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Osdoit M, Yau C, Symmans WF, Boughey JC, Ewing CA, Balassanian R, Chen YY, Krings G, Wallace AM, Zare S, Fadare O, Lancaster R, Wei S, Godellas CV, Tang P, Tuttle TM, Klein M, Sahoo S, Hieken TJ, Carter JM, Chen B, Ahrendt G, Tchou J, Feldman M, Tousimis E, Zeck J, Jaskowiak N, Sattar H, Naik AM, Lee MC, Rosa M, Khazai L, Rendi MH, Lang JE, Lu J, Tawfik O, Asare SM, Esserman LJ, Mukhtar RA. Association of Residual Ductal Carcinoma In Situ With Breast Cancer Recurrence in the Neoadjuvant I-SPY2 Trial. JAMA Surg 2022; 157:1034-1041. [PMID: 36069821 PMCID: PMC9453630 DOI: 10.1001/jamasurg.2022.4118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Importance Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS). Objective To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response. Design, Setting, and Participants The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence. Interventions Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery. Main Outcomes and Measures The presence of DCIS and EFS, DRFS, and LRR. Results The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS. Conclusions and Relevance The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS. Trial Registration ClinicalTrials.gov Identifier NCT01042379.
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MESH Headings
- Adult
- Female
- Humans
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Neoadjuvant Therapy
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm, Residual/drug therapy
- Receptor, ErbB-2
- Retrospective Studies
- Young Adult
- Middle Aged
- Aged
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Affiliation(s)
- Marie Osdoit
- Department of Surgery, University of California San Francisco, San Francisco
| | - Christina Yau
- Department of Surgery, University of California San Francisco, San Francisco
| | - W. Fraser Symmans
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston
| | | | - Cheryl A. Ewing
- Department of Surgery, University of California San Francisco, San Francisco
| | - Ron Balassanian
- Department of Pathology, University of California San Francisco, San Francisco
| | - Yunn-Yi Chen
- Department of Pathology, University of California San Francisco, San Francisco
| | - Gregor Krings
- Department of Pathology, University of California San Francisco, San Francisco
| | - Anne M Wallace
- Department of Surgery, University of California San Diego, La Jolla
| | - Somaye Zare
- Department of Pathology, University of California San Diego, La Jolla
| | - Oluwole Fadare
- Department of Pathology, University of California San Diego, La Jolla
| | - Rachael Lancaster
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Shi Wei
- Department of Pathology, University of Alabama at Birmingham
| | - Constantine V. Godellas
- Department of Surgery, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Ping Tang
- Department of Pathology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota, Minneapolis
| | - Molly Klein
- Laboratory Medicine and Pathology, Masonic Cancer Center, Minneapolis, Minnesota
| | - Sunati Sahoo
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Tina J. Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jodi M. Carter
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | - Beiyun Chen
- Laboratory Medicine and Pathology, May Clinic, Rochester, Minnesota
| | | | - Julia Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia
| | - Michael Feldman
- Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia
| | - Eleni Tousimis
- Department of Surgery, Georgetown University, Washington, DC
| | - Jay Zeck
- Pathology and Laboratory Medicine, Georgetown University, Washington, DC
| | | | - Husain Sattar
- Department of Pathology, University of Chicago, Illinois
| | - Arpana M. Naik
- Department of Surgery, Oregon Health & Science University, Portland
| | | | - Marilin Rosa
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Laila Khazai
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Mara H. Rendi
- Department of Pathology, University of Washington, Seattle
| | - Julie E. Lang
- Department of Surgery, University of Southern California, Los Angeles
| | - Janice Lu
- Department of Medicine, University of Southern California, Los Angeles
| | - Ossama Tawfik
- Department of Pathology, University of Kansas, Kansas City
| | | | - Laura J. Esserman
- Department of Surgery, University of California San Francisco, San Francisco
| | - Rita A. Mukhtar
- Department of Surgery, University of California San Francisco, San Francisco
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Gopwani SR, Adams E, Rooney A, Tousimis E, Ramsey K, Warusha S. Impact of a Workflow-Integrated Web Tool on Resource Utilization and Information-Seeking Behavior in an Academic Anesthesiology Department: Longitudinal Cohort Survey Study. JMIR Med Educ 2021; 7:e26325. [PMID: 34309566 PMCID: PMC8367122 DOI: 10.2196/26325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Medical resident reading and information-seeking behavior is limited by time constraints as well as comfort in accessing and assessing evidence-based resources. Educational technology interventions, as the preferred method for millennial leaners, can reduce these barriers. We implemented an educational web tool, consisting of peer-reviewed articles as well as local and national protocols and policies, built into the daily workflow of a university-based anesthesiology department. We hypothesized that this web tool would increase resource utilization and overall perceptions of the educational environment. OBJECTIVE The goal of this study was to demonstrate that an educational web tool designed and built into the daily workflow of an academic anesthesia department for trainees could significantly decrease barriers to resource utilization, improve faculty-trainee teaching interactions, and improve the perceptions of the educational environment. METHODS Following Institutional Review Board approval, a longitudinal cohort survey study was conducted to assess trainee resource utilization, faculty evaluation of trainees' resource utilization, and trainee and faculty perceptions about the educational environment. The survey study was conducted in a pre-post fashion 3 months prior to web tool implementation and 3 months following implementation. Data were deidentified and analyzed unpaired using Student t tests for continuous data and chi-square tests for ordinal data. RESULTS Survey response rates were greater than 50% in all groups: of the 43 trainees, we obtained 27 (63%) preimplementation surveys and 22 (51%) postimplementation surveys; of the 46 faculty members, we obtained 25 (54%) preimplementation surveys and 23 (50%) postimplementation surveys. Trainees showed a significant improvement in utilization of peer-reviewed articles (preimplementation mean 8.67, SD 6.45; postimplementation mean 18.27, SD 12.23; P=.02), national guidelines (preimplementation mean 2.3, SD 2.40; postimplementation mean 6.14, SD 5.01; P<.001), and local policies and protocols (preimplementation mean 2.23, SD 2.72; postimplementation mean 6.95, SD 6.09; P=.02). There was significant improvement in faculty-trainee educational interactions (preimplementation mean 1.67, SD 1.33; postimplementation mean 6.05, SD 8.74; P=.01). Faculty assessment of trainee resource utilization also demonstrated statistically significant improvements across all resource categories. Subgroups among trainees and faculty showed similar trends toward improvement. CONCLUSIONS Learning technology interventions significantly decrease the barriers to resource utilization, particularly among millennial learners. Further investigation has been undertaken to assess how this may impact learning, knowledge retention, and patient outcomes.
