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De la Cruz Ku G, Desai A, Narvaez-Rojas AR, Zheng C, Collier A, Weber L, Kassira W, Avisar E, Möller MG. Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles. Surgeon 2023:S1479-666X(23)00151-8. [PMID: 38161142 DOI: 10.1016/j.surge.2023.12.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/12/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment. DESCRIPTION OF THE TECHNIQUE Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side. CONCLUSION This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.
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Affiliation(s)
- Gabriel De la Cruz Ku
- Universidad Cientifica del Sur, Lima, Peru; Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Anshumi Desai
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alexis R Narvaez-Rojas
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; International Coalition on Surgical Research, Universidad Nacional Autonoma de Nicaragua, Managua, Nicaragua
| | - Caiwei Zheng
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amber Collier
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lee Weber
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Wrood Kassira
- Division of Plastic Surgery, DeWitt Daughtry Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mecker G Möller
- Division of Surgical Oncology, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; International Coalition on Surgical Research, Universidad Nacional Autonoma de Nicaragua, Managua, Nicaragua; Department of Surgery, Pritzker School of Medicine, University of Chicago. Chicago, IL, USA.
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Taswell CSS, Avisar E, Reis IM, Panthaki Z, Meshman JJ, Freedman LM, Kesmodel SB, Takita C. Delayed Nipple-Areola Complex Radiotherapy after Nipple Sparing Mastectomy and Immediate Reconstruction for Invasive Breast Cancer or DCIS: Long-Term Results of a Phase I Study. Int J Radiat Oncol Biol Phys 2023; 117:e205. [PMID: 37784863 DOI: 10.1016/j.ijrobp.2023.06.1087] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To report long-term outcomes of a novel nipple-sparing approach in patients with DCIS or early-stage breast cancer that would not be eligible for nipple sparing mastectomy due to multifocality/multicentricity or tumor less than 2 cm from the nipple-areola complex (NAC). MATERIALS/METHODS We conducted a phase I pilot study approved by Institutional IRB. Eligible patients had a biopsy confirming DCIS or invasive breast cancer, and a surgical recommendation for mastectomy due to extent of disease, with tumor at least 1 cm from the NAC. Nipple sparing mastectomy (NSM) was performed after negative shave biopsy behind the nipple was obtained at time of surgery, followed by immediate reconstruction per plastic surgeon's preference. NAC RT was administered 5 to 8 weeks postoperative. A 3+3 dose-escalation design was used to test RT doses of 25, 30, 35 Gy in 10 fractions, given BID, 6 hours apart with electrons. Dose-limiting toxicity (DLT) was specified as RT-related NAC loss or any grade 4/5 AE up to 1-month from end of RT. Adverse events were assessed using CTCAE. v 4.0. Patients completed cosmesis and satisfaction assessment at standard follow up visits. RESULTS From 2010-2017, 18 women were treated on the study, 6 per dose level. Median age was 45.5 (range 30-63). 100% of patients were White, of those 44.5% were Hispanic. 17% had DCIS and 83% had invasive breast cancer (all ER+, 14 pStage T1N0, 1 pStage T1N1mi). Endocrine therapy was given to all ER+ invasive breast cancer patients. With a median F/U of 80.5 months, there was no RT-related DLT or grade 4/5 AEs (73 G1, 15 G2, 6 G3). All grade 3 AEs were related to the surgery (infection, pain, allergy to tape). There was no local recurrence in the NAC, with 100% of nipple preservation with longer follow up. Two patients developed metastases 2 years after diagnosis (bone, liver). 1 DCIS patient developed a second ipsilateral breast cancer away from the NAC, later found to have BRCA2+ mutation. Patient reported cosmesis at last visit was 72% excellent, 16.5% good, and 5.5% poor. Physicians score worse cosmesis compared to patients with 39% scored excellent and 61% good. Patient reported satisfaction with nipple sparing treatment was high, with 94% of patients choosing this treatment again. CONCLUSION This novel approach of nipple preserving therapy using delayed adjuvant NAC RT after nipple sparing mastectomy, resulted in 100% nipple preservation without compromise of local control, in this specific patient population not eligible for nipple sparing mastectomy alone. This study supports further exploration of nipple preservation with a broader inclusion criterion.
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Affiliation(s)
- C S Seldon Taswell
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - E Avisar
- Division of Surgical Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - I M Reis
- University of Miami/Sylvester CCC, Miami, FL
| | - Z Panthaki
- Division of Plastic Surgery, University of Miami/Sylvester C. Cancer Center, Miami, FL
| | - J J Meshman
- Department of Radiation Oncology, University of Miami/ Sylvester Comprehensive Cancer Center, Miami, FL
| | - L M Freedman
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - S B Kesmodel
- Division of Surgical Oncology, University of Miami/Sylvester C. Cancer Center, Miami, FL
| | - C Takita
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
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Friedman-Eldar O, Melnikau S, Tjendra Y, Avisar E. Axillary Reverse Lymphatic Mapping in the Treatment of Axillary Accessory Breast Cancer: A Case Report and Review of Management. Eur J Breast Health 2022; 18:1-5. [DOI: 10.4274/ejbh.galenos.2021.2021-7-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022]
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Burke J, Friedman-Eldar O, Halfteck G, Silva IDC, Baumrucker CC, Reyes FV, Lessard AS, Kassira W, Franceschi D, Kesmodel SB, Avisar E, Goel N, Möller MG. Persistent and interdependent: Racial disparities and their mechanisms in postmastectomy breast reconstruction. Surgery 2022; 172:25-30. [PMID: 35241302 DOI: 10.1016/j.surg.2022.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Racial disparities in accessing postmastectomy breast reconstruction persist despite expansion of insurance coverage. An updated examination with a broad assessment of mediating factors in a "majority minority" community is needed. METHODS Data were collected on all patients undergoing mastectomy for breast cancer from 2011 to 2019 in a private academic center and adjacent safety-net hospital. Multivariable logistic regression was used to assess the effect of race on postmastectomy breast reconstruction, controlling for predetermined potentially mediating and confounding variables. RESULTS Of 1,554 patients, 63.8% (n = 203) of non-Hispanic White, 33.4% (n = 102) of Black, and 47.9% (n = 438) of Hispanic patients underwent postmastectomy breast reconstruction. Multivariable logistic regression showed that Black patients (odds ratio [OR] 3.6, 95% confidence internal [CI]: 2.2-5.9; P < .0001) undergo significantly less postmastectomy breast reconstruction than White patients. Age, insurance status, stage, and hospital type mediated this relationship. CONCLUSION Black patients have substantially reduced rates of postmastectomy breast reconstruction compared with White patients, which is mediated by socioeconomic factors.
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Affiliation(s)
- Jonathan Burke
- Department of Surgery, New York University School of Medicine, NY.
| | - Orli Friedman-Eldar
- University of Miami Miller School of Medicine, FL; Jackson Memorial Hospital, Miami, FL
| | - Gili Halfteck
- University of Miami Miller School of Medicine, FL; Jackson Memorial Hospital, Miami, FL
| | | | | | | | - Anne-Sophie Lessard
- Division of Plastic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Wrood Kassira
- Division of Plastic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Susan B Kesmodel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Neha Goel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL
| | - Mecker G Möller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, FL. https://twitter.com/MeckeritaMoller
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Mathelin C, Lodi M, Alghamdi K, Arboleda-Osorio B, Avisar E, Anyanwu S, Boubnider M, Costa MM, Elder E, Elonge T, Gebrim L, Hao X, Imoto S, Meka E, Mouelle M, Mundinger A, Ostapenko V, Özbaş S, Özmen T, Özmen V, Pienkowski T, Sarria G, Selim A, Semiglazov V, Schneebaum S. The Senologic International Society Survey on Ductal Carcinoma <i>In Situ</i>: Present and Future. Eur J Breast Health 2022; 18:205-221. [DOI: 10.4274/ejbh.galenos.2022.2022-4-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/08/2022] [Indexed: 12/01/2022]
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Friedman-Eldar O, Ozmen T, El Haddi SJ, Goel N, Tjendra Y, Kesmodel SB, Moller MG, Franceschi D, Layton C, Avisar E. Axillary Response to Neoadjuvant Therapy in Node-Positive, Estrogen Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Breast Cancer Patients: Predictors and Oncologic Outcomes. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11473-9. [PMID: 35303178 DOI: 10.1245/s10434-022-11473-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 02/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND One potential benefit of neoadjuvant therapy (NAT) in node-positive, estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative (HER2-) patients is axillary downstaging to avoid axillary dissection. OBJECTIVE The aim of this study was to evaluate axillary response to NAT with chemotherapy (NCT) or endocrine therapy (NET) and identify potential predictors of response. METHODS A prospectively collected database was queried for node-positive, ER+, HER2- breast cancer patients treated with NAT and surgery from January 2011 to September 2020. Axillary response was categorized into pathologic complete response (pCR) versus no pCR, and was correlated to demographic and clinicopathologic parameters in a logistic regression model. RESULTS A cohort of 176 eligible patients was identified and 178 breast cancers were included in the study. The overall axillary pCR rate was 12.3% (22/178). NCT and NET achieved response rates of 13.9% (19/137) and 7.3% (3/41), respectively (p = 0.232). A significantly higher axillary pCR rate was identified in patients with clinical stage II at diagnosis (12/60, 20%) compared with stage III (10/118, 8.4%; p = 0.03). NET patients with ypN0 were younger and were treated for a longer period of time (>6 months). Completion axillary dissection was omitted in the majority (73.7%) of NCT patients achieving axillary pCR. CONCLUSIONS For patients with node-positive, ER+, HER2- breast cancer, a lower burden of disease at the time of diagnosis (stage II) is associated with a significantly higher axillary pCR, enabling those patients to be spared axillary dissection. Further studies are necessary to define the role of genomic profiling in predicting axillary response.
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Affiliation(s)
- Orli Friedman-Eldar
- Department of Surgical Oncology, Jackson Memorial Hospital, Miami, FL, USA.
