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Golan O, Khatib M, Menes TS, Freitas VAR, Kessner R, Neeman R, Mauda-Havakuk M, Mercer D, Amitai Y. Pushing the envelope in breast conserving surgery - is multiple-wire localization (3 or more wires) associated with increased risk of compromised margins and long-term recurrence? Eur J Radiol 2024; 176:111511. [PMID: 38776805 DOI: 10.1016/j.ejrad.2024.111511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION In the last two decades there has been a paradigm shift with breast conserving surgery (BCS) being applied to larger and more extensive breast malignancies. The aim of this study is to examine the success of BCS being performed in patients with extensive breast malignancies requiring at least 3 wires for localization, and to assess possible risk factors for failure. MATERIALS AND METHODS We performed a retrospective single center review of 232 patients who underwent BCS between 2010 and 2020 requiring at least 3 wires for localization, thus comprising the multi-wire group (MWG). The cohort included a control group of 232 single-wire BCS patients (SWG) chronologically matched with the MWG. Patients with either invasive malignancy or ductal carcinoma in situ (DCIS) were included in the study. Clinical, radiological, and pathological data was collected. Proportions of positive surgical margins, re-lumpectomies and conversion to mastectomy were calculated. Survival analysis for locoregional and distant recurrence was performed. RESULTS Women in the MWG were younger (mean age 57 vs. 63.1, P < 0.001), had larger tumor size (mean size 5.1 cm vs. 1.3 cm, p < 0.001), a higher prevalence of calcifications on mammograms (72 % vs. 17 %, P < 0.001), a higher proportion of positive lymph nodes (75 % vs. 45 %, P = 0.019), and an elevated incidence of a ductal carcinoma in situ (DCIS) component (72 % vs. 38 %, P < 0.001). Positive surgical margins were higher in the MWG (13 % vs 7 %, P = 0.03), which lead to higher proportions of re-lumpectomies or conversion to mastectomies (7 % vs 4 %, P = 0.17). On multivariate analysis of the entire cohort, patients with positive margins were more likely to have a DCIS component (77 % vs 53 %, P = 0.001), an infiltrating lobular carcinoma (ILC) component (15 % vs 9 %, P = 0.013), and positive ER hormonal status (94 % vs 85 %, p = 0.05). The number of wires was not an independent predictor of positive margins. On long-term analysis, the locoregional disease-free survival was similar between the SWG and MWG (P = 0.1). However, the MWG showed higher rates of distant metastasis (12 % vs 4 %, P = 0.006). CONCLUSIONS BCS requiring 3 or more wires is associated with a slightly higher proportion of positive margins. The increased risk of positive margins appears to be related to the type of tumor (DCIS component, ILC component and ER status) rather than to the number of wires. The number of wires does not significantly impact locoregional disease-free survival.
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Affiliation(s)
- Orit Golan
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Marian Khatib
- Tel Aviv University, Sackler School of Medicine, Department of Surgery, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Tehillah S Menes
- Tel Aviv University, Sackler School of Medicine, Department of Surgery, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
| | - Vivianne A R Freitas
- University of Toronto, Joint Department of Medical Imaging - University Health Network, Sinai Health System, Women's College Hospital, 610 University Avenue - M5G 2M9, Toronto, Ontario, Canada.
| | - Rivka Kessner
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Rina Neeman
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Michal Mauda-Havakuk
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal
| | - Diego Mercer
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Yoav Amitai
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
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Cil T, Boileau JF, Chia S, DeCoteau MJ, Jerzak KJ, Koch A, Nixon N, Quan ML, Roberts A, Brezden-Masley C. The Canadian Breast Cancer Symposium 2023 Meeting Report. Curr Oncol 2024; 31:1774-1802. [PMID: 38668038 PMCID: PMC11049169 DOI: 10.3390/curroncol31040135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/01/2024] [Accepted: 03/08/2024] [Indexed: 04/28/2024] Open
Abstract
On 15-16 June 2023, healthcare professionals and breast cancer patients and advocates from across Canada met in Toronto, Ontario, for the 2023 Canadian Breast Cancer Symposium (CBSC.). The CBSC. is a national, multidisciplinary event that occurs every 2 years with the goal of developing a personalized approach to the management of breast cancer in Canada. Experts provided state-of-the-art information to help optimally manage breast cancer patients, including etiology, prevention, diagnosis, experimental biology, and therapy of breast cancer and premalignant breast disease. The symposium also had the objectives of increasing communication and collaboration among breast cancer healthcare providers nationwide and providing a comprehensive and real-life review of the many facets of breast cancer. The sessions covered the patient voice, the top breast cancer papers from different disciplines in 2022, artificial intelligence in breast cancer, systemic therapy updates, the management of central nervous system metastases, multidisciplinary management of ductal carcinoma in situ, special populations, optimization-based individual prognostic factors, toxicity management of novel therapeutics, survivorship, and updates in surgical oncology. The key takeaways of these sessions have been summarized in this conference report.
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Affiliation(s)
- Tulin Cil
- Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada; (T.C.); (A.K.)
| | | | - Stephen Chia
- British Columbia Cancer Centre, University of British Columbia, Vancouver, BC V5Z 4E6, Canada;
| | - MJ DeCoteau
- Rethink Breast Cancer, Toronto, ON M4M 3G3, Canada;
| | - Katarzyna J. Jerzak
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.J.J.); (A.R.)
| | - Anne Koch
- Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada; (T.C.); (A.K.)
| | - Nancy Nixon
- Department of Surgery and Oncology, University of Calgary, Calgary, AB T2N 4Z6, Canada; (N.N.); (M.L.Q.)
| | - May Lynn Quan
- Department of Surgery and Oncology, University of Calgary, Calgary, AB T2N 4Z6, Canada; (N.N.); (M.L.Q.)
| | - Amanda Roberts
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (K.J.J.); (A.R.)