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Affiliation(s)
- Sumeet R Gopwani
- Department of Anesthesiology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Erin Adams
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, United States
| | - Alexandra Rooney
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, United States
| | - Eleni Tousimis
- Department of Surgery, Breast Center, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Katherine Ramsey
- Department of Anesthesiology, Kaiser Permanente Mid-Atlantic Permanente Group, Rockville, MD, United States
| | - Sohan Warusha
- Department of Anesthesiology, Temple University Hospital, Philadelphia, PA, United States
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3
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Valente SA, Tendulkar RD, Cherian S, Shah C, Ross DL, Lottich SC, Laronga C, Broman KK, Donnelly ED, Bethke KP, Shaw C, Lockney NA, Pederson A, Rudolph R, Hasselle M, Kelemen P, Hermanto U, Ashikari A, Kang S, Hoefer RA, McCready D, Fyles A, Escallon J, Rohatgi N, Graves J, Graves G, Willey SC, Tousimis E, Riley L, Deb N, Tu C, Small W, Grobmyer SR. TARGIT-R (Retrospective): 5-Year Follow-Up Evaluation of Intraoperative Radiation Therapy (IORT) for Breast Cancer Performed in North America. Ann Surg Oncol 2021; 28:2512-2521. [PMID: 33433786 DOI: 10.1245/s10434-020-09432-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 11/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) has been investigated for patients with low-risk, early-stage breast cancer. The The North American experience was evaluated by TARGIT-R (retrospective) to provide outcomes for patients treated in "real-world" clinical practice with breast IORT. This analysis presents a 5-year follow-up assessment. METHODS TARGIT-R is a multi-institutional retrospective registry of patients who underwent lumpectomy and IORT between the years 2007 and 2013. The primary outcome of the evaluation was ipsilateral breast tumor recurrence (IBTR). RESULTS The evaluation included 667 patients with a median follow-up period of 5.1 years. Primary IORT (IORT at the time of lumpectomy) was performed for 72%, delayed IORT (after lumpectomy) for 3%, intended boost for 8%, and unintended boost (primary IORT followed by whole-breast radiation) for 17% of the patients. At 5 years, IBTR was 6.6% for all the patients, with 8% for the primary IORT cohort and 1.7% for the unintended-boost cohort. No recurrences were identified in the delayed IORT or intended-boost cohorts. Noncompliance with endocrine therapy (ET) was associated with higher IBTR risk (hazard ratio [HR], 3.67). Patients treated with primary IORT who were complaint with ET had a 5-year IBTR rate of 3.9%. CONCLUSION The local recurrence rates in this series differ slightly from recent results of randomized IORT trials and are notably higher than in previous published studies using whole-breast radiotherapy for similar patients with early-stage breast cancer. Understanding differences in this retrospective series and the prospective trials will be critical to optimizing patient selection and outcomes going forward.
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Affiliation(s)
| | | | | | | | - Darrel L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - S Chace Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | | | - Eric D Donnelly
- Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Kevin P Bethke
- Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | | | | | | | - Ray Rudolph
- Memorial University Medical Center, Savannah, GA, USA
| | | | - Pond Kelemen
- St. Johns Riverside Hospital, Dobbs Ferry, NY, USA
| | | | | | - Song Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - Richard A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | | | | | | | | | | | | | | | - Eleni Tousimis
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Lee Riley
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nimisha Deb
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Chao Tu
- Cleveland Clinic, Cleveland, OH, USA
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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Bekeny JC, Singh T, Luvisa K, Wirth PJ, Black CK, Abdou S, Song DH, Del Corral G, Willey SC, Tousimis E, Fan KL. Delivery of nipple-sparing mastectomy within a single healthcare system: The impact of provider preferences. Breast J 2020; 27:149-157. [PMID: 33274577 DOI: 10.1111/tbj.14112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/13/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022]
Abstract
Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM.