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Tolga Ozmen
- Department of Surgical Oncology, Jackson Memorial Hospital, Miami, FL, USA
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Salah James El Haddi
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Youley Tjendra
- Division of Surgical Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Susan B Kesmodel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mecker G Moller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina Layton
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Friedman-Eldar O, Ozmen T, Haddi SJE, Goel N, Tjendra Y, Kesmodel SB, Moller MG, Franceschi D, Layton C, Avisar E. ASO Visual Abstract: Axillary Response to Neoadjuvant Therapy in Node-Positive ER+/HER2- Breast Cancer Patients-Predictors and Oncologic Outcomes. Ann Surg Oncol 2022. [PMID: 35286530 DOI: 10.1245/s10434-022-11531-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Orli Friedman-Eldar
- Department of Surgical Oncology, Jackson Memorial Hospital, Miami, FL, USA. .,Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Tolga Ozmen
- Department of Surgical Oncology, Jackson Memorial Hospital, Miami, FL, USA.,Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Salah James El Haddi
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Youley Tjendra
- Division of Surgical Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Susan B Kesmodel
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mecker G Moller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina Layton
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Melnikau S, Layton C, Ozmen T, Allen M, Avisar E. Abstract P1-01-14: Axillary assessment by Systemic Axillary Sonography (SAS) for axillary disease treated with neoadjuvant chemotherapy. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p1-01-14] [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
Objective. For patients with breast cancer related lymph node metastases, neoadjuvant chemotherapy (NAC) can de-escalate axillary surgery. A radiologic marker (RM) is commonly placed at the time of the initial biopsy to ensure removal of that node at final surgery, but the utility of this marker is largely debated. Systematic Axillary Sonography (SAS) consists of a thorough sonographic axillary staging before and after NAC with possible post NAC node biopsy and has been previously suggested as an alternative. The primary aim of this study was to assess the effectiveness of SAS in axillary evaluation after NAC. The secondary aim was to compare the effectiveness of SAS to RM. Methods. A retrospective analysis of prospectively collected data from 95 patients from 2010 to 2020 at University of Miami Hospital and Jackson Memorial Hospital. Study inclusion criteria were positive axillary lymph node (LN) biopsy, NAC, performance of SAS and axillary surgery. Results. 89 patients were analyzable. The median age was 49±12. All patients had clinical axillary exam and axillary US with positive LN biopsy. 62 patients had additional breast MRI before treatment. All patients had clinical axillary exam and axillary US after chemotherapy. 58 patients had post-treatment MRI and 49 repeated axillary LN biopsy. Pre-treatment clinical exam of the axilla had a sensitivity of 73%. When MRI was added the sensitivity rose to 95%. Since axillary US and positive axillary node biopsy were a prerequisite, the sensitivity of pre-NAC US cannot be assessed. After chemotherapy, all patient underwent axillary examination and US assessment. Repeated axillary clinical exam had low sensitivity of 31% and high specificity of 85%. Repeat MRI exam showed low sensitivity and specificity of 53% and 49% respectively. Post-NAC US without subsequent LN biopsy had a sensitivity of 55% with specificity of 67%. The addition of repeat axillary LN biopsy increased the sensitivity of SAS to 100%. 59 patients in our group had RM placed during pre-NAC axillary LN biopsy. 24 underwent axillary dissection without sentinel lymph node biopsy (SLNB) and 35 patients had a SLNB. The RM was retrieved in 32/35 patients. The “clipped” node was also sentinel node in 66% (12/35). The final pathology revealed benign results in all “clipped” non-sentinel nodes. 18% (6/33) of patients with “clipped” node were diagnosed with axillary metastases in “non-clipped” lymph nodes. Conclusion. SAS is a cheap, quick and reliable method facilitating pre and post-treatment assessment and restaging of the axilla after NAC. Post-NAC biopsy, when indicated, better defines eligibility for axillary surgery decreasing morbidity and cost. In this study, placement of a RM was of no significant benefit.
Patient characteristicsRaceTumor gradeWhite, non-hispanic19Gr 13White-hispanic46Gr 240Black, non-hispanic18Gr 346Asian3Receptor statusUnknown3HR+/HER2-42Age49+/-12HR+/HER2+19BMI29+/-5.7HR-/HER2+7Menopausal statusHR-/HER2-21Premenopausal49Tumor sizePostmenopausal40T19T238T328T414LN statusN158N221N310
Citation Format: Siarhei Melnikau, Christina Layton, Tolga Ozmen, Megan Allen, Eli Avisar. Axillary assessment by Systemic Axillary Sonography (SAS) for axillary disease treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-14.
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Affiliation(s)
- Siarhei Melnikau
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
| | - Christina Layton
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Miami, FL
| | - Tolga Ozmen
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
| | - Megan Allen
- University of Miami Miller School of Medicine, Miami, FL
| | - Eli Avisar
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
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Keren T, Persitz J, Gutman Tirosh A, Mattan R, Avisar E. Thumb carpometacarpal joint soft-tissue lesions in an asymptomatic population. An MRI study. Hand Surgery and Rehabilitation 2022; 41:199-203. [DOI: 10.1016/j.hansur.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/20/2021] [Accepted: 12/31/2021] [Indexed: 10/19/2022]
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Friedman-Eldar O, Layton C, De Castro Silva I, Moller MG, Allen A, Franceschi D, Isrow D, Samuels S, Takita C, Avisar E. Surgical and Oncologic Outcomes With Intraoperative Radiation Therapy for Early Breast Cancer. Am Surg 2021:31348211047499. [PMID: 34732085 DOI: 10.1177/00031348211047499] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND For selected patients with early-stage breast cancer (BC), intraoperative radiation therapy (IORT) has emerged as a convenient alternative to standard whole breast irradiation (WBI). We report a single institution experience with IORT in terms of oncologic outcomes, toxicities, and cosmesis. METHODS Clinicopathological and perioperative outcomes of patients who underwent IORT for early-stage BC at a public hospital from 2017 to 2020 were retrospectively retrieved. Toxicity was categorized to acute or chronic based on 6 months post-IORT cutoff. RESULTS 85 patients underwent IORT and had complete data, aged 49-85 years (mean 62). Intraoperative radiation therapy added 23 minutes on average to the total operative time. Final stage was 0, I, and II in 40%, 58.9%, and 1.1% of patients, respectively. Mean tumor size was 0.8 cm (range .1-2.1), with ductal histology comprising 94% of cases. Surgical margins were positive in 2 patients, and adjuvant WBI was required in 5 patients. After a median follow-up of 17 months (range 3-41), none of the patients had local recurrence and no mortality was recorded. Early wound complications included wound dehiscence (n = 1), seroma/hematoma (n = 15), and re-operation with loss of nipple-areola complex (n = 1). Chronic skin toxicities were reported in 10 (12%) patients and good or excellent cosmetic outcome was reported in 93% of patients. CONCLUSIONS Utilizing IORT among low-risk early BC patients may be a safe and more convenient alternative to traditional WBI, with low toxicity rate, acceptable cosmetic results, and good oncologic outcomes at 17 months. Longer follow-up and further prospective controlled studies are needed to confirm these findings.
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Affiliation(s)
- Orli Friedman-Eldar
- Department of Surgical Oncology, 23215Jackson Memorial Hospital, Miami, FL, USA.,Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina Layton
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iago De Castro Silva
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mecker G Moller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ahkeel Allen
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Derek Isrow
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Stuart Samuels
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Cristiane Takita
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
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Ozmen T, Layton C, Friedman-Eldar O, Melnikau S, Kesmodel S, Avisar E. Long-Term Results of Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the Prevention of Breast Cancer-Related Clinical Lymphedema after Axillary Lymph Node Dissection. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ozmen T, Layton C, Friedman-Eldar O, Melnikau S, Kesmodel S, Avisar E. Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) for the Prevention of Breast Cancer-related Lymphedema after Axillary Lymph Node Dissection. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ozmen T, Layton C, Friedman-Eldar O, Melnikau S, Kesmodel S, Avisar E. Long-term results of simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.514] [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
514 Background: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. SLYMPHA is a safe and relatively simple method, which decreases incidence of LE dramatically. Our initial study showed an 88% decrease in clinical LE rate after a median follow up of 15 months. The aim of this study was to confirm these results after a longer follow up period. Methods: All patients, undergoing ALND between January 2014 and November 2020 were included in the study. During follow-up visits, tape-measuring limb circumference method was used to detect clinical LE. The incidence of clinical LE was compared between patients with and without SLYMPHA. Univariate and multivariate analysis were used to assess the role of other factors in the appearance of clinical LE. Results: 580 patients were included in the study. 35% of cohort underwent SLYMPHA. Mean follow-up time was 44 ±31.9 months. Patients, who underwent SLYMPHA, had a significantly lower LE rate (10% vs 26%; p=0.002; OR 0.4 [0.31-0.77]). Diabetes and removing ³22 lymph nodes also correlated with increased LE however this effect disappeared on multivariate analysis. Conclusions: SLYMPHA is a safe and relatively simple method, which continued its efficacy after 4-years follow up. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.[Table: see text]
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Affiliation(s)
- Tolga Ozmen
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Christina Layton
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Orli Friedman-Eldar
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Siarhei Melnikau
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Susan Kesmodel
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Eli Avisar
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
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Ozmen T, Layton C, Friedman Eldar O, Melnikau S, Kesmodel S, Avisar E. Simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer-related lymphedema after axillary lymph node dissection. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e12581] [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
e12581 Background: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. Simplified Lymphatic Microsurgical Preventing Healing Approach (SLYMPHA) is a safe and relatively simple method, which decreases incidence of LE dramatically. Our initial study showed an 88% decrease in clinical LE rate. In the initial study, we used arm circumference measurement for the diagnosis of LE and median follow up was 15 months. The aim of this study was to confirm these results after a long-term follow up period and by using bioimpedance spectroscopy (L-Dex) technology in detecting LE. Methods: All patients, undergoing ALND with or without SLYMPHA between January 2014 and November 2020 were included in the study. Patients with no postoperative L-Dex measurements were excluded. A L-Dex score outside the normal range (± 10 L-Dex unit) or >10 L-Dex unit increase above patient’s baseline was considered as LE. The incidence of LE was compared between patients with and without SLYMPHA. Results: 194 patients were included in the study. 57% of cohort underwent SLYMPHA. Mean follow-up time was 47 ±37 months. Patients, who underwent SLYMPHA, had a significantly lower rate of LE (16% vs 32%; p=0.01; OR 0.4 [0.2-0.8]). Conclusions: SLYMPHA is a safe and relatively simple method, which continued its efficacy after a long-term follow up period. It should be considered as an adjunct procedure to ALND for all patients during initial surgery. [Table: see text]
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Affiliation(s)
- Tolga Ozmen
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Christina Layton
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Orli Friedman Eldar
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Siarhei Melnikau
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Susan Kesmodel
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
| | - Eli Avisar
- University of Miami, Miller School of Medicine, Division of Surgical Oncology, Miami, FL
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Goel N, Yadegarynia S, Rodgers S, Kelly K, Collier A, Franceschi D, Moller M, Avisar E, Kesmodel SB. Axillary response rates to neoadjuvant chemotherapy in breast cancer patients with advanced nodal disease. J Surg Oncol 2021; 124:25-32. [PMID: 33852160 DOI: 10.1002/jso.26480] [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: 02/09/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Utilization of sentinel lymph node biopsy (SLNB) in breast cancer patients with positive nodes after neoadjuvant chemotherapy (NAC) has increased. We examine axillary response rates after NAC in patients with clinical N2-3 disease to determine whether SLNB should be considered. METHODS Breast cancer patients with clinical N2-3 (AJCC 7th Edition) disease who received NAC followed by surgery were selected from our institutional tumor registry (2009-2018). Axillary response rates were assessed. RESULTS Ninety-nine patients with 100 breast cancers were identified: 59 N2 (59.0%) and 41 (41.0%) N3 disease; 82 (82.0%) treated with axillary lymph node dissection (ALND) and 18 (18.0%) SLNB. The majority (99.0%) received multiagent NAC. In patients undergoing ALND, cCR was observed in 20/82 patients (24.4%), pathologic complete response (pCR) in 15 patients (18.3%), and axillary pCR in 17 patients (20.7%). In patients with a cCR, pCR was identified in 60.0% and was most common in HER2+ patients (34.6%). CONCLUSION In this analysis of patients with clinical N2-3 disease receiving NAC, 79.3% of patients had residual nodal disease at surgery. However, 60.0% of patients with a cCR also had a pCR. This provides the foundation to consider evaluating SLNB and less extensive axillary surgery in this select group.