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Däster K, Garcia RP, Masannat Y, Kothari A. Oncoplastic breast surgery in Europe. Gland Surg 2024; 13:248-256. [PMID: 38455355 PMCID: PMC10915426 DOI: 10.21037/gs-23-380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024]
Abstract
Oncoplastic breast surgery (OPS) has become an integral part of breast cancer surgery for both breast conservation and mastectomies. In recent years, the emphasis on early detection and the advances in systemic and locoregional therapy has improved prognosis leading to an increased focus on survivorship and quality of life issues including patients' short and long-term aesthetic appearance as a key part of the surgical management. There is a significant variation across Europe in the type of specialist performing breast cancer surgery and the provision of OPS as such. In the traditional model, breast cancer care was provided by gynecologists in some countries, general surgeons, surgical oncologists, and breast surgeons in others. However recently, surgeons throughout Europe have extended their skill-base to include level 1 and 2 OPS and implant- and pedicle-flap based breast reconstruction. For breast surgeons to become proficient in these techniques, a standardized level of training and expertise is needed. The European Society of Mastology (EUSOMA) set standards for a specialist health professional in the field of breast cancer, the European Union of Medical Specialists (UEMS) examinations and the global curriculum that was developed by the American Society of Surgical Oncology (SSO) and the European Society of Surgical Oncology (ESSO) aims to improve standards of OPS practice across Europe. The new generation of breast surgeons, therefore, should be equipped with the necessary skill set to provide high quality OPS while keeping abreast of novel technologies and techniques aiming to provide patients with excellent long-term quality of life.
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Affiliation(s)
| | | | - Yazan Masannat
- Broomfield Hospital, Mid and South Essex NHS Trust, Chelmsford, UK
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Chagpar AB. Change. Am J Surg 2023; 226:756-759. [PMID: 37328327 DOI: 10.1016/j.amjsurg.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, United States.
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Altınok P, Tekçe E, Kızıltan HŞ, Gücin Z, Mayadağlı A. Impact of Radiotherapy Volumes on Late-Term Cosmetic Outcomes and Quality of Life in Patients With Unifocal and Multifocal/Multicentric Breast Cancer After Breast-Conserving Surgery. Eur J Breast Health 2023; 19:287-296. [PMID: 37795008 PMCID: PMC10546804 DOI: 10.4274/ejbh.galenos.2023.2023-5-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/27/2023] [Indexed: 10/06/2023]
Abstract
Objective Breast-conserving surgery (BCS) followed by radiotherapy (RT) is the standard treatment for early-stage breast cancer. The use of an additional RT dose (boost) to the tumour bed improves local control but may worsen quality of life (QOL) and cosmetic results. Multifocal/multicentric tumours (MMTs) pose a challenge as they require larger boost volumes. This study investigated the impact of RT volumes on late-term cosmetic outcomes and QOL in patients with unifocal and MMTs who underwent adjuvant RT after BCS. Materials and Methods Retrospective data of 367 patients who underwent BCS between 2012 and 2014 were reviewed. A cohort of 121 patients with at least six months of completed RT were prospectively included in the study. Cosmetic results were evaluated using a modified scoring system, and QOL was assessed using The European Cancer Treatment and Organization Committee tools. Results The results showed that the inclusion of regional lymphatics in the RT treatment field significantly affected QOL, particularly in terms of role functioning and social functioning. Higher boost volume ratios were associated with increased pain-related symptoms. However, the presence of MMTs did not significantly affect cosmetic outcomes compared to unifocal tumours. Conclusion The size of the boost and inclusion of regional lymphatics in RT significantly impact QOL in patients undergoing BCS. Tumour foci number does not affect cosmetic outcomes. These findings emphasize the need for careful consideration of RT volumes to minimize long-term adverse effects on QOL. Future prospective studies should evaluate early side effects and baseline QOL scores to provide a comprehensive assessment.
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Affiliation(s)
- Pelin Altınok
- Department of Radiation Oncology, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ertuğrul Tekçe
- Department of Radiation Oncology, Bezmialem Vakıf University Faculty of Medicine, İstanbul, Turkey
| | - Huriye Şenay Kızıltan
- Department of Radiation Oncology, Başakşehir Çam ve Sakura City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Zühal Gücin
- Department of Pathology, Bezmialem Vakıf University Faculty of Medicine, İstanbul, Turkey
| | - Alpaslan Mayadağlı
- Department of Radiation Oncology, Bezmialem Vakıf University Faculty of Medicine, İstanbul, Turkey
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Boughey JC, Rosenkranz KM, Ballman KV, McCall L, Haffty BG, Cuttino LW, Kubicky CD, Le-Petross HT, Giuliano AE, Van Zee KJ, Hunt KK, Hahn OM, Carey LA, Partridge AH. Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance). J Clin Oncol 2023; 41:3184-3193. [PMID: 36977292 PMCID: PMC10256355 DOI: 10.1200/jco.22.02553] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/11/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023] Open
Abstract
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.
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Affiliation(s)
| | - Kari M. Rosenkranz
- Dartmouth Hitchcock Medical Center, Dartmouth College—Norris Cotton Cancer Center, Lebanon, NH
| | - Karla V. Ballman
- Alliance Statistics and Data Management Center, Weill Cornell Medicine, New York, NY
| | - Linda McCall
- Alliance Statistics and Data Management Center, Duke University, Durham, NC
| | | | | | - Charlotte D. Kubicky
- Oregon Health and Science University, Legacy Good Samaritan Hospital and Medical Center, Portland, OR
| | | | | | | | - Kelly K. Hunt
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olwen M. Hahn
- Alliance for Clinical Trials in Oncology Operations Office, Chicago, IL
| | - Lisa A. Carey
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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7
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Davies C, Whisker L, Skillman J, Macmillan D, Holcombe C, Fairbrother P, Potter S. Current practice and provision of oncoplastic breast-conserving surgery in the UK: results of the ANTHEM national practice questionnaire. Breast Cancer Res Treat 2023:10.1007/s10549-023-06924-0. [PMID: 37213038 DOI: 10.1007/s10549-023-06924-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/19/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Oncoplastic breast-conserving surgery (OPBCS) may be a better option than mastectomy ± immediate breast reconstruction (IBR) for women with breast cancer but studies directly comparing the techniques are lacking. We surveyed UK breast units to determine the current practice of OPBCS to inform the design of a future comparative study. METHODS An electronic survey was developed to explore the current practice of OPBCS. This included the local availability of volume displacement and/or replacement techniques; number of cases performed; contraindications and approach to contralateral symmetrisation. Summary data for each survey item were calculated and overall provision of care examined. RESULTS 58 UK centres completed the survey, including 43 (74%) stand-alone breast and 15 (26%) combined breast/plastics units. Over 40% of units (n = 24) treated more than 500 cancers/year. Most units offered volume displacement techniques (TMs) (97%). Over two-thirds (n = 39. 67%) of units offered local perforator flaps (LPF). Approximately a half of units (10/19) not performing LPF were planning to introduce them in the next 12-24 months. A third (n = 19, 33%) of units routinely performed simultaneous contralateral symmetrisation mostly with two-surgeon operating. There were limited oncological restrictions to OPBCS with no contraindications for multifocal cancers in most centres; 65% of units (36/55) offered OPBCS for multicentric disease. Extensive DCIS was a contraindication in a minority of units. CONCLUSIONS OPBCS is widely available in the UK but contraindications and approaches to contralateral symmetrisation were variable. Work is now needed to prospectively evaluate the outcomes of OPBCS vs mastectomy ± IBR to support informed decision-making.