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Affiliation(s)
- Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Tanvee Singh
- Georgetown University School of Medicine, Washington, DC, USA
| | - Kyle Luvisa
- Georgetown University School of Medicine, Washington, DC, USA
| | - Peter J Wirth
- Georgetown University School of Medicine, Washington, DC, USA
| | - Cara K Black
- Georgetown University School of Medicine, Washington, DC, USA
| | - Salma Abdou
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - David H Song
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Shawna C Willey
- Inova Schar Cancer Institute, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Eleni Tousimis
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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5
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Osdoit M, Yau C, Symmans WF, Boughey JC, Asare SM, Balassanian R, Carter JM, Chen YY, Cole K, Khazai L, Klein M, Kokh D, Krings G, Sahoo S, Ahrendt G, Chiba A, Ewing C, Godellas C, Jaskowiak N, Killelea B, Krontiras H, Lancaster R, Lang J, Lee MC, Naik A, Rao R, Tchou J, Tierney S, Tousimis E, Tuttle T, Wallace A, Parker B, Esserman LJ, Mukhtar RA. Abstract P3-08-16: The impact of residual ductal carcinoma in situ on breast cancer recurrence in the neoadjuvant I-SPY2 TRIAL. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p3-08-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Patients who achieve a pathological complete response (pCR- defined as no invasive cancer) after neoadjuvant chemotherapy (NAC) for breast cancer (BC) have improved outcomes, but there is still controversy about the significance of residual ductal carcinoma in situ (DCIS) on local recurrence rate (LRR). The I-SPY 2 TRIAL is an adaptive neoadjuvant platform trial evaluating novel experimental regimens in comparison to standard chemotherapy in women with high-risk breast cancer. The purpose of this study is to determine if residual DCIS after NAC in early BC affects LRR in patients with or without residual invasive disease in the I-SPY 2 TRIAL.
Methods: 933 I-SPY 2 patients with residual cancer burden (RCB) and follow-up data were included in this analysis. Residual DCIS was defined as any carcinoma in situ > 0% on RCB evaluation. Local recurrence was defined as recurrence in breast, chest wall or locoregional nodes and/or skin and subcutaneous tissue. We stratified our cohort into four groups: those without residual invasive disease (defined as RCB0) ± residual DCIS, and those with residual invasive disease (RCB>0) ± residual DCIS. We estimated LRR within each group using the Kaplan Meier method; and used Cox proportional hazards models to assess LRR differences between groups, with: patients with no residual disease (invasive or in situ) as reference group.
Results: Among 933 patients assessed, median follow up time was 3.9 years. RCB 0 status was achieved in 337 patients (36%). Of these, 267 (29%) had no residual DCIS, which represents our reference group, and 70 (7%) had residual DCIS. Among 596 (64%) patients who had RCB>0, 296 (32%) had residual DCIS. For patients with RCB0 without DCIS and RCB0 with DCIS, the LRR at 3 years were similar: 2% vs 3% respectively (Hazard ratio: 1.29 [0.26-6.39]). Results were also similar in the RCB>0 group, with a LRR of 10% at 3 years in those without residual DCIS, and 11% in those with residual DCIS. Both RCB>0 groups had significantly higher LRR when compared to the patients with RCB0 without DCIS (Hazard ratio: 5.25 [2.20-12.5]) and HR 5.85 [2.47-13.9] respectively).
Conclusion: There was no association between residual DCIS and LRR after neoadjuvant chemotherapy, regardless of resolution of invasive disease. Further work is needed to determine whether residual DCIS should drive locoregional therapy decisions after neoadjuvant chemotherapy for invasive breast cancer.
Citation Format: Marie Osdoit, Christina Yau, W. Fraser Symmans, Judy C. Boughey, Smita M. Asare, Ron Balassanian, Jodi M. Carter, Yunn-Yi Chen, Kimberly Cole, Laila Khazai, Molly Klein, Dina Kokh, Gregor Krings, Sunati Sahoo, Gretchen Ahrendt, Akiko Chiba, Cheryl Ewing, Constantine Godellas, Nora Jaskowiak, Brigid Killelea, Helen Krontiras, Rachael Lancaster, Julie Lang, M. Catherine Lee, Arpana Naik, Roshni Rao, Julia Tchou, Shannon Tierney, Eleni Tousimis, Tod Tuttle, Anne Wallace, I-SPY 2 TRIAL Consortium, Bev Parker, Laura J. Esserman, Rita A. Mukhtar. The impact of residual ductal carcinoma in situ on breast cancer recurrence in the neoadjuvant I-SPY2 TRIAL [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-16.
