxel demonstrated antitumor activity and an acceptable safety profile in the neoadjuvant treatment of breast cancer. Ongoing and future trials will further evaluate preoperative nab-paclitaxel in breast cancer, including in combination with many novel immunological targeted therapies.