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Affiliation(s)
- Charlotte Davies
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Douglas Macmillan
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Christopher Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | | | - Shelley Potter
- Bristol Breast Care Centre, Southmead Hospital, Southmead Road, Westbury-On-Trym, Bristol, BS10 5NB, UK
- Translational Health Sciences, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, UK
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Alser O. The Feasibility of Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from the ACOSOG Z11102 (Alliance) Trial: A Comment. Ann Surg Oncol 2023; 30:3281. [PMID: 37005964 DOI: 10.1245/s10434-023-13373-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Osaid Alser
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Liu X, Wang Y, Cao K, Yao L, Hu L, Sun J, Zhang J, Xu Y, Xie Y. Impact of multifocal or multicentric disease on local recurrence and survival in breast cancer patients with or without BRCA1/2 variants. Breast Cancer Res Treat 2023; 199:25-33. [PMID: 36930346 DOI: 10.1007/s10549-023-06904-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/23/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE Multifocal or multicentric (MFMC) breast cancer is mainly focused on breast cancer patients with unknown BRCA status, the incidence and clinical relevance of MFMC disease in BRCA1/2 carriers is less explored to date. Our study was to investigate the incidence of MFMC disease in BRCA1/2 carriers and whether MFMC disease influences local recurrence and clinical outcomes. METHODS In this retrospective study, 479 breast cancer patients with BRCA1/2 variants and 1437 age-matched noncarriers were enrolled and patients received either breast-conserving therapy (BCT) or mastectomy with or without radiotherapy. RESULTS The rates of MFMC disease in BRCA1 and BRCA2 carriers, and noncarriers were 33.0% (61 of 185), 37.4% (110 of 294), and 31.2% (449 of 1437), respectively. MFMC disease in BRCA2 carriers was significantly higher than that in noncarriers (P = 0.039). After a median follow-up of 8.1 years, among patients treated with BCT, BRCA2 carriers with MFMC disease experienced a significantly higher rate of ipsilateral breast tumor recurrence (IBTR) than those with unifocal disease (16.7% vs 4.1%, P = 0.044). Moreover, BRCA2 carriers with MFMC disease had a significantly worse RFS (unadjusted hazard ratio [HR], 3.65 [95% CI 1.40-9.52]; P = 0.008), DRFS (unadjusted HR, 3.07 [95% CI 1.07-8.80]; P = 0.037), and OS (unadjusted HR, 4.96 [95% CI 1.18-20.02]; P = 0.029) than those with unifocal disease when treated with BCT. CONCLUSION MFMC breast cancer is more common in BRCA2 carriers, and BRCA2 carriers with MFMC disease treated with BCT exhibit a higher rate of IBTR and may have a poor survival.
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Affiliation(s)
- Xuejing Liu
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yanjie Wang
- Department of Ultrasound, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Kun Cao
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Lu Yao
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Li Hu
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Jie Sun
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Juan Zhang
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ye Xu
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yuntao Xie
- Familial & Hereditary Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China.
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Downs-Canner S, Cody HS. Five decades of progress in surgical oncology: Breast. J Surg Oncol 2022; 126:852-859. [PMID: 36087082 PMCID: PMC9472874 DOI: 10.1002/jso.27035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 11/06/2022]
Abstract
Surgery remains the single most effective treatment for breast cancer but coincident with a deeper understanding of tumor biology and advances in multidisciplinary care (encompassing breast imaging, systemic adjuvant therapy, radiotherapy, and genomics) continues to de-escalate, supported by strong level I data. We have moved from mastectomy to breast conservation, and from routine axillary dissection to sentinel lymph node biopsy to selective omission of axillary node staging altogether. We have further de-escalated through consensus over margin width in breast conservation, through improvements in neoadjuvant therapy, and by demonstrating no benefit for upfront surgery in patients with stage IV disease. For patients with ipsilateral breast tumor recurrence, reconservation surgery and reirradiation are promising. Cell cycle and immune checkpoint inhibitors, when added to conventional systemic therapy, have now moved beyond stage IV disease to phase III trials in the adjuvant and neoadjuvant settings, promising even further de-escalation of surgery. Finally, with genomic profiling we are moving away from the primacy of axillary node status for prognostication and into a new era allowing prediction of response to therapy.
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Affiliation(s)
- Stephanie Downs-Canner
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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11
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De-Escalating the Management of In Situ and Invasive Breast Cancer. Cancers (Basel) 2022; 14:cancers14194545. [PMID: 36230468 PMCID: PMC9559495 DOI: 10.3390/cancers14194545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time. Abstract It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.