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Affiliation(s)
| | | | | | | | - Smita M. Asare
- 4Quantum Leap Healthcare Collaborative, San Francisco, CA
| | | | | | | | | | | | - Molly Klein
- 7Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Dina Kokh
- 8University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | | | | | | | - Julie Lang
- 14University of Southern California, Los Angeles, CA
| | | | - Arpana Naik
- 15Oregon Health & State University, Portland, OR
| | | | - Julia Tchou
- 17University of Pennsylvania, Philadephia, PA
| | | | | | - Tod Tuttle
- 20University of Minnesota, Minneapolis, MN
| | | | - Bev Parker
- 22I-SPY 2 Advocacy Group, San Francisco, CA
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Abstract
The introduction of more targeted systemic therapies, better screening modalities with earlier diagnosis and dramatically improved reconstructive techniques has allowed more minimally invasive approaches to breast surgery. The recent introduction of nipple sparing mastectomy (NSM) has dramatically improved the cosmetic outcomes and quality of life (QoL) for patients undergoing mastectomy. This technique involves preservation of both the skin envelope including the nipple areolar complex commonly through a barely visible inframammary skin incision followed by immediate breast reconstruction. An ideal candidate includes women with small breasts, absence of ptosis, low BMI and not actively smoking. High risk patients include those with radiation treatment, active smokers, macromastia, high BMI >30 kg/m2, grade 2 or 3 ptosis and active smokers. There are several new techniques to approach complex high risk patients which have expanded the candidates for NSM.
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Affiliation(s)
- Eleni Tousimis
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Michelle Haslinger
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
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Gold HT, Walter D, Tousimis E, Hayes MK. New Breast Cancer Radiotherapy Technology Confers Higher Complications and Costs Before Effectiveness Proven: A Medicare Data Analysis. Inquiry 2018; 55:46958018759115. [PMID: 29502466 PMCID: PMC5846914 DOI: 10.1177/0046958018759115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A new breast cancer treatment, brachytherapy-based accelerated partial breast radiotherapy (RT), was adopted before long-term effectiveness evidence, potentially increasing morbidity and costs compared with whole breast RT. The aim of this study was to estimate complication rates and RT-specific and 1-year costs for a cohort of female Medicare beneficiaries diagnosed with breast cancer (N = 47 969). We analyzed 2005-2007 Medicare claims using multivariable logistic regression for complications and generalized linear models (log link, gamma distribution) for costs. Overall, 11% (n = 5296) underwent brachytherapy-based RT; 9.4% had complications. Odds of any complication were higher (odds ratio [OR]: 1.62; 95% confidence interval [CI]: 1.49-1.76) for brachytherapy versus whole breast RT, similarly to seroma (OR: 2.85; 95% CI: 1.97-4.13), wound complication/infection (OR: 1.72; 95% CI: 1.52-1.95), cellulitis (OR: 1.48; 95% CI: 1.27-1.73), and necrosis (OR: 2.07; 95% CI: 1.55-2.75). Mean RT-specific and 1-year total costs for whole breast RT were $6375, and $19 917, $4886, and $4803 lower than brachytherapy ( P < .0001). Multivariable analyses indicated brachytherapy yielded 76% higher RT costs (risk ratio: 1.76; 95% CI: 1.74-1.78, P < .0001) compared with whole breast RT. Brachytherapy had higher complications and costs before long-term evidence proved its effectiveness. Policies should require treatment registries with reimbursement incentives to capture surveillance data for new technologies.
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Affiliation(s)
| | | | - Eleni Tousimis
- 2 MedStar Georgetown University Hospital, Washington, DC, USA
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Moo TA, Pinchinat T, Mays S, Landers A, Christos P, Alabdulkareem H, Tousimis E, Swistel A, Simmons R. Oncologic Outcomes After Nipple-Sparing Mastectomy. Ann Surg Oncol 2016; 23:3221-5. [PMID: 27380643 DOI: 10.1245/s10434-016-5366-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is increasingly used as an alternative to traditional mastectomy because it provides improved aesthetic results. The data on its oncologic safety are limited. The authors' institution has performed NSM during the past 10 years for both oncologic and prophylactic indications. This study aimed to examine oncologic outcomes after NSM for breast cancer. METHODS The study retrospectively examined all NSM cases managed between July 2007 and July 2013. Descriptive statistics were used to characterize the study cohort. Kaplan-Meier survival analysis was performed to estimate recurrence-free survival, specifically the 36-month recurrence-free survival proportion. RESULTS A total of 721 nipple-sparing mastectomies were performed for 413 patients: 45 (10.9 %) to reduce risk and 368 (89.1 %) for breast cancer. In the breast cancer group, 29.8 % of the patients had ductal carcinoma in situ, and 70.2 % had invasive cancer. The mean follow-up time was 32 months (range 0.01-90.2 months). In the breast cancer group, the Kaplan-Meier 3-year recurrence-free survival rate was 93.6 % (95 % confidence interval, 89.9-96.0 %). Eight patients (2.2 %) had locoregional recurrences, including one in the nipple. Nine patients (2.4 %) had distant recurrence, and six patients (1.6 %) had a diagnosis of both local and distant recurrences. CONCLUSIONS The findings showed a locoregional recurrence rate of 2.2 %, with an overall recurrence rate of 6.3 % for patients undergoing NSM for the treatment of breast cancer. The majority of these recurrences were distant, with one recurrence at the nipple. These results are promising, but a longer follow-up evaluation of this cohort is necessary.