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Affiliation(s)
- Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sina Yadegarynia
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Steve Rodgers
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kristin Kelly
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Amber Collier
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dido Franceschi
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mecker Moller
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eli Avisar
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Susan B Kesmodel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Mathelin C, Ame S, Anyanwu S, Avisar E, Boubnider WM, Breitling K, Anie HA, Conceição JC, Dupont V, Elder E, Elfgen C, Elonge T, Iglesias E, Imoto S, Ioannidou-Mouzaka L, Kappos EA, Kaufmann M, Knauer M, Luzuy F, Margaritoni M, Mbodj M, Mundinger A, Orda R, Ostapenko V, Özbaş S, Özmen V, Pagani O, Pieńkowski T, Schneebaum S, Shmalts E, Selim A, Pavel Z, Lodi M, Maghales-Costa M. Breast Cancer Management During the COVID-19 Pandemic: The Senologic International Society Survey. Eur J Breast Health 2021; 17:188-196. [PMID: 33870120 DOI: 10.4274/ejbh.galenos.2021.2021-1-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 01/25/2021] [Accepted: 03/09/2021] [Indexed: 01/19/2023]
Abstract
Objective In early 2020, the spread of coronavirus disease-2019 (COVID-19) led the World Health Organization to declare this disease a pandemic. Initial epidemiological data showed that patients with cancer were at high risk of developing severe forms of COVID-19. National scientific societies published recommendations modifying the patients' breast cancer (BC) management to preserve, in theory, quality oncologic care, avoiding the increased risk of contamination. The Senology International Society (SIS) decided to take an inventory of the actions taken worldwide. This study investigates COVID-19-related changes concerning BC management and analyzes the will to maintain them after the pandemic, evaluating their oncological safety consequences. Materials and Methods SIS network members participated in an online survey using a questionnaire (Microsoft® Forms) from June 15th to July 31st, 2020. Results Forty-five responses from 24 countries showed that screening programs had been suspended (68%); magnetic resonance imagines were postponed (73%); telemedicine was preferred when possible (71%). Surgeries were postponed: reconstructive (77%), for benign diseases (84%), and in patients with significant comorbidities (66%). Chemotherapy and radiotherapy protocols had been adapted in 28% of patients in both. Exception for telemedicine (34%), these changes in practice should not be continued. Conclusion The SIS survey showed significant changes in BC's diagnosis and treatment during the first wave of the COVID-19 pandemic, but most of these changes should not be maintained. Indeed, women have fewer severe forms of COVID-19 and are less likely to die than men. The risk of dying from COVID-19 is more related to the presence of comorbidities and age than to BC. Stopping screening and delaying treatment leads to more advanced stages of BC. Only women aged over 65 with BC under treatment and comorbidities require adaptation of their cancer management.
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Affiliation(s)
- Carole Mathelin
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg Cedex, France.,Immediate the Senology International Society (SIS) Past President, France
| | - Shanti Ame
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg Cedex, France
| | - Stanley Anyanwu
- The Senology International Society Vice-President for Africa, Nigeria
| | - Eli Avisar
- Miller School of Medicine, University of Miami, USA
| | | | | | | | | | | | - Elisabeth Elder
- Westmead Breast Cancer Institute, University of Sydney, Australia
| | | | | | - Edelmiro Iglesias
- The Senology International Society (SIS) Vice-President for Europe, Spain
| | | | | | - Elisabeth A Kappos
- Breast Center and Department of Plastic, Reconstructive, Aesthetic and Handsurgery, University Hospital Basel, Switzerland
| | | | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Franck Luzuy
- Department of Breast Surgery, Hirslanden Clinic, Geneva, Switzerland
| | | | - Mamadou Mbodj
- Department of Nuclear Medicine, General Hospital Idrissa POUYE, Dakar, Senegal
| | | | - Ruben Orda
- The Senology International Society (SIS) International School of Senology, Israel
| | | | | | - Vahit Özmen
- The Senology International Society (SIS) Standing Committee, Turkey
| | - Olivia Pagani
- Department of Oncology, Breast Unit and Institute of Oncology of Southern Switzerland
| | | | | | - Ekaterina Shmalts
- Department of Oncology, Multi-field Clinical Medical Centre "Medical City", Tyumen, Russia
| | - Ashraf Selim
- Department of Radiology, Cairo University, Egypt
| | - Zotov Pavel
- Department of Oncology, Tyumen State Medical University, Russia
| | - Massimo Lodi
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg Cedex, France
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17
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Cho-Vega JH, Cao T, Ledon J, Moller M, Avisar E, Elgart G, Tan JH, Fan YS, Grichnik JM. Diagnostic application of cyclin D1 fluorescent in situ hybridization for histologically undetermined early lesions of acral melanoma in situ: A case series. Ann Diagn Pathol 2021; 50:151681. [PMID: 33341705 DOI: 10.1016/j.anndiagpath.2020.151681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
Histologically undetermined early acral melanoma in situ (HUAMIS) is rare but a diagnostic challenge, being clinically and dermoscopically MIS (late onset, a large size (>7 mm), parallel ridges pattern) but microscopically without recognizable cytological atypia. Cyclin D1 (CCND1) gene amplification is a genetic aberration occurring in the early radial growth phase of AMs and could thus help determine malignancy for this disease. We determine the value of CCND1 amplification by FISH as a diagnostic marker for HUAMIS. CCND1 amplification was examined in paraffin-embedded skin biopsies and excisions using a dual-probes fluorescence in situ hybridization (FISH) (11q13 and CEP11). One FISH-negative case 6 was additionally examined by Mypath Melanoma (qRT-PCR). Seventeen cases (12 dysplastic nevi, 3 AMIS, and 2 invasive AM) were served as negative controls for FISH. All six patients (4 females and 2 males) were Hispanic. Pigment lesions were on the left plantar foot (4), right third finger palm (1), and right thumb subungual (1). All cases showed similar clinical and dermoscopical characteristics, including late onset (50 to 74 years old), long duration (from 2 to 15 years), large-sized pigments (from 16 to 40 mm), and a parallel ridge pattern. Junctional melanocytes with no or minimal atypia from five cases showed CCND1 amplifications. Four of 5 cases were received 1st or/and 2nd wide excisions, which demonstrated foci of histologically overt MIS. One FISH-negative case 6 demonstrated "likely malignancy" scores (>2) by Mypath Melanoma (qRT-PCR). None of negative controls showed the amplification. We propose here a simple CCND1 FISH is a practical diagnostic test to determine the malignancy of the very early progression phase of AM preceding histopathologically defined MIS. Cases presented here could be an indolent subtype of AMIS characterized by carrying a long latent radial growth phase without vertical growth, mimicking lentigo maligna.