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Hong R, Xu B. Breast cancer: an up-to-date review and future perspectives. CANCER COMMUNICATIONS (LONDON, ENGLAND) 2022; 42:913-936. [PMID: 36074908 PMCID: PMC9558690 DOI: 10.1002/cac2.12358] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/16/2022] [Accepted: 08/21/2022] [Indexed: 11/10/2022]
Abstract
Breast cancer is the most common cancer worldwide. The occurrence of breast cancer is associated with many risk factors, including genetic and hereditary predisposition. Breast cancers are highly heterogeneous. Treatment strategies for breast cancer vary by molecular features, including activation of human epidermal growth factor receptor 2 (HER2), hormonal receptors (estrogen receptor [ER] and progesterone receptor [PR]), gene mutations (e.g., mutations of breast cancer 1/2 [BRCA1/2] and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [PIK3CA]) and markers of the immune microenvironment (e.g., tumor-infiltrating lymphocyte [TIL] and programmed death-ligand 1 [PD-L1]). Early-stage breast cancer is considered curable, for which local-regional therapies (surgery and radiotherapy) are the cornerstone, with systemic therapy given before or after surgery when necessary. Preoperative or neoadjuvant therapy, including targeted drugs or immune checkpoint inhibitors, has become the standard of care for most early-stage HER2-positive and triple-negative breast cancer, followed by risk-adapted post-surgical strategies. For ER-positive early breast cancer, endocrine therapy for 5-10 years is essential. Advanced breast cancer with distant metastases is currently considered incurable. Systemic therapies in this setting include endocrine therapy with targeted agents, such as CDK4/6 inhibitors and phosphoinositide 3-kinase (PI3K) inhibitors for hormone receptor-positive disease, anti-HER2 targeted therapy for HER2-positive disease, poly(ADP-ribose) polymerase inhibitors for BRCA1/2 mutation carriers and immunotherapy currently for part of triple-negative disease. Innovation technologies of precision medicine may guide individualized treatment escalation or de-escalation in the future. In this review, we summarized the latest scientific information and discussed the future perspectives on breast cancer.
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Affiliation(s)
- Ruoxi Hong
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, 510060, P. R. China
| | - Binghe Xu
- State Key Laboratory of Molecular Oncology and Department of Medical Oncology, Cancer Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100006, P. R. China
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13
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Kim SY, Cho N. Breast Magnetic Resonance Imaging for Patients With Newly Diagnosed Breast Cancer: A Review. J Breast Cancer 2022; 25:263-277. [PMID: 36031752 PMCID: PMC9411024 DOI: 10.4048/jbc.2022.25.e35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Despite the high sensitivity and widespread use of preoperative magnetic resonance imaging (MRI), the American Cancer Society and the National Comprehensive Cancer Network guidelines do not recommend the routine use of preoperative MRI owing to the conflicting results and lack of clear benefit to the surgical outcome (reoperation and mastectomy) and long-term clinical outcomes (local recurrence and metachronous contralateral breast cancer). Preoperative MRI detects additional cancers that are occult at mammography and ultrasound but increases the rate of mastectomy. Concerns about overdiagnosis and overtreatment of preoperative MRI might be mitigated by adjusting the confounding factors when conducting studies, using the state-of-the-art image-guided biopsy technique, applying the radiologists’ cumulative experiences in interpreting MRI findings, and performing multiple lumpectomies in patients with multicentric cancer. Among the various imaging methods, dynamic contrast-enhanced MRI has the highest accuracy in predicting pathologic complete response after neoadjuvant chemotherapy. Prospective trials aimed at applying the MRI information to the de-escalation of surgical or radiation treatments are underway. In this review, current studies on the clinical outcomes of preoperative breast MRI are updated, and circumstances in which MRI may be useful for surgical planning are discussed.
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Affiliation(s)
- Soo-Yeon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Nariya Cho
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.
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14
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Abstract
INTRODUCTION As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance. AREAS COVERED Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment. EXPERT OPINION The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York
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15
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Guirguis MS, Checka C, Adrada BE, Whitman GJ, Dryden MJ, Sun J, Ding QQ, Le-Petross H, Rauch GM, Clemens M, Moseley T. Bracketing with Multiple Radioactive Seeds to Achieve Negative Margins in Breast Conservation Surgery: Multiple Seeds in Breast Surgery. Clin Breast Cancer 2022; 22:e158-e166. [PMID: 34187752 PMCID: PMC8639835 DOI: 10.1016/j.clbc.2021.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Breast conservation surgery (BCS) is the treatment of choice for unifocal, early-stage breast cancer. The ability to offer BCS to a wider subset of patients, including those with multifocal/multicentric cancer as well as extensive ductal carcinoma in situ, has emerged over time, especially in those undergoing joint oncoplastic reconstruction and those treated with neoadjuvant therapy. However, localization techniques using multiple radioactive seeds for bracketing in this patient subset have not been validated. MATERIALS AND METHODS A single-institution retrospective review was conducted of all patients with breast cancer who underwent BCS, guided by multiple bracketed iodine I 125 radioactive seeds between January 2014 and April 2017. RESULTS Bracketing of breast cancer using 2 or more radioactive seeds was performed in 157 breasts in 156 patients. Negative margins were achieved in 124 of 157 (79%) breasts, including 33 cases (21%) that underwent targeted margin reexcision at the time of surgery after intraoperative, multidisciplinary margin assessment. Thirty-three cases (21%) resulted in close or positive margins, of which 11 (7%) and 10 (6.4%) underwent completion mastectomy or repeat lumpectomy, respectively. Twelve patients (7.6%) did not undergo reexcision. En bloc resection was successful in 134 of 157 (85.4%) lumpectomies. Eighty-nine percent of the procedures were coupled with oncoplastic reconstruction. CONCLUSION Bracketing techniques using multiple radioactive seeds expands the indications for breast conservation therapy in patients who would have traditionally required mastectomy. Intraoperative margin assessment improves surgical and pathologic success. Larger defects created by multifocal resection are optimally managed in concert with oncoplastic reconstruction to minimize asymmetries and aesthetic defects.