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Affiliation(s)
- Tracy Ann Moo
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Simone Mays
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Alyssa Landers
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Paul Christos
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Eleni Tousimis
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Rache Simmons
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
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Obayomi-Davies O, Kole TP, Oppong B, Rudra S, Makariou EV, Campbell LD, Anjum HM, Collins SP, Unger K, Willey S, Tousimis E, Collins BT. Stereotactic Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Rationale, Feasibility, and Early Experience Using the CyberKnife Radiosurgery Delivery Platform. Front Oncol 2016; 6:129. [PMID: 27242967 PMCID: PMC4876543 DOI: 10.3389/fonc.2016.00129] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 05/10/2016] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The efficacy of accelerated partial breast irradiation (APBI) utilizing brachytherapy or conventional external beam radiation has been studied in early-stage breast cancer treated with breast-conserving surgery. Data regarding stereotactic treatment approaches are emerging. The CyberKnife linear accelerator enables excellent dose conformality to target structures while adjusting for target and patient motion. We report our institutional experience on the technical feasibility and rationale for stereotactic accelerated partial breast irradiation (SAPBI) delivery using the CyberKnife radiosurgery system. METHODS Ten patients completed CyberKnife SAPBI (CK-SAPBI) in 2013 at Georgetown University Hospital. Four gold fiducials were implanted around the lumpectomy cavity prior to treatment under ultrasound guidance. The synchrony system tracked intrafraction motion of the fiducials. The clinical target volume was defined on contrast enhanced CT scans using surgical clips and post-operative changes. A 5 mm expansion was added to create the planning treatment volume (PTV). A total dose of 30 Gy was delivered to the PTV in five consecutive fractions. Target and critical structure doses were assessed as per the National Surgical Adjuvant Breast and Bowel Project B-39 study. RESULTS At least three fiducials were tracked in 100% of cases. The Mean treated PTV was 70 cm(3) and the mean prescription isodose line was 80%. Mean dose to target volumes and constraints are as follows: 100% of the PTV received the prescription dose (PTV30). The volume of the ipsilateral breast receiving 30 Gy (V30) and above 15 Gy (V > 15) was 14 and 31%, respectively. The ipsilateral lung volume receiving 9 Gy (V9) was 3%, and the contralateral lung volume receiving 1.5 Gy (V1.5) was 8%. For left-sided breast cancers, the volume of heart receiving 1.5 Gy (V1.5) was 31%. Maximum skin dose was 36 Gy. At a median follow-up of 1.3 years, all patients have experienced excellent/good breast cosmesis outcomes, and no breast events have been recorded. CONCLUSION CyberKnife stereotactic accelerated partial breast irradiation is an appealing technique for partial breast irradiation offering improvements over existing APBI techniques. Our early findings indicate that CK-SAPBI delivered in five daily fractions is feasible, well tolerated, and is a reliable platform for delivering APBI.
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Affiliation(s)
- Olusola Obayomi-Davies
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Thomas P Kole
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Bridget Oppong
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Sonali Rudra
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Erini V Makariou
- Department of Radiology, MedStar Georgetown University Hospital , Washington, DC , USA
| | - Lloyd D Campbell
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Hozaifa M Anjum
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Sean P Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Keith Unger
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Shawna Willey
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Eleni Tousimis
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Brian T Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
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Pharmer LA, Koslow SB, Martins D, Theodore R, Christos PJ, Talmor M, Simmons RM, Tousimis E, Swistel AJ. Abstract P6-08-01: Analysis of patient-reported outcomes following nipple-sparing mastectomy and implant reconstruction. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p6-08-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Nipple-sparing mastectomy (NSM) is gaining popularity among women undergoing prophylactic and therapeutic mastectomy. Using the BREAST-Q, a validated condition-specific patient-reported outcome instrument which measures postsurgical patient satisfaction and health-related quality of life (HR-QoL), we sought to determine whether satisfaction and HR-QoL differ between patients undergoing NSM and skin-sparing mastectomy (SSM) with immediate implant reconstruction.
Methods: From 2005 to 2012, a total of 572 patients underwent mastectomy; of these 261 patients (46%) had NSM. All mastectomy patients were mailed the BREAST-Q reconstruction questionnaire consisting of 3 scales (scored 0-100): Satisfaction with Breasts, Satisfaction with Outcome, and Psychosocial Well-Being. Excluded from this analysis were males, autologous tissue reconstruction, and conversion from NSM to SSM. Comparisons were made between NSM and SSM groups using univariable analysis and multivariable linear regression models (MVA).
Results: The BREAST-Q completion rate was 27% with a median time from surgery to survey of 36 months (range 4 to 86). Women undergoing NSM, compared to SSM, were younger (mean 46 v 50 years; p = 0.01), more likely to be married (80% v 52%; p = 0.001), have bilateral mastectomies (79% v 59%; p = 0.01), and had less time between surgery and BREAST-Q completion (median 25 v 49 months; p<0.001). 19 NSM patients (25%) and 7 SSM patients (13%) underwent prophylactic mastectomy (p = 0.07). There were no differences regarding tumor characteristics or treatment. Patients undergoing NSM, compared to SSM, had a higher unadjusted mean score for Satisfaction with Breasts (71 v 60; p<0.001), Satisfaction with Outcome (80 v 69; p = 0.003), and Psychosocial Well-Being (84 v 74; p = 0.006). On MVA analysis, NSM (compared to SSM) was associated with greater Satisfaction with Breasts (adjusted mean difference: +13, 95% Confidence Interval[CI]: 6-21, p = 0.001), Satisfaction with Outcome (adjusted mean difference: +17, 95% CI: 7-27, p = 0.001), and Psychosocial Well-Being (adjusted mean difference: +12, 95% CI: 3-22, p = 0.013), after controlling for age at mastectomy, marital status, laterality, cancer vs. non-cancer diagnosis, post-mastectomy radiation treatment, and time from mastectomy to BREAST-Q completion. Not being married (adjusted mean difference: +8, 95% CI: 2-15, p = 0.014) and having a bilateral mastectomy (adjusted mean difference: +8, 95% CI: 1-14, p = 0.029) were also significant predictors of increased Satisfaction with Breasts.