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Affiliation(s)
- Jeong Hee Cho-Vega
- Departments of Pathology, Miller School of Medicine, University of Miami, Florida, USA.
| | - Theresa Cao
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Florida, USA
| | - Jennifer Ledon
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Florida, USA
| | - Mecker Moller
- Surgical Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Florida, USA
| | - Eli Avisar
- Surgical Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Florida, USA
| | - George Elgart
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Florida, USA
| | - Jing Hong Tan
- Molecular Pathology, Miller School of Medicine, University of Miami, Florida, USA
| | - Yao-Shan Fan
- Molecular Pathology, Miller School of Medicine, University of Miami, Florida, USA
| | - James M Grichnik
- Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Florida, USA
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18
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Ozmen T, Avisar E. The Impact of Advanced Image-Guided Breast Surgery and Oncoplastic Techniques on Margin Positivity in Breast Conserving Surgery. Cureus 2020; 12:e11831. [PMID: 33409073 PMCID: PMC7781498 DOI: 10.7759/cureus.11831] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective Positive margins remain a significant psychological and economic burden after breast conserving surgery. The aim of this study was to test the hypothesis that advanced oncoplastic techniques as well as intraoperative integrative imaging with intraoperative ultrasound and mobile digital specimen radiography decreases positive margin rate in breast conserving surgery. Methods A single-institution retrospective review of a prospectively collected database was performed. Patients with breast neoplasms who underwent lumpectomy with or without using intraoperative integrative imaging approaches and oncoplastic techniques were included. The primary outcome was positive margin rate for each technique. Results A total of 392 patients were included in the study. The median age of the cohort was 59 years. Overall positive margin rate was 15%. Ductal carcinoma in situ (DCIS) histology and larger tumor size were associated with higher positive margin rate. Intraoperative integrative imaging significantly decreased positive margin rate (9% vs. 18%, p=0.018). Oncoplastic techniques also decreased positive margin rate from 16% to 12%, however this was not significant. Conclusion Positive margin rate was significantly lower when intraoperative integrative imaging was used. Oncoplastic techniques also decreased positive margin rate in a selected group of patients with large tumor size. We suggest incorporating these techniques in all breast conserving surgery cases.
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Affiliation(s)
- Tolga Ozmen
- Surgical Oncology, University of Miami, Miller School of Medicine, Miami, USA
| | - Eli Avisar
- Surgical Oncology, University of Miami, Miller School of Medicine, Miami, USA
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19
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Azab B, Amundson JR, Cioci A, Stuart H, Yakoub D, Avisar E, Moffat F, Livingstone AS, Franceschi D. The Usefulness of the Pretreatment Neutrophil/Lymphocyte Ratio as a Predictor of the 5-Year Survival in Stage 1-3 Triple Negative Breast Cancer Patients. Breast Care (Basel) 2020; 16:43-49. [PMID: 33716631 DOI: 10.1159/000506463] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background We have previously shown that the neutrophil/lymphocyte ratio (NLR) is a predictor of survival among breast cancer patients. The aim of this study was to determine the predictive value of NLR among different nodal and chemotherapy subgroups of triple negative breast cancer (TNBC). Methods Patients with stage 1-3 TNBC who underwent treatment from 2007 to 2014 and had blood counts prior to treatments were included. Patients were categorized into high (≥2) and low (<2) NLR groups. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Results The average follow-up time was 54 months. The high NLR group had worse OS (HR 2.8, CI 1.3-5.9, p < 0.001) and DFS (HR 2.3, CI 1.2-4.2, p < 0.001) than the low NLR group. After adjusting for confounding variables, high NLR was an independent prognostic factor for both OS (HR 5.5, CI 2.2-13.7, p < 0.0001) and DFS (HR 5.2, CI 2.3-11.6, p < 0.0001). Categorization of TNBC patients by NLR (high vs. low) and nodal status (positive vs. negative) resulted in four groups with significantly different OS and DFS (log rank p < 0.0001). Significant improvements in OS (p < 0.001) and DFS (p < 0.001) were observed for patients who received chemotherapy and had high NLR but not for patients with low NLR (p = 0.65 and p = 0.07, respectively). Conclusion High pretreatment NLR is an independent predictor of poor OS and DFS among TNBC patients. Combining NLR and pN provides better risk stratification for TNBC patients. Chemotherapy appears to be beneficial only in patients with high NLR. Larger prospective studies are needed to validate these findings.
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Affiliation(s)
- Basem Azab
- Surgical Oncology, Sentara Healthcare, Hampton, Virginia, USA
| | - Julia R Amundson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Alessia Cioci
- Department of Surgical Oncology, University of Miami, Miami, Florida, USA
| | - Heather Stuart
- Department of Surgical Oncology, University of British Colombia, Vancouver, British Columbia, Canada
| | - Danny Yakoub
- Department of Surgical Oncology, University of Tennessee, Memphis, Tennessee, USA
| | - Eli Avisar
- Department of Surgical Oncology, University of Miami, Miami, Florida, USA
| | - Fredrick Moffat
- Department of Surgical Oncology, University of Miami, Miami, Florida, USA
| | - Alan S Livingstone
- Department of Surgical Oncology, University of Miami, Miami, Florida, USA
| | - Dido Franceschi
- Department of Surgical Oncology, University of Miami, Miami, Florida, USA
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20
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Cohen BL, Collier AL, Kelly KN, Goel N, Kesmodel SB, Yakoub D, Moller M, Avisar E, Franceschi D, Macedo FI. Surgical Management of the Axilla in Patients with Occult Breast Cancer (cT0 N+) After Neoadjuvant Chemotherapy. Ann Surg Oncol 2020; 27:1830-1841. [PMID: 31989360 DOI: 10.1245/s10434-020-08227-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Occult breast cancer (OBC) is a rare clinical entity. Current surgical management includes axillary lymphadenectomy (ALND) with or without mastectomy. We sought to investigate the role of sentinel lymph node biopsy (SLNB) in patients with OBC treated with neoadjuvant chemotherapy (NAC). METHODS Patients with clinical T0N+ breast cancer were selected from the National Cancer Data Base (NCDB, 2004-2014) and compared according to axillary surgical approach, SLNB (≤ 4 LNs) or ALND (> 4 LNs). Primary outcome was overall survival (OS), calculated using Kaplan-Meier methods. Secondary outcome was complete pathological response (pCR). RESULTS A total of 684 patients with OBC were identified: 470 (68.7%) underwent surgery upfront and 214 (31.3%) received NAC. Of the NAC patients, 34 (15.9%) underwent SLNB and 180 (84.1%) ALND. One hundred and fifty-three (72%) patients received radiotherapy (RT). There was no difference in pCR rates between the ALND and SLNB (34.3% vs 24.5%, respectively p = 0.245). In patients undergoing surgery first, improved OS was observed with ALND compared to SLNB (106.9 vs 85.5 months, p = 0.013); however, no difference in OS was found in patients who received NAC (105.6 vs 111.3 months, p = 0.640). RT improved OS in patients who underwent NAC followed by SLNB (RT, 123 months vs no RT, 64 months, p = 0.034). Of NAC patients who did not undergo RT, ALND had superior survival compared to SLNB (113 vs 64 months, p = 0.013). CONCLUSION This is the first comparative analysis assessing the surgical management of the axilla in patients with OBC who underwent NAC. In this population, there was a decrease in survival in patients who underwent SLNB alone; however, with the addition of RT, there was no difference in OS between SLNB and ALND. SLNB plus RT may be considered as an alternative to ALND in patients with OBC who have a good response to NAC.
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Affiliation(s)
- Brianna L Cohen
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amber L Collier
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kristin N Kelly
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Susan B Kesmodel
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danny Yakoub
- Division of Surgical Oncology, University of Tennessee at Memphis, Memphis, TN, USA
| | - Mecker Moller
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Francis I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA.
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21
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Kelly KN, Ryon E, Allen A, Franceschi D, Moller M, Avisar E, Kobetz EN, Merchant N, Kesmodel SB, Goel N. Overcoming Disparities: Multidisciplinary Breast Cancer Care at a Public Safety-Net Hospital. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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Kelly KN, Ryon E, Macedo FIB, Franceschi D, Moller M, Avisar E, Kobetz EN, Merchant N, Kesmodel SB, Goel N. Comprehensive Analysis of Breast Cancer Survival Outcomes in a Public Safety-Net Hospital Compared with an Adjacent Academic Cancer Center. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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23
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Ghanta S, Allen A, Vinyard AH, Berger R, Aoun J, Rosenkrantz Spoont J, Avisar E. Breast fibromatosis: Making the case for primary vs secondary subtypes. Breast J 2019; 26:697-701. [PMID: 31429159 DOI: 10.1111/tbj.13506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/13/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 02/06/2023]
Abstract
Fibromatosis of the breast is a rare condition that can be locally aggressive. The mainstay of treatment remains wide local excision, with varied adjuvant therapy as needed. The authors describe their experience in the treatment of a series of patients and propose the classification of primary and secondary breast fibromatosis. A single-institution retrospective analysis of patients treated for breast fibromatosis from 2003 to 2017 was completed. Demographic data, pertinent past medical history, and treatment modalities were reviewed. Primary breast fibromatosis was defined as arising in the absence of previous surgery or radiation therapy to the ipsilateral breast. Secondary breast fibromatosis was defined as arising in the setting of previous surgery or radiation therapy to the ipsilateral breast. A total of 16 patients were included with the median age 40 (28-64) years. The average size of the lesion was 6.37 cm (range of 1.5-15 cm). Mean follow-up time was 65 months. Surgical excision was completed in 14 patients, with two recurrences. There were no recurrences in patients with surgical margins >1 cm. Two patients were treated nonsurgically. There were seven patients with primary fibromatosis of the breast and nine patients with secondary fibromatosis of the breast. Fibromatosis of the breast is difficult to diagnose prior to surgical excision. We advocate for the multi-disciplinary treatment of this disease process with an aggressive surgical approach to achieve margins >1 cm.
