Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review

PURPOSE

Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review.

METHODS

A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review.

RESULTS

The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors.

CONCLUSION

CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.

An international update of the EORTC questionnaire for assessing quality of life in breast cancer patients: EORTC QLQ-BR45

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23 was one of the first disease-specific questionnaires developed in 1996 to assess quality of life (QoL) in patients with breast cancer (BC). However, since 1996 major changes in BC treatment have occurred, requiring an update of the EORTC BC module. This study presents the results of the phase I-III update of the QLQ-BR23 questionnaire.

PATIENTS AND METHODS

The update of the EORTC QLQ-BR23 module followed standard EORTC guidelines. A systematic literature review revealed 83 potential relevant QoL issues during phases I and II. After shortening the issues list and following interviews with patients and health care providers, 15 relevant issues were transformed into 27 items. The preliminary module was pretested in an international, multicentre phase III study to identify and solve potential problems with wording comprehensibility and acceptability of the items. Descriptive statistics are provided. Analyses were qualitative and quantitative. We provide a psychometric structure of the items.

RESULTS

The phase I and II results indicated the need to supplement the original QLQ-BR23 with additional items related to newer therapeutic options. The phase III study recruited a total of 250 patients (from 12 countries). The final updated phase III module contains a total of 45 items: 23 items from the QLQ-BR23 and 22 new items. The new items contain two multi-item scales: a target symptom scale and a satisfaction scale. The target symptom scale can be divided into three subscales: endocrine therapy, endocrine sexual and skin/mucosa scale.

CONCLUSION

Our work has led to the development of a new EORTC QLQ-BR45 module that provides a more accurate and comprehensive assessment of the impact of new and scalable treatments on patients' QoL. The final version of the EORTC QLQ-BR45 is currently available for use in clinical practice. The final phase IV study is underway to confirm psychometric properties of the module.

Recommendation of adjuvant trastuzumab treatment in HER-2-positive breast cancer patients: insights from quality indicator data collected in certified breast cancer centers in Germany, Italy, Austria, and Switzerland

PURPOSE

In 2003, a certification system was introduced to ensure high standards of oncological care in breast cancer patients in Germany. Certified breast cancer centers (BCCs) must fulfill specific requirements including quality indicators (QI) derived from the clinical guidelines that are evaluated in annual audits. When target values for QIs are not fulfilled, centers need to give explanations. We analyzed data from BCCs for a selected indicator: the recommendation of trastuzumab for patients with early HER-2-positive invasive breast cancer. We investigated explanations given in cases when trastuzumab was not recommended to see whether this was justified.

METHODS

Patient data from 274 BCCs treating 53,777 primary cases in 2015 were analyzed using descriptive statistics.

RESULTS

In the 274 BCC sites, 5700 primary patients with early HER-2-positive breast cancer were treated in 2015. 128 sites (46.7%) did not reach the target value of 95% trastuzumab recommendation and thus had to give explanations. In these 128 sites, 2663 primary HER-2-positive breast cancer patients were treated, 343 (12.9%) of whom did not receive a recommendation for adjuvant trastuzumab treatment. All 128 sites delivered explanations. Overall, 450 explanations were given, allowing multiple explanations for single patients. No explanation was given for 8 of the 343 patients (2.3%). The most common given explanation was multi-/comorbidity (45.5%).

CONCLUSIONS

The analysis suggests thorough decision-making when quality indicator target values for a trastuzumab recommendation were not fulfilled. Our data do not provide information on whether such decisions have an impact on treatment outcome for these patients.

Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma

OBJECTIVES

Clinical long-term outcomes of women with uterine leiomyosarcoma (ULMS) with different types of hysterectomy (open abdominal, vaginal, laparoscopic and switch from laparoscopic to open abdominal) were compared according to morcellation and other factors.

MATERIALS

The clinical cancer registry Regensburg (Germany) registered 64 patients between 2004 and 2013 with ULMS. A retrospective cohort analysis was performed using the Kaplan-Meier method to estimate 5-year overall survival (OAS), recurrence-free survival (RFS) and recurrence rates. To compare surgery with or without morcellation log rank test was used. To adjust for age, FIGO stage, grading and other factors multivariable Cox regression models were applied to estimate hazard ratios (HR).

RESULTS

In the cohort of 64 patients 15 underwent morcellation, preferably during laparoscopic surgery. Although numbers were small we performed analysis for OAS and RFS. Median OAS for morcellation was 10.6 vs. 6.4 years for non morcellation. 5y-OAS was 76.0 % for morcellation compared to 54.8 % in patients without morcellation (p = 0.115). Cox regression models rendered an unadjusted (univariable) HR 0.428 for morcellation vs. non-morcellation (p = 0.125) and an adjusted (multivariable) HR 0.644 (p = 0.406). 5y-RFR was 64.0 % compared to 42.8 % in patients without morcellation (p = 0.104; unadjusted HR 0.484, p = 0.111; adjusted HR 0.607, p = 0.306).

CONCLUSION

In general, the prognosis of patients with ULMS is poor. In our cohort, women who underwent hysterectomy with morcellation had a better cumulative OAS and RFS than women without morcellation. Although we adjusted for differences between women with and without morcellation regarding age, grading and stage, there were no statistically significant differences between the groups.

Ki-67 is a prognostic parameter in breast cancer patients: results of a large population-based cohort of a cancer registry

The proliferation marker Ki-67 is one of the most controversially discussed parameters for treatment decisions in breast cancer patients. The purpose of this study was to evaluate the routine use and value of Ki-67 as a prognostic marker, and to analyze the associations between Ki-67 and common histopathological parameters in the routine clinical setting. Data from the clinical cancer registry Regensburg (Bavaria, Germany) were analyzed. Within the total data pool of 4,692 female patients, who had been diagnosed between 2005 and 2011, in 3,658 cases Ki-67 was routinely determined. Thus, a total of 3,658 patients with invasive breast cancer were included in the present study and used for statistical analysis. Ki-67 expression was associated with the common histopathological parameters. The strongest correlation was found between grading and Ki-67 (P < 0.001). In terms of survival analyses, Ki-67 was categorized into five categories (reference category Ki-67 ≤15 %) due to a nonlinear relationship to overall survival (OS). In multivariable analysis, Ki-67 was an independent prognostic parameter both for disease-free survival (DFS) (Ki-67 > 45 %, HR = 1.96, P = 0.001) as well as for OS (Ki-67: 26-35 %, HR = 1.71, P = 0.017; Ki-67: 36-45 %, HR = 2.05, P = 0.011; Ki-67 > 45 %, HR = 2.06, P = 0.002) independent of common clinical and histopathological factors. The 5-year DFS (OS) rate was 86.7 % (89.3 %) in patients with a Ki-67 value ≤15 % compared to 75.8 % (82.8 %) in patients with a Ki-67 value >45 %. Based on the data from a large cohort of a clinical cancer registry, it was demonstrated that Ki-67 is frequently determined in routine clinical work. Ki-67 expression is associated with common histopathological parameters, but is an additional independent prognostic parameter for DFS and OS in breast cancer patients. Future work should focus on standardization of Ki-67 assessment and specification of its role in treatment decisions.