Conclusion: These findings suggest that, in the setting of implant reconstruction, NSM is associated with higher patient satisfaction with their breasts, overall outcome, and improved emotional/social well being.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-01.
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Affiliation(s)
- LA Pharmer
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - SB Koslow
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - D Martins
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - R Theodore
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - PJ Christos
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - M Talmor
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - RM Simmons
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - E Tousimis
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
| | - AJ Swistel
- Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY; MedStar Georgetown University Hospital, Washington, DC
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11
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Arora N, Martins D, Ruggerio D, Tousimis E, Swistel AJ, Osborne MP, Simmons RM. Effectiveness of a noninvasive digital infrared thermal imaging system in the detection of breast cancer. Am J Surg 2008; 196:523-6. [PMID: 18809055 DOI: 10.1016/j.amjsurg.2008.06.015] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 06/04/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Digital infrared thermal imaging (DITI) has resurfaced in this era of modernized computer technology. Its role in the detection of breast cancer is evaluated. METHODS In this prospective clinical trial, 92 patients for whom a breast biopsy was recommended based on prior mammogram or ultrasound underwent DITI. Three scores were generated: an overall risk score in the screening mode, a clinical score based on patient information, and a third assessment by artificial neural network. RESULTS Sixty of 94 biopsies were malignant and 34 were benign. DITI identified 58 of 60 malignancies, with 97% sensitivity, 44% specificity, and 82% negative predictive value depending on the mode used. Compared to an overall risk score of 0, a score of 3 or greater was significantly more likely to be associated with malignancy (30% vs 90%, P < .03). CONCLUSION DITI is a valuable adjunct to mammography and ultrasound, especially in women with dense breast parenchyma.
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Affiliation(s)
- Nimmi Arora
- Department of Surgery, New York Presbyterian Hospital-Cornell, New York, NY, USA
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12
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Arora N, Martins D, Huston TL, Christos P, Hoda S, Osborne MP, Swistel AJ, Tousimis E, Pressman PI, Simmons RM. Sentinel Node Positivity Rates With and Without Frozen Section for Breast Cancer. Ann Surg Oncol 2007; 15:256-61. [PMID: 17879116 DOI: 10.1245/s10434-007-9600-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 07/31/2007] [Accepted: 08/01/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is used to detect breast cancer axillary metastases. Some surgeons send the sentinel lymph node (SLN) for intraoperative frozen section (FS) to minimize delayed axillary dissections. There has been concern that FS may discard nodal tissue and thus underdiagnose small metastases. This study examines whether evaluation of SLN by FS increases the false-negative rate of SLNB. METHODS A retrospective analysis of SLNB from 659 patients was conducted to determine the frequency of node positivity among SLNB subjected to both FS and permanent section (PS) versus PS alone. Statistical analysis was performed by the chi(2) square test, and a logistic regression model was applied to estimate the effect of final node positivity between the two groups. RESULTS FS was performed in 327 patients and PS was performed in all 659 patients. Among patients undergoing both FS and PS (n = 327), the final node positivity rate was 33.0% compared with 19.6% among patients undergoing PS alone (n = 332). After adjustment for patient age, tumor diameter, grade, and hormone receptor status in a multivariate logistic regression model, there remained an increased likelihood of final node positivity for patients undergoing both procedures relative to PS alone (adjusted odds ratio, 2.1; 95% confidence interval, 1.3-3.6; P = .005). CONCLUSIONS There was a higher rate of SLN positivity in specimens evaluated by both FS and PS. Therefore, evaluating SLN by FS does not underdiagnose small metastases nor produce a higher false-negative rate. Intraoperative FS offers the advantage of less delayed axillary dissections.
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Affiliation(s)
- Nimmi Arora
- Department of Surgery, Weill Medical College of Cornell University, 525 E. 68th St., New York, NY 10065, USA
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13
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Huston TL, Pressman PI, Moore A, Vahdat L, Hoda SA, Kato M, Weinstein D, Tousimis E. The presentation of contralateral axillary lymph node metastases from breast carcinoma: a clinical management dilemma. Breast J 2007; 13:158-64. [PMID: 17319857 DOI: 10.1111/j.1524-4741.2007.00390.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Metastases to the contralateral axillary lymph nodes in breast cancer patients are uncommon. Involvement of the contralateral axilla is a manifestation of systemic disease (stage IV) or a regional metastasis from a new occult primary (T0N1, stage II). The uncertain laterality of the cancer responsible for these metastases complicates overall disease staging and is a management dilemma for clinicians. Seven women who developed contralateral axillary metastases (CAM), but did not have evidence of systemic disease were identified. Patient demographics, histopathologic tumor characteristics, treatment and outcome were examined. The median age was 49 years. A family history of breast cancer was present in six (86%). The initial breast cancers were located in all quadrants. They were generally hormone receptor negative, HER-2/neu overexpressing and associated with lymphovascular invasion. There was a median interval of 71 months between initial breast cancer diagnosis and CAM presentation. Surgical management of the CAM included simple excision in one (14%) and axillary lymph node dissection in five (71%). Adjuvant treatment consisted of chemotherapy in seven (100%) and hormonal therapy in one (14%). The median follow-up from the diagnosis of CAM was 35 months and three women were alive without disease, two were alive with disease and two had died of disease. With surgical treatment, there were no axillary recurrences in this series. When patients present with CAM and no evidence of systemic disease or a new primary in the contralateral breast, surgical treatment should be considered for local control and possibly improved relapse-free survival.