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Affiliation(s)
- Swapna Ghanta
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Ahkeel Allen
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Alicia Huff Vinyard
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Rachel Berger
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Jessica Aoun
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | | | - Eli Avisar
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
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Libson S, Perez E, Takita C, Avisar E. Post Mastectomy Radiation for Stage II Breast Cancer Patients with T1/T2 Lesions. Eur J Breast Health 2019; 15:71-75. [PMID: 31001607 DOI: 10.5152/ejbh.2019.4481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/14/2018] [Accepted: 02/21/2019] [Indexed: 11/22/2022]
Abstract
Objective Post mastectomy radiation (PMR) is usually recommended for T3 or N2 breast cancer (BC). The role of PMR for stage II BC with T1/T2 lesions remains controversial. The aim of this study was to assess the role of PMR in this subgroup of patients. Materials and Methods A retrospective analysis of a prospectively collected database of all stage II BC patients treated with mastectomy at our institution between the years 2005-2008 was performed. Demographics, disease-free survival rates were compared between the patients receiving radiation vs. those who were not irradiated. Results Eighty-two patients underwent mastectomies for stage II disease with a T1/T2 lesion. Twenty-two of those (27%) received PMR. Loco regional recurrence (LRR) occurred only in the non -irradiated (NR) group. A Kaplan Meier analysis of time to LRR in the NR group was performed. Mean time to local failure was 78.9 months, 6% at 3 years and 13% at 5 years. The time to LRR was significantly lower in the estrogen receptor (ER) negative group compared to the ER positive group (64 vs. 82 months, p=0.029). LRR free rate at 5 years was 100% in low grade tumors vs. 53% in high grade tumors, (p=0.001). In a Cox regression multivariate analysis none of those factors maintained significance. Conclusion ER negative status, high grade and node negativity were associated with LRR. A prospective trial randomizing stage II BC patients with T1/T2 lesions, negative hormone receptors and high-grade tumors to PMR following mastectomy arm vs. no radiation arm is recommended.
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Affiliation(s)
- Shai Libson
- Department of General Surgery, Miami University School of Medicine, Miami, USA
| | - Eduardo Perez
- Department of General Surgery, Miami University School of Medicine, Miami, USA
| | - Christiane Takita
- Department of Radiation Oncology, Miami University School of Medicine, Miami, USA
| | - Eli Avisar
- Department of General Surgery, Miami University School of Medicine, Miami, USA
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Slingerland JM, Mark P, Hurley J, Net J, Collado-Mesa F, Lippman M, Avisar E, Yepes M, Jorda M, Gomez C. Abstract P4-15-06: Results of a randomized double blind trial of neoadjuvant anastrozole plus placebo vs anastrozole plus saracatinib for ER+ postmenopausal breast cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p4-15-06] [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
Antiestrogen mediated cell cycle arrest requires the CDK inhibitor, p27. Src kinase mediates p27 loss and antiestrogen resistance in ER+ breast cancer lines in vitro. In ER+ xenografts, the Src inhibitor, saracatinib, restored antiestrogen responses in resistant tumors. This led to a Phase I/randomized double-blind Phase II trial to test effects of saracatinib with anastrozole for ER+ and/or PR+ postmenopausal breast cancer.
Phase I accrued 12 subjects and showed 175 mg po saracatinib is safely given with 1 mg po daily anastrozole with good PK . In Phase II, postmenopausal women with new ER+ and/or PR+, HER2- breast cancers ≥ 2 cm were randomized 2:1 to either neoadjuvant anastrozole with saracatinib or anastrozole/placebo over 6 months. Response was assayed by clinical 2D measurements each cycle and by MRI pre-study, at 10 weeks and prior to surgery. The Phase II primary endpoint was to test if tumor volume decrease (from 2D clinical measures) with dual therapy (dual) exceeded that of monotherapy (mono) by >20%. Secondary endpoints included tumor response by 3D MRI measures and by RECIST, PK and toxicity, and molecular predictors of drug efficacy in pre-/ post-therapy tumors. Of 58 subjects, 15% were Black, 5% Asian and 79% White. 61% were Hispanic. Dual therapy was well tolerated, with the following grade 1 toxicities: flu-like syndrome 20%, non-pruritic rash 48% (17% for mono), self-limited diarrhea in 55% (33% mono). Transaminasemia with dual therapy was 52.5% and 17% with mono. 6/59 stopped dual due to drug related AEs: 2 had gr 3 hepatitis, one gr 3 anemia, 3 had grade 3 urticarial rash. Dual Rx increased mean anastrozole levels to 50 ng/ml vs 38 ng/ml for mono (T test p= 5.45201 E-05). Mean saracatinib level, 269 ng/ml, was similar to prior studies. All of 50 evaluable subjects showed clinical and MRI tumor responses. 17% in both groups progressed, usually after 16 weeks. Mean tumor vol (calculated from 2D clinic measures) declined more rapidly (by 63% in dual vs 55% in mono at 8 weeks), but both groups showed an 89% mean tumor volume decrease by 20 weeks. Clinical RECIST showed size reductions of 61% in dual and 62% after monotherapy. Tumor volumes based on 3D MRI show a non-significant trend to greater response to dual therapy, with mean volume decreased by 64% vs 45% at the end of dual vs monotherapy. RECIST response by MRI also showed a trend to greater % decrease tumor size post treatment by 34% vs 25% in dual vs mono. Thus, clinical volumetric assessment of response to this neoadjuvant endocrine therapy may overestimate response compared to volumes calculated by MRI, while RECIST may underestimate it. Pathologic responses based on initial and residual tumor burden calculated from initial and final tumor volumes and % cellularity in biopsy and surgical specimens will be presented.
Citation Format: Slingerland JM, Mark P, Hurley J, Net J, Collado-Mesa F, Lippman M, Avisar E, Yepes M, Jorda M, Gomez C. Results of a randomized double blind trial of neoadjuvant anastrozole plus placebo vs anastrozole plus saracatinib for ER+ postmenopausal breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-15-06.
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Affiliation(s)
- JM Slingerland
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - P Mark
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - J Hurley
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - J Net
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - F Collado-Mesa
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - M Lippman
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - E Avisar
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - M Yepes
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - M Jorda
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
| | - C Gomez
- Sylvester Comprehensive Cancer Center U of Miami, Miami, FL; Stanford Cancer Institute at Stanford University, Stanford, CA
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Fiorino S, Di Saverio S, Leandri P, Tura A, Birtolo C, Silingardi M, de Biase D, Avisar E. The role of matricellular proteins and tissue stiffness in breast cancer: a systematic review. Future Oncol 2018; 14:1601-1627. [PMID: 29939077 DOI: 10.2217/fon-2017-0510] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Malignancies consist not only of cancerous and nonmalignant cells, but also of additional elements, as extracellular matrix. The aim of this review is to summarize meta-analyses, describing breast tissue stiffness and risk of breast carcinoma (BC) assessing the potential relationship between matricellular proteins (MPs) and survival. A systematic computer-based search of published articles, according to PRISMA statement, was conducted through Ovid interface. Mammographic density and tissue stiffness are associated with the risk of BC development, suggesting that MPs may influence BC prognosis. No definitive conclusions are available and additional researches are required to definitively clarify the role of each MP, mammographic density and stiffness in BC development and the mechanisms involved in the onset of this malignancy.
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Affiliation(s)
- Sirio Fiorino
- Internal Medicine 'C' Unit, Maggiore Hospital, Local Health Unit of Bologna, Bologna, Italy
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Box 201, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Paolo Leandri
- Internal Medicine 'C' Unit, Maggiore Hospital, Local Health Unit of Bologna, Bologna, Italy
| | - Andrea Tura
- Metabolic Unit, CNR Institute of Neuroscience, Padova, Italy
| | - Chiara Birtolo
- Geriatric Unit, Azienda USL-Maggiore Hospital, Largo Nigrisoli 3, Bologna, Italy
| | - Mauro Silingardi
- Internal Medicine 'A' Unit, Maggiore Hospital, Local Health Unit of Bologna, Bologna, Italy
| | - Dario de Biase
- Department of Pharmacy & Biotechnology, Molecular Pathology Unit, University of Bologna, Bologna, Italy
| | - Eli Avisar
- Division of Surgical Oncology, Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Picado O, Khazeni K, Allen C, Yakoub D, Avisar E, Kesmodel SB. Extent of regional lymph node surgery and impact on outcomes in patients with early-stage breast cancer and limited axillary disease undergoing mastectomy. Breast Cancer Res Treat 2018; 171:461-469. [DOI: 10.1007/s10549-018-4840-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 05/28/2018] [Indexed: 11/24/2022]
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Ozmen T, Lazaro M, Vinyard A, Avisar E. Abstract P3-01-17: Evaluation of “Systematic sonographic axillary staging” on clinically node positive breast cancer patients becoming clinically node negative after neoadjuvant chemotherapy. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p3-01-17] [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
Purpose
Accumulating evidence supports usage of sentinel lymph node biopsy (SLNB) for clinically node positive (cN+) breast cancer (BC) patients, who become clinically node negative (ycN-) after neoadjuvant chemotherapy (NAC). How to reassess the axilla after NAC is a challenging issue. In our institution, Systematic Sonographic Axillary Staging (SSAS) is currently being tested in this group of patients. The aim of this study is to analyze the early results of this approach.
Method
During initial presentation, systematic sonographic axillary staging is done preferentially by the surgeon. Needle biopsy is then performed of suspicious node(s). At completion of NAC, the axilla is again systematically staged sonographically, taking into account the pre-treatment disease locations. Any residual morphologically suspicious node undergoes a repeat needle biopsy. According to the evidence of residual disease, the patient is either scheduled for axillary dissection (AD) or for SLNB.
We analyzed early results of SSAS on patients, who converted ycN (-) after NAC. Strictly adherence to SSAS protocol was the only inclusion criteria.
Results
A total of 25 patients were included. On repeat axillary USG after NAC, 11 patients had normal appearing and 14 patients had suspicious appearing lymph nodes (LNs). 14 patients underwent repeat biopsy; 9 patients had benign and 5 patients had malign pathology results. 20 patients underwent SLNB. Among 20 patients, 12 patients had negative SLNB and 8 patients had positive SLNB (4 patients had benign appearing LNs on repeat USG and 4 patients had benign biopsy results). 13 patients underwent AD (8 patients after positive SLNB and 5 patients directly after positive US-guided biopsy result). Among 8 patients with positive SLNB, 4 patients had macrometastatic disease (>2mm) on SLNB. In 3 of these 8 patients, no additional disease was found on AD, while 1 patient had only isolated tumor cell and 1 patient had only micrometastasis (Table 1).