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Affiliation(s)
| | - Cristina Checka
- University of Texas MD Anderson Cancer Center, Breast Surgical Oncology
| | | | - Gary J. Whitman
- University of Texas MD Anderson Cancer Center, Breast Imaging
| | - Mark J. Dryden
- University of Texas MD Anderson Cancer Center, Breast Imaging
| | - Jia Sun
- University of Texas MD Anderson Cancer Center, Biostatistics
| | - Qing-Qing Ding
- University of Texas MD Anderson Cancer Center, Anatomical Pathology
| | | | - Gaiane M. Rauch
- University of Texas MD Anderson Cancer Center, Abdominal Imaging
| | - Mark Clemens
- University of Texas MD Anderson Cancer Center, Plastic Surgery
| | - Tanya Moseley
- University of Texas MD Anderson Cancer Center, Breast Imaging
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16
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Al-Hilli Z, Weiss A, Armani A, Boughey JC, Blair SL. Breast cancer-The catalyst of contemporary trials design. J Surg Oncol 2021; 125:7-16. [PMID: 34897706 DOI: 10.1002/jso.26722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/07/2022]
Abstract
Surgical trials in breast cancer have catalyzed contemporary trial design for solid organ cancers and are a prime example of surgeons taking the lead in clinical trial design. Surgeons have lead trials that have improved patient outcomes and quality of life without sacrificing oncologic safety. We have evolved from radical mastectomy to breast conservation and sentinel node biopsy. Contemporary trial design in breast cancer now focus on personalizing care based on tumor genomics.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anna Weiss
- Department of Surgery, Brigham and Women Hospital, Boston, Massachusetts, USA
| | - Ava Armani
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah L Blair
- Department of Surgery, University of California San Diego, San Diego, California, USA
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17
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Cuttino LW, McCall L, Kubicky C, Ballman KV, Le-Petross H, Hunt KK, Haffty B, Rosenkranz KM, Boughey JC. The Feasibility of Radiation Therapy after Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from ACOSOG Z11102 (Alliance) Trial. Int J Radiat Oncol Biol Phys 2021; 112:636-642. [PMID: 34634438 PMCID: PMC8928138 DOI: 10.1016/j.ijrobp.2021.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
Purpose: Historically, multiple ipsilateral breast cancer (MIBC) has been a contraindication to breast-conserving therapy. We report the feasibility of radiation therapy (RT) after breast-conserving therapy in MIBC from the Alliance Z11102 trial. Methods and Materials: Delineation of targets and organs at risk was performed according to the Radiation Therapy Oncology Group contouring consensus definitions. RT was delivered to the whole breast to 45 to 50 Gy in standard daily fractions of 1.8 to 2.0 Gy. A boost of 10 to 16 Gy in 2.0-Gy daily fractions to each tumor bed was mandatory. Results: A total of 236 eligible patients were enrolled in the study between July 23, 2012 and August 19, 2016. Of those, 195 (83%) completed RT. No patient underwent mastectomy for failure to meet the RT dose constraints. Higher absolute boost volume was associated with increased incidence of grade 2 or higher dermatitis (odds ratio, 1.21; 95% confidence interval, 1.041.41; P = .014). Higher relative boost volume as a percentage of the overall breast volume was not associated with increased dermatitis. Neither absolute nor relative boost volume appeared to significantly influence overall cosmesis. Conclusions: Breast conservation followed by whole breast RT plus boost to each tumor bed was feasible in the majority of patients with MIBC. Increasing radiation boost volume was associated with increased incidence of acute dermatitis, but was not associated with worse overall cosmesis.
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Affiliation(s)
- Laurie W Cuttino
- Sarah Cannon Cancer Institute at Henrico Doctors' Hospital, Richmond, Virginia.
| | - Linda McCall
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina
| | | | - Karla V Ballman
- Alliance Statistics and Data Center, Weill Medical College of Cornell University, New York, New York
| | | | | | - Bruce Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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18
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Oncoplastic Breast Surgery: Is it reliable in the treatment of multifocal breast cancer? A preliminary report of a prospective randomized controlled trial. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.926930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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19
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Weiser R, Polychronopoulou E, Kuo YF, Haque W, Hatch SS, Tyler DS, Gradishar WJ, Klimberg VS. De-escalation of Endocrine Therapy in Early Hormone Receptor-positive Breast Cancer: When Is Local Treatment Enough? Ann Surg 2021; 274:654-663. [PMID: 34506321 DOI: 10.1097/sla.0000000000005064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify subgroups of hormone receptor-positive (HR+) breast cancer patients that might not benefit from adding endocrine therapy (ET) to their local treatment. BACKGROUND De-escalation in breast cancer treatment has included surgery, radiation, and chemotherapy and has often focused on older patient populations. Systemic ET has yet to be de-escalated, though it carries serious side-effects, decreasing quality of life over 5 to 10 years. We hypothesize the 21-gene recurrence score (RS) could identify subgroups of younger patients whose long-term survival is unaffected by adjuvant ET. METHODS The National Cancer Database was used to identify women aged ≥50, with HR+, HER2-negative tumors, ≤3 cm in size, N0 status, and a RS≤25, who underwent breast-conserving surgery in 2010 to 2016. Kaplan-Meier and Cox proportional hazards models were used to identify association between treatment and overall survival (OS). RESULTS Of the 45,217 patients identified, 80.6% were 50 to 69 years old. 42,632 (94.3%) patients received ET and 2585 (5.7%) did not. The 5-year OS was 96.4% for patients receiving ET and 93.1% for those who did not (P < 0.001). After adjusting for all covariates, patients aged 50 to 69 with RS < 11 showed no statistically significant improvement in OS when adding ET to surgery, with or without radiation (P = 0.40). With RS 11 to 25, there was a significant improvement of OS with ET plus radiation (P < 0.001). CONCLUSIONS Local treatment only, with de-escalation of long-term ET, for patients aged 50 to 69 with RS < 11, seems not to impact OS and should have an anticipated quality of life improvement. Prospective studies investigating this approach are warranted.
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Affiliation(s)
- Roi Weiser
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Efstathia Polychronopoulou
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas
| | - Sandra S Hatch
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, Texas
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
- MD Anderson Cancer Center, Houston, Texas
| | - William J Gradishar
- Department of Medicine & Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - V Suzanne Klimberg
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
- MD Anderson Cancer Center, Houston, Texas
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20
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Savioli F, Seth S, Morrow E, Doughty J, Stallard S, Malyon A, Romics L. Extreme Oncoplasty: Breast Conservation in Patients with Large, Multifocal, and Multicentric Breast Cancer. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:353-359. [PMID: 34079367 PMCID: PMC8164874 DOI: 10.2147/bctt.s296242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/22/2021] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Extreme Oncoplastic Breast Conservation Surgery (EOBCS) is offered in selected patients with multifocal or multicentric breast cancer (MFMC). Recent evidence has suggested that EOBCS may be a valuable resource for patients with MFMC who may avoid the risk associated with mastectomy in favour of the benefits of breast conservation without risking their oncological outcomes. Our study examined the practice of EOBCS in two regional breast units in Glasgow, United Kingdom. MATERIALS AND METHODS A prospectively collected database of 50 patients treated with EOBC in two breast units in Glasgow between 2007 and 2018 were evaluated, and clinical outcomes were observed. RESULTS Fifty patients (median age 55) underwent EOBCS, of which 43 (86%) had invasive disease. Median tumour size was 55mm (50-90) and multifocal disease was identified in 22 (44%) patients. Nine patients (18%) were found to have positive margins and underwent a second procedure, with 6 (12%) proceeding to mastectomy. Five-year disease free survival rate was 91.5%, while cancer-specific survival was 95.7%. CONCLUSION EOBCS is oncologically safe in short-term follow-up. Large scale studies are required to confirm these preliminary results, in order to offer EOBCS as a valid option to patients with advanced or multifocal breast cancer.