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Affiliation(s)
- Tara L Huston
- Department of Surgery at the New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York 10021, USA
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14
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Huston TL, Pigalarga R, Osborne MP, Tousimis E. The influence of additional surgical margins on the total specimen volume excised and the reoperative rate after breast-conserving surgery. Am J Surg 2006; 192:509-12. [PMID: 16978962 DOI: 10.1016/j.amjsurg.2006.06.021] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 06/04/2006] [Accepted: 06/04/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND It is unclear whether the additional removal of breast tissue during breast-conserving therapy (BCT) for breast cancer beyond the standard lumpectomy reduces the incidence of inadequate microscopic margins found at pathological examination and subsequent reoperation. This study compares the reoperative rates after initial BCT in 3 groups of patients who underwent lumpectomy with complete resection of 4 to 6 additional margins, lumpectomy with selective resection of 1 to 3 additional margins, or standard lumpectomy. METHODS Retrospective data were reviewed from 171 selected cases of BCT, from May 2000 to February 2006. Forty-five cases involved lumpectomy with complete resection of 4 to 6 additional margins; 77 involved lumpectomy with selective resection of 1 to 3 additional margins, whereas 49 involved standard lumpectomy. All samples underwent pathologic analysis of inked resection margins by permanent section. The 3 groups were compared for patient demographics, tumor size and histologic subtype, tumor stage, margin status, excised specimen volume, and eventual subsequent reoperation. Adequate surgical margin was defined as any negative margin greater than 2 mm. RESULTS The group with complete resection of 4 to 6 additional margins had a subsequent reoperation rate of 17.7%, whereas the group with selective resection of 1 to 3 additional margins and the standard lumpectomy group had a subsequent reoperation rate of 32.5% and 38.7%, respectively, because of inadequate margins. The mean total excised specimen volume in the 3 groups was 129.19, 46.04, and 37.44 cm3, respectively. CONCLUSIONS The complete resection of 4 to 6 additional margins during the initial BCT resulted in the lowest subsequent reoperation rate, and the largest total volume specimen excised among the 3 techniques studied.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm Staging
- Reoperation
- Retrospective Studies
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Affiliation(s)
- Tara L Huston
- New York Presbyterian Hospital, Cornell University, 425 East 61st Street, 8th Floor, New York, NY 10021, USA
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15
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Naik R, Jin D, Chuang E, Gold E, Tousimis E, Christos P, De Dalmas T, Donovan D, Rafii S, Vahdat L. Circulating endothelial progenitor cells correlate to stage in patients with invasive breast cancer. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
616 Background: Tumor growth and metastasis is dependent on neo-angiogenesis. Both pre-existing and circulating vascular cells have been shown to contribute to the assembly of tumor neo-vessels in specific tumors. Mobilization of endothelial progenitor cells (EPCs) from the bone marrow constitutes a crucial step in the formation of de novo blood vessels, and levels of peripheral blood EPCs have been shown to be increased in certain malignant states. However, the role of circulating EPCs in breast cancer is largely unknown. Methods: We recruited twenty-five patients with biopsy-proven invasive breast cancer (BC) at Weill Cornell Breast Center to participate in a pilot study investigating the correlation of circulating EPCs to extent of disease and initiation of chemotherapy. For each patient, a baseline sample was drawn before systemic treatment, and for seventeen of those patients, a second sample was taken after the first round of chemotherapy. Levels of peripheral blood EPCs, as defined by co-expression of CD133 and VEGFR2, were quantified by flow cytometry. Results: BC patients with stage III & IV disease had statistically higher levels of circulating EPCs than did patients with stage I & II disease (median=165,000 EPCs/5×106MNCs vs. median=6,920 EPCs/5x106MNCs, respectively, p < 0.0001 by Wilcoxon rank-sum test). In addition, in late-stage patients, levels of EPCs demonstrated a statistically significant drop after initiation of chemotherapy (median=162,500 EPCs/5x106MNCs [pre] vs. median=117,500 EPCs/5x106MNCs [post], p = 0.01 by Wilcoxon signed-rank test). Conclusion: These results suggest that circulating EPCs may serve as a potential tumor biomarker in breast cancer and that EPCs may represent a plausible target for future therapeutic intervention. Supported in part by the Mentored Medical Student in Clinical Research Program (General Clinical Research Center/National Institutes of Health Grant M01RR00047), Madeline & Stephen Anbinder Clinical Scholar Award, and Anne Moore Breast Cancer Research Fund No significant financial relationships to disclose.