Table 1. Size of the axillary involvement among patients with positive SLNB Sentinel Lymph Node BiopsyAxillary DissectionPatient #LN* (+) / Total LNs removedSize of involvement (mm)LN* (+) / Total LNs removedSize of involvement (mm)11/611/50.122/42.50/5-31/363/19141/210/3-51/11.50/21-62/21.53/32.573/357/10384/447/133* LN = lymph node
Conclusion
Systematic sonographic axillary staging is a reliable approach to cN (+) patients, who become ycN0 after NAC. This observation should be tested in a larger study.
Citation Format: Ozmen T, Lazaro M, Vinyard A, Avisar E. Evaluation of “Systematic sonographic axillary staging” on clinically node positive breast cancer patients becoming clinically node negative after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-17.
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Affiliation(s)
- T Ozmen
- University of Miami, Miller School of Medicine, Miami, FL
| | - M Lazaro
- University of Miami, Miller School of Medicine, Miami, FL
| | - A Vinyard
- University of Miami, Miller School of Medicine, Miami, FL
| | - E Avisar
- University of Miami, Miller School of Medicine, Miami, FL
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Ozmen T, Lazaro M, Zhou Y, Vinyard A, Avisar E. Abstract P5-22-05: Evaluation of simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p5-22-05] [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: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) has been proposed as an effective adjunct to ALND for the prevention of LE. This procedure however requires microsurgical techniques. The aim of this study was to assess the efficiency of Simplified-LYMPHA (SLYMPHA) in preventing LE in a prospective cohort of patients.
Methods: All patients, undergoing ALND with or without SLYMPHA between January 2014 and December 2016 were included in the study. SLYMPHA is a slightly modified and simplified version of LYMPHA. It is performed by the operating surgeon performing the ALND. One or more lymphatic channels identified by reverse arm mapping are inserted using a sleeve technique into the cut end of a neighboring vein. During follow-up visits, tape-measuring limb circumference method was used to detect clinical LE. Demographic, clinical, surgical and pathologic factors were recorded. The incidence of clinical LE was compared between ALND with and without SLYMPHA. Univariate and multivariate analysis were used to assess the role of other factors in the appearance of clinical LE.
Results: 406 patients were included in the study. SLYMPHA procedure was attempted in 81 patients and was completed successfully in 90% of patients. Early complication rates were similar between patients who underwent SLYMPHA and who did not (4% vs. 4.13%; p = 0.948). Median follow-up time was 15±13.73 [1-32] months. Patients, who underwent SLYMPHA, had a significantly lower rate of clinical LE both in univariate and multivariate analysis (3% vs 19%; p = 0.001; OR 0.12 [0.03-0.5]). Excising > 22 lymph nodes and a co-diagnosis of diabetes were also correlated with higher clinical LE rates on univariate analysis, but only excising > 22 lymph nodes remained to be significant on multivariate analysis.
Conclusions: SLYMPHA is a safe and relatively simple method, which decreases incidence of clinical LE dramatically. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.
Citation Format: Ozmen T, Lazaro M, Zhou Y, Vinyard A, Avisar E. Evaluation of simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-05.
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Affiliation(s)
- T Ozmen
- University of Miami, Miller School of Medicine, Miami, FL
| | - M Lazaro
- University of Miami, Miller School of Medicine, Miami, FL
| | - Y Zhou
- University of Miami, Miller School of Medicine, Miami, FL
| | - A Vinyard
- University of Miami, Miller School of Medicine, Miami, FL
| | - E Avisar
- University of Miami, Miller School of Medicine, Miami, FL
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Chang JM, Kosiorek HE, Dueck AC, Leong SPL, Vetto JT, White RL, Avisar E, Sondak VK, Messina JL, Zager JS, Garberoglio C, Kashani-Sabet M, Pockaj BA. Stratifying SLN incidence in intermediate thickness melanoma patients. Am J Surg 2017; 215:699-706. [PMID: 29502857 DOI: 10.1016/j.amjsurg.2017.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/08/2017] [Accepted: 12/11/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Guidelines for melanoma recommend sentinel lymph node biopsy (SLNB) in patients with melanomas ≥1 mm thickness. Recent single institution studies have found tumors <1.5 mm a low-risk group for positive SLNB. METHODS A retrospective review of the Sentinel Lymph Node Working Group multicenter database identified patients with intermediate thickness melanoma (1.01-4.00 mm) who had SLNB, and assessed predictors for positive SLNB. RESULTS 3460 patients were analyzed, 584 (17%) had a positive SLNB. Univariate factors associated with a positive SLNB included age <60 (p < .001), tumor on the trunk/lower extremity (p < .001), Breslow depth ≥2 mm (p < .001), ulceration (p < .001), mitotic rate ≥1/mm2 (p = .01), and microsatellitosis (p < .001). Multivariate analysis revealed age, location, and Breslow depth as significant predictors. Patients ≥75 with lesions 1.01-1.49 mm on the head/neck/upper extremity and 1.5-1.99 mm without high-risk features had <5% risk of SLN positivity. CONCLUSIONS Intermediate thickness melanoma has significant heterogeneity of SLNB positivity. Low-risk subgroups can be found among older patients in the absence of high-risk features.
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Affiliation(s)
- James M Chang
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - Amylou C Dueck
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - John T Vetto
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Richard L White
- Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Eli Avisar
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vernon K Sondak
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Jane L Messina
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Carlos Garberoglio
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
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Ozmen T, Lazaro M, Zhou Y, Vinyard A, Avisar E. Evaluation of simplified lymphatic microsurgical preventing healing approach (SLYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.563] [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
563 Background: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) has been proposed as an effective adjunct to ALND for the prevention of LE. This procedure however requires microsurgical techniques. The aim of this study was to assess the efficiency of Simplified-LYMPHA (SLYMPHA) in preventing LE in a prospective cohort of patients. Methods: All patients, undergoing ALND with or without SLYMPHA between January 2014 and December 2016 were included in the study. SLYMPHA is a slightly modified and simplified version of LYMPHA. It is performed by the operating surgeon performing the ALND. One or more lymphatic channels identified by reverse arm mapping are inserted using a sleeve technique into the cut end of a neighboring vein. During follow-up visits, tape-measuring limb circumference method was used to detect clinical LE. Demographic, clinical, surgical and pathologic factors were recorded. The incidence of clinical LE was compared between ALND with and without SLYMPHA. Univariate and multivariate analysis were used to assess the role of other factors in the appearance of clinical LE. Results: 406 patients were included in the study. SLYMPHA procedure was attempted in 81 patients and was completed successfully in 90% of patients. Early complication rates were similar between patients who underwent SLYMPHA and who did not (4% vs. 4.13%; p = 0.948). Median follow-up time was 15±13.73 [1-32] months. Patients, who underwent SLYMPHA, had a significantly lower rate of clinical LE both in univariate and multivariate analysis (3% vs 19%; p = 0.001; OR 0.12 [0.03-0.5]). Excising > 22 lymph nodes and a co-diagnosis of diabetes were also correlated with higher clinical LE rates on univariate analysis, but only excising > 22 lymph nodes remained to be significant on multivariate analysis. Conclusions: SLYMPHA is a safe and relatively simple method, which decreases incidence of clinical LE dramatically. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.
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Affiliation(s)
- Tolga Ozmen
- University of Miami, Department of Surgical Oncology, Miami, FL
| | - Mesa Lazaro
- University of Miami, Department of Surgical Oncology, Miami, FL
| | - Yan Zhou
- University of Miami, Department of Surgical Oncology, Miami, FL
| | - Alicia Vinyard
- University of Miami, Department of Surgical Oncology, Miami, FL
| | - Eli Avisar
- University of Miami Miller School of Medicine, Miami, FL
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Abstract
The role of surgery in breast cancer treatment and axillary staging is changing. It is not very far from today, when axillary dissection was the standard treatment and staging procedure for all stages of breast cancer. Today, we are on the edge of omitting axillary dissection even in patients with the axillary disease. In this review, we walked through the changes in axillary management throughout the past hundred years.
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Affiliation(s)
- Tolga Ozmen
- Surgical Oncology, University of Miami, Miller School of Medicine
| | | | - Eli Avisar
- Department of Surgery, University of Miami, Miller School of Medicine
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Schuitevoerder D, Leong SPL, Zager JS, White RL, Avisar E, Kosiorek H, Dueck A, Fortino J, Kashani-Sabet M, Hart K, Vetto JT. Is pelvic sentinel node biopsy necessary for lower extremity and trunk melanomas? Am J Surg 2017; 213:921-925. [PMID: 28411863 DOI: 10.1016/j.amjsurg.2017.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 12/17/2016] [Revised: 01/17/2017] [Accepted: 03/21/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There is currently no consensus regarding how to address pelvic sentinel lymph nodes (PSLNs) in melanoma. Thus, our objectives were to identify the incidence and clinical impact of PSLNs. METHODS Retrospective review of a prospectively collected multi-institutional melanoma database. RESULTS Of 2476 cases of lower extremity and trunk melanomas, 227 (9%) drained to PSLNs (181 to both PSLNs and superficial (inguinal or femoral) sentinel lymph nodes (SSLN) and 46 to PSLNs alone). Seventeen (7.5%) of 227 PSLN cases were positive for nodal metastasis, 8 of which drained to PSLNs only while 9 drained to both PSLNs and SSLNs. Complication rates between PSLN and SSLN biopsy were similar (15% vs. 14% respectively). In 181 cases with drainage to both SSLNs and PSLNs, PSLN biopsy upstaged one patient (0.6%), and completion dissection based on a positive PSLN did not upstage any. CONCLUSIONS PSLN biopsy is safe, however in the setting of negative SSLNs there is minimal clinical impact. We therefore recommend PSLN biopsy when the SSLNs are positive or when the tumor drains to PSLNs alone.