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Affiliation(s)
- Francesca Savioli
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Subodh Seth
- Department of Breast Surgery, Forth Valley Royal Hospital, Larbert, UK
| | - Elizabeth Morrow
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Julie Doughty
- Department of Breast Surgery, Gartnavel General Hospital, Glasgow, UK
| | - Sheila Stallard
- Department of Breast Surgery, Gartnavel General Hospital, Glasgow, UK
| | - Andy Malyon
- Canniesburn Department of Plastic Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Laszlo Romics
- Academic Unit of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Department of Breast Surgery, New Victoria Hospital, Glasgow, UK
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21
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Loibl S, Poortmans P, Morrow M, Denkert C, Curigliano G. Breast cancer. Lancet 2021; 397:1750-1769. [PMID: 33812473 DOI: 10.1016/s0140-6736(20)32381-3] [Citation(s) in RCA: 631] [Impact Index Per Article: 210.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.
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Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carsten Denkert
- German Breast Group, Neu-Isenburg, Germany; Institute of Pathology, Philipps University of Marburg, Marburg, Germany; University Hospital Marburg, Marburg, Germany
| | - Giuseppe Curigliano
- European Institute of Oncology IRCCS, Milan, Italy; University of Milano, Milan, Italy
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22
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Vane MLG, Hunter-Squires J, Kim S, Smidt ML, Giuliano AE. Women Could Avoid Axillary Lymph Node Dissection by Choosing Breast-Conserving Therapy Instead of Mastectomy. Ann Surg Oncol 2021; 28:2522-2528. [PMID: 33586070 DOI: 10.1245/s10434-021-09674-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/08/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The ACOSOG Z0011 trial showed that completion axillary lymph node dissection (cALND) can be safely omitted for some patients with T1-2 clinically node-negative breast cancer with one to two involved sentinel lymph nodes (SLNs) treated with breast-conserving therapy (BCT). There is little evidence for the safety of omitting cALND for mastectomy-treated patients. Consequently, cALND is often recommended for sentinel node-positive patients treated with mastectomy. The aim of this study is to determine the proportion of patients who could avoid cALND by choosing BCT instead of mastectomy at a tertiary cancer center. PATIENTS AND METHODS All T1-2 clinically node-negative breast cancer patients treated with BCT or mastectomy between 2012 and 2017 with metastases in the SLN(s) were selected from a prospectively maintained database. Clinical factors and outcomes were evaluated between the two groups. Differences were compared using Wilcoxon rank-sum test, chi-square test or Fisher's exact test as appropriate. Significance was set at the 0.05 level for all analyses. RESULTS A total of 306 patients were included, 199 (65.0%) of whom were treated with BCT and 107 (35.0%) with mastectomy. Patients treated with mastectomy were more often treated with cALND compared with those treated with BCT (71.0% versus 26.6%, p < 0.0001). Overall, 52 of the mastectomy patients (68.4%) could have avoided cALND if they had chosen BCT. CONCLUSIONS Patients treated with mastectomy are more likely to receive cALND than those treated with BCT. Axillary management should be addressed during discussion of primary tumor therapy, and cALND may be avoided when patients choose BCT instead of mastectomy.
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Affiliation(s)
- Marissa L G Vane
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Sungjin Kim
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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23
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Wu JM, Turashvili G. A Survey of Breast Pathologists' Practice in Staging Multiple Foci of Invasive Carcinoma. Clin Breast Cancer 2020; 21:e506-e511. [PMID: 33386230 DOI: 10.1016/j.clbc.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer (AJCC) staging system is the reference standard for describing the extent of neoplastic disease on the basis of the size of primary tumor (T), and the presence of regional lymph node (N) involvement and distant metastasis (M). Multiple foci of invasive breast carcinoma may pose staging challenges to the reporting pathologist. We set out to evaluate the practice of local breast pathologists with regard to staging of multiple foci of invasive carcinoma. PATIENTS AND METHODS Breast pathologists were surveyed at a Community of Interest in Breast Pathology meeting. The live voting survey contained 6 case-based scenarios of multiple foci of invasive mammary carcinoma of the same or different histologic type and with unilateral or bilateral involvement. A supporting illustration was provided for each case. RESULTS There was poor interobserver agreement with no consensus reached among the respondents in any of the cases. Staging choices varied from staging tumors together irrespective of histology or procedure type to staging tumors of the same histologic type together, or staging each tumor focus separately. Confusion was particularly evident when tumor foci with different histologic types were present. CONCLUSION Inconsistencies exist in the reporting of AJCC pathologic TNM stage for multiple foci of invasive carcinoma. The results serve as a reminder that education and strict adherence to the AJCC guidelines is essential for establishing standard practice in order to provide accurate cancer staging and ensure optimal clinical management.
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Affiliation(s)
- Jessie M Wu
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Gulisa Turashvili
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.
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24
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Rosenkranz KM, Ballman K, McCall L, McCarthy C, Kubicky CD, Cuttino L, Hunt KK, Giuliano A, Van Zee KJ, Haffty B, Boughey JC. Cosmetic Outcomes Following Breast-Conservation Surgery and Radiation for Multiple Ipsilateral Breast Cancer: Data from the Alliance Z11102 Study. Ann Surg Oncol 2020; 27:4650-4661. [PMID: 32699926 PMCID: PMC7554157 DOI: 10.1245/s10434-020-08893-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/04/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
| | - Karla Ballman
- Alliance Statistics and Data Center, Weill Medical College of Cornell University, New York, NY, USA
| | - Linda McCall
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA
| | | | | | - Laurie Cuttino
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Kelly K Hunt
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Bruce Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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25
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Crown A, Handy N, Weed C, Laskin R, Rocha FG, Grumley J. Oncoplastic Breast-Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use in Patients with Traditional Indications for Mastectomy? Ann Surg Oncol 2020; 28:2199-2209. [PMID: 32989659 DOI: 10.1245/s10434-020-09044-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/03/2020] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Breast Surgery, True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | - Nicketti Handy
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Christina Weed
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ruby Laskin
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Flavio G Rocha
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Janie Grumley
- Margie Peterson Breast Center, John Wayne Cancer Institute, Santa Monica, CA, USA.