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Affiliation(s)
- R. Naik
- Weill Medical College of Cornell University, New York, NY
| | - D. Jin
- Weill Medical College of Cornell University, New York, NY
| | - E. Chuang
- Weill Medical College of Cornell University, New York, NY
| | - E. Gold
- Weill Medical College of Cornell University, New York, NY
| | - E. Tousimis
- Weill Medical College of Cornell University, New York, NY
| | - P. Christos
- Weill Medical College of Cornell University, New York, NY
| | - T. De Dalmas
- Weill Medical College of Cornell University, New York, NY
| | - D. Donovan
- Weill Medical College of Cornell University, New York, NY
| | - S. Rafii
- Weill Medical College of Cornell University, New York, NY
| | - L. Vahdat
- Weill Medical College of Cornell University, New York, NY
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16
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Affiliation(s)
- Tara L Huston
- Department of Surgery, New York- Presbyterian/Weill-Cornell Medical College, NY 10021, USA
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Intra M, Rotmensz N, Viale G, Mariani L, Bonanni B, Mastropasqua MG, Galimberti V, Gennari R, Veronesi P, Colleoni M, Tousimis E, Galli A, Goldhirsch A, Veronesi U. Clinicopathologic characteristics of 143 patients with synchronous bilateral invasive breast carcinomas treated in a single institution. Cancer 2004; 101:905-12. [PMID: 15329896 DOI: 10.1002/cncr.20452] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Synchronous bilateral invasive breast carcinoma (SBIBC) ranged in incidence from 0.3% to as high as 12%. METHODS Between April 1997 and February 2003, 143 consecutive patients with SBIBC were treated at the European Institute of Oncology (Milan, Italy). Their information was collected prospectively in a database. The bilateral tumors were divded into left and right tumors. Tumor size, histology, grade, lymph node status, estrogen (ER) and progesterone receptor (PgR) status, HER-2 expression, peritumoral vascular invasion (PVI), Ki-67 expression, extensive in situ component (EIC), and multifocality between the two groups were analyzed. During the same time period, 6218 patients with unilateral invasive breast carcinoma (UIBC) were analyzed in the same manner for comparison with the patients with SBIBC. RESULTS There were no significant differences between left and right tumors, and the observed histopathologic agreement within the same patient was significantly superior than statistically expected for all characteristics except size, lymph node status, and multifocality. When compared with patients with UIBC, patients with SBIBC were more likely to present with smaller tumors and showed a higher frequency of invasive lobular carcinoma, lower histologic grade, higher rate of ER and PgR positivity, and lower PVI and Ki-67 expression. CONCLUSIONS The high concordance of histopathologic characteristics between SBIBC within the same patient could reflect a particular hormonal environment that influenced either the initiation and development of these lesions simultaneously and independently from the single or multi-clonal origin, either a less aggressive biological behavior compared with UIBC. In particular, the strong agreement of the observed EIC in SBIBC within the same patient seemed to definitively exclude the metastatic origin of these tumors.
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Affiliation(s)
- Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, Milan, Italy.
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Tousimis E, Van Zee KJ, Fey JV, Hoque LW, Tan LK, Cody HS, Borgen PI, Montgomery LL. The accuracy of sentinel lymph node biopsy in multicentric and multifocal invasive breast cancers. J Am Coll Surg 2003; 197:529-35. [PMID: 14522317 DOI: 10.1016/s1072-7515(03)00677-x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has proved to be an accurate alternative to complete axillary lymph node dissection (ALND) in clinically node-negative breast cancer patients. Multicentric (MC) and multifocal (MF) invasive breast cancers are considered to be relative contraindications to SLNB. We examine the accuracy of SLNB in patients with MC and MF invasive breast cancers. STUDY DESIGN From September 1996 to August 2001, a total of 3,501 patients with clinically node-negative breast cancer underwent SLNB using both blue dye and radioisotope at our institution. A total of 70 patients had MC or MF invasive breast cancer, a successful SLNB, and mastectomy for local control. All had >/=10 axillary nodes excised (including the SLN) in a planned ALND. Exclusion criteria included MC and MF in situ carcinoma; breast conservation; previous breast irradiation, ALND, or SLNB; recurrent breast cancer; neoadjuvant chemotherapy; or ALND based solely on SLNB pathologic examination. RESULTS; The incidence of axillary metastases was 54% (38 of 70). SLNB accuracy was 96% (67 of 70), sensitivity 92% (35 of 38), and false-negative rate 8% (3 of 38). All patients with an inaccurate SLNB had a dominant invasive tumor >5 cm and one patient had palpable axillary disease intraoperatively. The SLN was the only site of axillary metastasis in 37% (14 of 38). Results were compared with those of published SLNB validation studies, most of which reflect experience with single-site invasive breast cancers. No statistically significant difference was noted for accuracy, sensitivity, or false-negative rate. CONCLUSIONS SLNB accuracy in MC and MF disease is comparable with that of published validation studies. MC and MF patients with a dominant T3 tumor (>5 cm) or axillary disease palpable intraoperatively should have a concurrent formal ALND. Our retrospective data suggest SLNB may be used as a reliable alternative to conventional ALND in selected patients with MC or MF disease. Further studies in this patient population are warranted.
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Affiliation(s)
- Eleni Tousimis
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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