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Affiliation(s)
| | - Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Richard L White
- Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Eli Avisar
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heidi Kosiorek
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Amylou Dueck
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jeanine Fortino
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - Kyle Hart
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - John T Vetto
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
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Alazhri J, Saclarides C, Avisar E. A rare complication resulting in a rare disease: radiation-induced male breast cancer. BMJ Case Rep 2016; 2016:10.1136/bcr-2015-211874. [PMID: 27084898 DOI: 10.1136/bcr-2015-211874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The increase in survival after childhood radiation therapy for some blood malignancies has led to an increase in the diagnosis of radiation-induced secondary solid malignancies (SSM). We report a young man presenting with invasive breast cancer 19 years after receiving radiation therapy and bone marrow transplant for acute lymphocytic leukaemia in childhood. This latency period is longer than previously reported. Therefore, survivors of radiation-treated primary cancer should be closely monitored for SSM, including breast cancer, for the rest of their lives.
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Affiliation(s)
- Jamila Alazhri
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Constantine Saclarides
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Eli Avisar
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Ardalan B, Gombosh M, Franceschi D, Avisar E, Yakoub D, Ribeiro A, Garrido J, Merchant N, Livingstone AS. Neoadjuvant and adjuvant, floxuridine, leucovorin, oxaliplatin, and docetaxel (FLOD) in patients with locally advanced operable gastroesophageal adenocarcinoma: A phase II study with pathologic responses and long term follow-up. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.124] [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
124 Background: A complete pathological response to neoadjuvant chemotherapy without the use of radiation has infrequently been reported in operable chemo-naïve stage III gastro esophageal adenocarcinoma patients. Methods: Twenty-nine patients were enrolled in this study. Neoadjuvant therapy consisted of Floxuridine, Leucovorin, Oxaliplatin, and Docetaxel and was administered in 2, four week cycles. Chemotherapy consisted on day one and day fifteen; Oxaliplatin, Docetaxel, FUDR, and Leucovorin. The latter two drugs were given concurrently over twenty four hours. On day eight, chemotherapy consisted of Docetaxel, FUDR, and Leucovorin. Following therapy, patients underwent surgical resection. Those patients having residual disease were offered adjuvant chemotherapy. Patients having a complete pathological response were not offered any further therapy. Results: Twenty-four out of twenty-nine patients completed neoadjuvant therapy and underwent esophagectomy. Two were declared inoperable after treatment. Three patients died prior to surgery. The median follow-up of all patients is now sixty months. The median overall survival has not been reached at sixty months. Five yr actual OS is 51%. Clinical response to neoadjuvant therapy was seen in (72.4%) patients. Complete pathological response to neoadjuvant therapy was seen in (16.7%) who are disease free at sixty month follow-ups. Seven out of twenty-four patients achieved partial pathological response (29.1%) and received adjuvant chemotherapy. They are all alive (100%). Eight patients achieved less than partial pathological response and received adjuvant chemotherapy, four out of eight are alive at sixty months (50%). Grade three and four toxicities were seen in sixteen out of twenty nine patients during neoadjuvant therapy. Grade three and four toxicities were seen in six out of fourteen patients during adjuvant therapy. Conclusions: Our chemotherapy regimen of Floxuridine, Leucovorin, Oxaliplatin and Docetaxel (FLOD) has resulted in long term survival in patients with adenocarcinoma of the esophagus. Clinical trial information: NCT00448760.
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Affiliation(s)
| | | | - Dido Franceschi
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Eli Avisar
- University of Miami Miller School of Medicine, Miami, FL
| | - Danny Yakoub
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | | | | | - Nipun Merchant
- University of Miami Miller School of Medicine, Miami, FL
| | - Alan S Livingstone
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
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Al-Azhri J, Koru-Sengul T, Miao F, Saclarides C, Byrne MM, Avisar E. Predictors of Surgery Types after Neoadjuvant Therapy for Advanced Stage Breast Cancer: Analysis from Florida Population-Based Cancer Registry (1996-2009). Breast Cancer (Auckl) 2015; 9:99-108. [PMID: 26691964 PMCID: PMC4677798 DOI: 10.4137/bcbcr.s31503] [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] [Received: 07/09/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the established guidelines for breast cancer treatment, there is still variability in surgical treatment after neoadjuvant therapy (NT) for women with large breast tumors. Our objective was to identify predictors of the type of surgical treatment: mastectomy versus breast-conserving surgery (BCS) in women with T3/T4 breast cancer who received NT. METHODS Population-based Florida Cancer Data System Registry, Florida’s Agency for Health Care Administration, and US census from 1996 to 2009 were linked for women diagnosed with T3/T4 breast cancer and received NT followed by either BCS or mastectomy. Analysis of multiple variables, such as sociodemographic characteristics (race, ethnicity, socioeconomic status, age, marital status, and urban/rural residency), tumor’s characteristics (estrogen/progesterone receptor status, histology, grade, SEER stage, and regional nodes positivity), treatment facilities (hospital volume and teaching status), patients’ comorbidities, and type of NT, was performed. RESULTS Of 1,056 patients treated with NT for T3/T4 breast cancer, 107 (10%) had BCS and 949 (90%) had mastectomy. After adjusting with extensive covariables, Hispanic patients (adjusted odds ratio (aOR) = [3.50], 95% confidence interval (CI): 1.38–8.84, P = 0.008) were more likely to have mastectomy than BCS. Compared to localized SEER stage, regional stage with direct extension (aOR = [3.24], 95% CI: 1.60–6.54, P = 0.001), regional stage with direct extension and nodes (aOR = [4.35], 95% CI: 1.72–11.03, P = 0.002), and distant stage (aOR = [4.44], 95% CI: 1.81–10.88, P = 0.001) were significantly more likely to have mastectomy than BCS. Compared to patients who received both chemotherapy and hormonal therapy, patients who received hormonal NT only (aOR = [0.29], 95% CI: 0.12–0.68, P = 0.004) were less likely to receive mastectomy. CONCLUSION Our study suggests that Hispanic ethnicity, advanced SEER stage, and type of NT are significant predictors of receiving mastectomy after NT.
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Affiliation(s)
- Jamila Al-Azhri
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. ; Department of Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Feng Miao
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Constantine Saclarides
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Margaret M Byrne
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Spector NL, Robertson FC, Bacus S, Blackwell K, Smith DA, Glenn K, Cartee L, Harris J, Kimbrough CL, Gittelman M, Avisar E, Beitsch P, Koch KM. Lapatinib Plasma and Tumor Concentrations and Effects on HER Receptor Phosphorylation in Tumor. PLoS One 2015; 10:e0142845. [PMID: 26571496 PMCID: PMC4646457 DOI: 10.1371/journal.pone.0142845] [Citation(s) in RCA: 17] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 10/26/2015] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The paradigm shift in cancer treatment from cytotoxic drugs to tumor targeted therapies poses new challenges, including optimization of dose and schedule based on a biologically effective dose, rather than the historical maximum tolerated dose. Optimal dosing is currently determined using concentrations of tyrosine kinase inhibitors in plasma as a surrogate for tumor concentrations. To examine this plasma-tumor relationship, we explored the association between lapatinib levels in tumor and plasma in mice and humans, and those effects on phosphorylation of human epidermal growth factor receptors (HER) in human tumors. EXPERIMENTAL DESIGN Mice bearing BT474 HER2+ human breast cancer xenografts were dosed once or twice daily (BID) with lapatinib. Drug concentrations were measured in blood, tumor, liver, and kidney. In a randomized phase I clinical trial, 28 treatment-naïve female patients with early stage HER2+ breast cancer received lapatinib 1000 or 1500 mg once daily (QD) or 500 mg BID before evaluating steady-state lapatinib levels in plasma and tumor. RESULTS In mice, lapatinib levels were 4-fold higher in tumor than blood with a 4-fold longer half-life. Tumor concentrations exceeded the in vitro IC90 (~ 900 nM or 500 ng/mL) for inhibition of HER2 phosphorylation throughout the 12-hour dosing interval. In patients, tumor levels were 6- and 10-fold higher with QD and BID dosing, respectively, compared to plasma trough levels. The relationship between tumor and plasma concentration was complex, indicating multiple determinants. HER receptor phosphorylation varied depending upon lapatinib tumor concentrations, suggestive of changes in the repertoire of HER homo- and heterodimers. CONCLUSION Plasma lapatinib concentrations underestimated tumor drug levels, suggesting that optimal dosing should be focused on the site of action to avoid to inappropriate dose escalation. Larger clinical trials are required to determine optimal dose and schedule to achieve tumor concentrations that maximally inhibit HER receptors. TRIAL REGISTRATION CLINICAL TRIAL REGISTRATION NCT00359190.