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26
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Nguyen QD, Tavana A, Sadruddin S, Chao C. Successful Lumpectomy in a Patient With Multicentric Breast Cancer. Cureus 2020; 12:e10072. [PMID: 32999790 PMCID: PMC7522052 DOI: 10.7759/cureus.10072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
When there is extensive breast cancer, patients typically undergo mastectomy. However, lumpectomy may still be performed for patients who are motivated to avoid a mastectomy and understand the risk for positive margins requiring second surgery in unique cases. This report details the surgical management and clinical reasoning behind lumpectomy for a multicentric breast cancer spanning 5 cm. The lumpectomy was a success with negative margins on final pathology.
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Affiliation(s)
- Quan D Nguyen
- Radiology, University of Texas Medical Branch, Galveston, USA
| | - Anahita Tavana
- Radiology, University of Texas Medical Branch, Galveston, USA
| | | | - Celia Chao
- Breast Surgery, University of Texas Medical Branch, Galveston, USA
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27
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Rosenkranz KM, Boughey JC. ASO Author Reflections: Multiple Ipsilateral Breast Cancer: Where Have We Been, Where are We Going. Ann Surg Oncol 2020; 27:686-687. [PMID: 32808160 DOI: 10.1245/s10434-020-08983-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/25/2020] [Indexed: 01/12/2023]
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28
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Rockoff SJ, Flanagan MR, Kim JN, Banda K, Calhoun KE, Lam DL. The Radiologist's Role in a Breast Multidisciplinary Tumor Board. JOURNAL OF BREAST IMAGING 2020; 2:372-381. [PMID: 38424959 DOI: 10.1093/jbi/wbaa030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Indexed: 03/02/2024]
Abstract
Breast multidisciplinary tumor boards (MTBs) play an important role in determining treatment. This article serves as a guide for the radiologist participating in a breast MTB, as the information presented at MTB can significantly influence treatment plans and dictate future steps for further patient work-up. Multidisciplinary tumor board preparation involves a careful review of the patient's history while gathering all relevant imaging studies, and reinterpreting them when appropriate. Presented images should be carefully selected, annotated, and displayed clearly before providing final recommendations for localization and incompletely assessed findings. Anatomic staging factors from the AJCC Breast Cancer Staging System, such as tumor size and degree of suspected skin involvement, should be described. In addition, there are many other types of information that the treatment specialists want to know. The surgeon is interested in anatomic information that will help them decide whether breast conservation therapy is feasible or if local structures, such as the nipple, can be spared. The radiation oncologist may need to know whether accelerated partial breast irradiation is feasible or if postmastectomy radiation therapy is indicated. The medical oncologist is looking for factors that may provide an indication for neoadjuvant therapy and ensuring there is a reliable follow-up method for evaluating the response to treatment, such as comparative MRI. Additionally, all specialists need to know the extent of suspected nodal involvement. By clearly and comprehensively presenting this information to the rest of the MTB team, the radiologist provides a vital contribution that guides treatment and ensures adherence to clinical guidelines.
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Affiliation(s)
- Steven J Rockoff
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
| | - Meghan R Flanagan
- University of Washington School of Medicine, Department of Surgery, Seattle, WA
| | - Janice N Kim
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, WA
| | - Kalyan Banda
- University of Washington School of Medicine, Department of Medicine, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kristine E Calhoun
- University of Washington School of Medicine, Department of Surgery, Seattle, WA
| | - Diana L Lam
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
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29
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Amin AL, Fan F, Winblad OD, Larson KE, Wagner JL. Ipsilateral and Concurrent Breast Cancer and Atypical Ductal Hyperplasia: Does Atypia Also Need Surgical Excision? Ann Surg Oncol 2020; 27:4786-4794. [PMID: 32705514 DOI: 10.1245/s10434-020-08896-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Standard-of-care management of atypical ductal hyperplasia (ADH) is surgical excision. Multiple studies have identified features of ADH in patients at low risk for upgrade who may benefit from omission of surgical excision. Patients with an ipsilateral breast cancer have been excluded from studies investigating observation for the management of ADH. METHODS This was a retrospective review of women with both a breast cancer and an ipsilateral separate site of ADH diagnosed on percutaneous biopsy, who underwent excision of both sites from 2008 to 2018. Radiographic and pathologic features of ADH and cancer were analyzed, including imaging size, biopsy modality, distance between sites, cancer subtype, grade, prognostic markers, ADH foci, and presence of necrosis or micropapillary features. Final pathology at the ADH site was used to determine upgrade. Multivariable logistic regression was performed to identify variables significantly associated with ADH upgrade to malignancy. RESULTS Among 62 women meeting the inclusion criteria, 11 (17.7%) upgraded to malignancy [9 ductal carcinoma in situ (DCIS), 2 invasive cancer] at the site of ADH. Upgrade was significantly higher with ipsilateral DCIS (p = 0.03), ultrasound biopsy at the ADH site (p = 0.01), and ADH with necrosis (p = 0.04). The group at lowest risk for upgrade had stereotactic biopsy and ADH without necrosis (0% upgrade). CONCLUSION The presence of breast cancer does not significantly increase the likelihood for upgrade at a separate site of ipsilateral concurrent ADH above contemporary reported upgrade rates of ADH alone (10-30%). When considering breast conservation for breast cancer, omitting excision of the site of ADH can be considered when low-risk features are present.
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Affiliation(s)
- Amanda L Amin
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA.
| | - Fang Fan
- Department of Pathology, The University of Kansas Health System, Kansas City, KS, USA
| | - Onalisa D Winblad
- Department of Radiology, The University of Kansas Health System, Kansas City, KS, USA
| | - Kelsey E Larson
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
| | - Jamie L Wagner
- Department of Surgery, The University of Kansas Health System, Kansas City, KS, USA
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30
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Kuhl CK, Lehman C, Bedrosian I. Imaging in Locoregional Management of Breast Cancer. J Clin Oncol 2020; 38:2351-2361. [PMID: 32442068 PMCID: PMC7343437 DOI: 10.1200/jco.19.03257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Constance Lehman
- Breast Imaging Section, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, Division of Surgery, University of Texas MD Anderson Cancer, Center, Houston, TX
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31
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Fayanju OM, Ren Y, Thomas SM, Greenup RA, Hyslop T, Hwang ES, Stewart JH. A Case-Control Study Examining Disparities in Clinical Trial Participation Among Breast Surgical Oncology Patients. JNCI Cancer Spectr 2020; 4:pkz103. [PMID: 32211583 PMCID: PMC7083236 DOI: 10.1093/jncics/pkz103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 11/07/2019] [Accepted: 12/01/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clinical trial participation among racial and ethnic minorities remains low despite national efforts. We sought to determine how participation in clinical trials by breast surgical oncology patients has changed over time and what characteristics are associated with participation. METHODS Women with breast cancer enrolled in National Cancer Institute-sponsored, cooperative-group trials from 2000 to 2012 and who underwent oncologic surgery (n = 17 125) were compared with trial-eligible women in the National Cancer Database diagnosed in 2000-2012 (n = 792 719). Race-specific trial participation was plotted over time by income and reported as a proportion of the combined cohorts. Factors associated with trial participation were estimated using logistic regression; we report odds ratios (ORs) with 95% confidence intervals (CIs). A P value less than .05 was considered statistically significant for all analyses. All tests were two-sided. RESULTS Participation declined across all groups over time because of a decrease in the scale and number of trials. In 2000-2003, Asian-Pacific Islander (7.17%), Hispanic (3.48%), and white (7.13%) patients from the highest income group had higher participation than their lower-income counterparts (Asian-Pacific Islander: 3.95%; Hispanic: 2.67%; white: 5.96%), but by 2008-2012, only high-income white patients participated more than lower-income whites (0.32% vs 0.25%, all P < .01). Black (OR = 0.80, 95% CI = 0.75 to 0.85) and Hispanic (OR = 0.84, 95% CI = 0.77 to 0.92) patients were less likely to participate than whites, but there were statistically significant interactions between income and race and ethnicity, with high-income black patients being approximately 50% less likely to participate than lower-income blacks (all P < .001). CONCLUSIONS Multifaceted interventions addressing the intersectionality of race, ethnicity, and other patient characteristics are needed to address persistent disparities in trial participation among breast surgical oncology patients.
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Affiliation(s)
- Oluwadamilola M Fayanju
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Women’s Cancer Program, Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Forge, Duke University, Durham, NC, USA
- Department of Surgery, Durham VA Medical Center, Durham, NC, USA
| | - Yi Ren
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC, USA
| | - Samantha M Thomas
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Rachel A Greenup
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Women’s Cancer Program, Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Terry Hyslop
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Women’s Cancer Program, Duke Cancer Institute, Durham, NC, USA
| | - John H Stewart
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
- Department of Surgery, University of Illinois Cancer Center, Chicago, IL, USA
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32
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Corso G, Magnoni F, Provenzano E, Girardi A, Iorfida M, De Scalzi AM, Invento A, Colleoni M, Cassano E, Trentin C, Gullo RL, Pravettoni G, Gilardi L, Grana CM, Intra M, Galimberti V, Veronesi P, De Lorenzi F, Leonardi MC. Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review. Future Oncol 2020; 16:395-412. [PMID: 32026709 DOI: 10.2217/fon-2019-0540] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.
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Affiliation(s)
- Giovanni Corso
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Monica Iorfida
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Trentin
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Lo Gullo
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Faculty of Medicine, University of Milan, Milan, Italy.,Applied Research Division for Cognitive & Psychological Science, European Institute of Oncology, IRCCS, Milan, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic & Reconstructive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
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33
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Masannat YA, Agrawal A, Maraqa L, Fuller M, Down SK, Tang SSK, Pang D, Kontos M, Romics L, Heys SD. Multifocal and multicentric breast cancer, is it time to think again? Ann R Coll Surg Engl 2020; 102:62-66. [PMID: 31891668 PMCID: PMC6937617 DOI: 10.1308/rcsann.2019.0109] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2019] [Indexed: 11/22/2022] Open
Abstract
Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.
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Affiliation(s)
- YA Masannat
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
- University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK
| | - A Agrawal
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - L Maraqa
- Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M Fuller
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
- University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK
| | - SK Down
- James Paget University Hospitals NHS Foundation Trust, Great, UK
- University of East Anglia, Norwich Medical School, Athens, Greece
| | - SSK Tang
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - D Pang
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - M Kontos
- National and Kapodistrian University of Athens, Athens, Greece
| | - L Romics
- New Victoria Hospital and Queen Elizabeth University Hospital, Glasgow, UK
| | - SD Heys
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
- University of Aberdeen, School of Medicine, Medical Science and Nutrition, Aberdeen, UK
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34
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Montagna G, Ritter M, Weber WP. News in surgery of patients with early breast cancer. Breast 2019; 48 Suppl 1:S2-S6. [DOI: 10.1016/s0960-9776(19)31114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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35
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Crown A, Rocha FG, Grumley JW. Oncoplastic Central Partial Mastectomy and Neoareolar Reduction Mammoplasty with Immediate Nipple Reconstruction: An Initial Report of a Novel Option for Breast Conservation in Patients with Subareolar Tumors. Ann Surg Oncol 2019; 26:4284-4293. [DOI: 10.1245/s10434-019-07731-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Indexed: 11/18/2022]
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36
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Surgical Therapy for Women with Multiple Synchronous Ipsilateral Breast Cancer (MIBC): Current Evidence to Guide Clinical Practice. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-0309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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37
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Winters ZE, Benson JR. Can Patients with Multiple Breast Cancers in the Same Breast Avoid Mastectomy by Having Multiple Lumpectomies to Achieve Equivalent Rates of Local Breast Cancer Recurrence? Response to the Preliminary Alliance 11102 Trial Report. Ann Surg Oncol 2018; 26:700-701. [PMID: 30414039 DOI: 10.1245/s10434-018-6982-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Zoe E Winters
- Surgery and Interventional Trials Unit, Division of Surgery and Interventional Science, University College London, Charles Bell House, 43 Foley Street, Fitzrovia, London, UK.
| | - John R Benson
- Cambridge University NHS Foundation Trust and School of Medicine, Anglia Ruskin University, Cambridge, UK
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