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Affiliation(s)
- Neil L. Spector
- Department of Medicine, Duke Cancer Center, Duke University Medical Center, Durham, North Carolina, United States of America
- * E-mail:
| | - Faith C. Robertson
- Department of Medicine, Duke Cancer Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Sarah Bacus
- Targeted Molecular Diagnostics/Quintiles, Westmont, Illinois, United States of America
| | - Kimberly Blackwell
- Department of Medicine, Duke Cancer Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Deborah A. Smith
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Kelli Glenn
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Leanne Cartee
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Jennifer Harris
- Pivot Oncology Consulting, Durham, North Carolina, United States of America
| | | | - Mark Gittelman
- Breast Cancer Specialists, Allentown, Pennsylvania, United States of America
| | - Eli Avisar
- Department of Surgery, University of Miami School of Medicine, Miami, Florida, United States of America
| | - Peter Beitsch
- Dallas Surgical Group, Dallas, Texas, United States of America
| | - Kevin M. Koch
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
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Gadde R, Tamariz L, Hanna M, Avisar E, Livingstone A, Franceschi D, Yakoub D. Metastatic gastric cancer (MGC) patients: Can we improve survival by metastasectomy? A systematic review and meta-analysis. J Surg Oncol 2015; 112:38-45. [PMID: 26074130 DOI: 10.1002/jso.23945] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 12/13/2014] [Accepted: 05/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognosis with current management strategies continues to be dismal in metastatic gastric cancer (MGC) patients. We aimed to evaluate the role of metastasectomy in improving survival. METHODS A comprehensive search of MEDLINE, EMBASE, SCOPUS, and Cochrane central databases (1965 to present) was performed. All comparative studies measuring survival in MGC patients undergoing metastasectomy versus other therapies were included. Pooled risk ratios with corresponding 95% confidence intervals (CI) were calculated for survival at 1, 3, and 5 years. RESULTS Sixteen studies with 1712 patients (378 patients in metastasectomy, 1334 patients in other therapies) were eligible for the final meta-analysis. Median age was 63 years. For patients undergoing metastasectomy, a significant survival advantage was observed at 1 year (RR 0.52, CI 0.43-0.62), 3 year (RR 0.75 CI 0.67-0.83), and 5 year (RR 0.82, CI 0.74-0.91); mean increased difference in survival conferred by metastasectomy averaged between 9.3 and 15.7 months; P < 0.001 for all results. Age, ECOG status, and STROBE score did not contribute to differences in survival. CONCLUSION Metastasectomy is associated with increased survival at 1, 3, and 5 years in MGC patients. Large prospective randomized controlled trials are critically needed to evaluate the role of metastasectomy in MGC.
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Affiliation(s)
- Rahul Gadde
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida.,Department of Internal Medicine, University of Miami-Miller School of Medicine, Miami, Florida
| | - Leonardo Tamariz
- Department of Internal Medicine, University of Miami-Miller School of Medicine, Miami, Florida
| | - Mena Hanna
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida
| | - Eli Avisar
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami-Miller School of Medicine, Miami, Florida
| | - Alan Livingstone
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami-Miller School of Medicine, Miami, Florida
| | - Dido Franceschi
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami-Miller School of Medicine, Miami, Florida
| | - Danny Yakoub
- Division of Surgical Oncology at Department of Surgery, University of Miami-Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami-Miller School of Medicine, Miami, Florida
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Gudenkauf LM, Antoni MH, Stagl JM, Lechner SC, Jutagir DR, Bouchard LC, Blomberg BB, Glück S, Derhagopian RP, Giron GL, Avisar E, Torres-Salichs MA, Carver CS. Brief cognitive-behavioral and relaxation training interventions for breast cancer: A randomized controlled trial. J Consult Clin Psychol 2015; 83:677-688. [PMID: 25939017 DOI: 10.1037/ccp0000020] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Women with breast cancer (BCa) report elevated distress postsurgery. Group-based cognitive-behavioral stress management (CBSM) following surgery improves psychological adaptation, though its key mechanisms remain speculative. This randomized controlled dismantling trial compared 2 interventions featuring elements thought to drive CBSM effects: a 5-week cognitive-behavioral training (CBT) and 5-week relaxation training (RT) versus a 5-week health education (HE) control group. METHOD Women with stage 0-III BCa (N = 183) were randomized to CBT, RT, or HE condition 2-10 weeks postsurgery. Psychosocial measures were collected at baseline (T1) and postintervention (T2). Repeated-measures analyses of variance (ANOVAs) tested whether CBT and RT treatments improved primary measures of psychological adaptation and secondary measures of stress management resource perceptions from pre- to postintervention relative to HE. RESULTS Both CBT and RT groups reported reduced depressive affect. The CBT group reported improved emotional well-being/quality of life and less cancer-specific thought intrusions. The RT group reported improvements on illness-related social disruption. Regarding stress management resources, the CBT group reported increased reliability of social support networks, while the RT group reported increased confidence in relaxation skills. Psychological adaptation and stress management resource constructs were unchanged in the HE control group. CONCLUSIONS Nonmetastatic breast cancer patients participating in 2 forms of brief, 5-week group-based stress management intervention after surgery showed improvements in psychological adaptation and stress management resources compared with an attention-matched control group. Findings provide preliminary support suggesting that using brief group-based stress management interventions may promote adaptation among nonmetastatic breast cancer patients.
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Affiliation(s)
| | | | | | - Suzanne C Lechner
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine
| | | | | | - Bonnie B Blomberg
- Sylvester Cancer Center, University of Miami Miller School of Medicine
| | | | | | | | - Eli Avisar
- Sylvester Cancer Center, University of Miami Miller School of Medicine
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Cox CE, Blumencranz P, Saez R, Wesolowski R, Dooley W, Stork-Sloots L, de Snoo F, Untch S, Avisar E. Abstract OT3-2-02: MINT I: Multi-Institutional Neo-adjuvant Therapy, MammaPrint Project I. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-ot3-2-02] [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:
Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomic assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. BRCRT2013].
Trial design:
MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict response to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.
Eligibility:
The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.
Objectives:
The objectives of the study are to:
1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.
2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.
3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.
4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.
5. Compare BluePrint with IHC-based subtype classification.
Statistical methods:
Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.
Accrual:
A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2014), 103 patients have been enrolled.
Citation Format: Charles E Cox, Peter Blumencranz, Ruben Saez, Robert Wesolowski, William Dooley, Lisette Stork-Sloots, Femke de Snoo, Sarah Untch, Eli Avisar. MINT I: Multi-Institutional Neo-adjuvant Therapy, MammaPrint Project I [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-2-02.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eli Avisar
- 7Miller School of Medicine, University of Miami
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Avisar E, Libson S, Perez E. Abstract P2-01-28: Prognosis of metastatic internal mammary sentinel nodes (IMSN) in breast cancer. Cancer Res 2015. [DOI: 10.1158/1538-7445.sabcs14-p2-01-28] [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
Introduction:
The presence of positive internal mammary nodes has historically been associated with a significant worse prognosis. Recent studies have also demonstrated a worse prognosis associated with drainage to the internal mammary nodes. Intense search for those nodes, biopsy, appropriate staging and modern treatment for positive IMSN might improve outcome. We sought to study the prognosis of pathologically positive IMSN at our institution.
Methods:
A retrospective analysis of a prospectively collected database including all breast cancer patients identified with an IMSN that was biopsied between 2005 and 2012 was performed. Demographics, histologic markers, patterns of recurrence as well as survival data were collected. Univariate and multivariate analysis were performed.
Results:
Thirteen of 82 patients with a biopsied IMSN were metastatic (16%). In 8 of those (62%), the biopsy resulted in a change in staging. In all cases of positive IMSN additional radiation to the internal mammary chain was added. Eighteen percent (18%) of positive nodes did not show drainage to the internal mammary basin during Lymphoscintigraphy. There was no statistical difference in regional and distant recurrences between the patients with positive IMSN and those with negative IMSN. Furthermore there was no difference in disease specific survival.
Conclusions:
Intense search for IMSN presence and biopsy of those nodes is associated with changes in staging and treatment for metastatic IMSN. In our study, pathologically positive IMSN were associated with a non- inferior prognosis than negative IMSN.
Citation Format: Eli Avisar, Shai Libson, Eduardo Perez. Prognosis of metastatic internal mammary sentinel nodes (IMSN) in breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-28.
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Affiliation(s)
- Eli Avisar
- 1University of Miami Miller School of Medicine
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Yakoub D, Avisar E, Koru-Sengul T, Miao F, Tannenbaum SL, Byrne MM, Moffat F, Livingstone A, Franceschi D. Factors associated with contralateral preventive mastectomy. Breast Cancer (Dove Med Press) 2015; 7:1-8. [PMID: 25609997 PMCID: PMC4293214 DOI: 10.2147/bctt.s72737] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Contralateral prophylactic mastectomy (CPM) is an option for women who wish to reduce their risk of breast cancer or its local recurrence. There is limited data on demographic differences among patients who choose to undergo this procedure. METHODS The population-based Florida cancer registry, Florida's Agency for Health Care Administration data, and US census data were linked and queried for patients diagnosed with invasive breast cancer from 1996 to 2009. The main outcome variable was the rate of CPM. Primary predictors were race, ethnicity, socioeconomic status (SES), marital status and insurance status. RESULTS Our population was 91.1% White and 7.5% Black; 89.1% non-Hispanic and 10.9% Hispanic. Out of 21,608 patients with a single unilateral invasive breast cancer lesion, 837 (3.9%) underwent CPM. Significantly more White than Black (3.9% vs 2.8%; P<0.001) and more Hispanic than non-Hispanic (4.5% vs 3.8%; P=0.0909) underwent CPM. Those in the highest SES category had higher rates of CPM compared to the lowest SES category (5.3% vs 2.9%; P<0.001). In multivariate analyses, Blacks compared to Whites (OR =0.59, 95% CI =0.42-0.83, P=0.002) and uninsured patients compared to privately insured (OR =0.60, 95% CI =0.36-0.98, P=0.043) had significantly less CPM. CONCLUSION CPM rates were significantly different among patients of different race, socio-economic class, and insurance coverage. This observation is not accounted for by population distribution, incidence or disease stage. More in-depth study of the causes of these disparities in health care choice and delivery is critically needed.
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Affiliation(s)
- Danny Yakoub
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Tulay Koru-Sengul
- Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA ; Department of Public Health Sciences, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Feng Miao
- Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Stacey L Tannenbaum
- Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Margaret M Byrne
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA ; Department of Public Health Sciences, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Frederick Moffat
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Alan Livingstone
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology at Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL, USA ; Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, FL, USA
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Libson S, Koshenkov V, Rodgers S, Hurley J, Avisar E. Breast conservation after neoadjuvant therapy for tumors ≥5 cm: A prospective cohort study. International Journal of Surgery Open 2015. [DOI: 10.1016/j.ijso.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Yakoub D, Avisar E, Koru-Sengul T, Miao F, Tannenbaum SL, Byrne MM, Moffat FL, Livingstone AS, Franceschi D. Factors associated with increasing rates of contralateral prophylactic mastectomy. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.26_suppl.57] [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
57 Background: Contralateral prophylactic mastectomy (CPM) is an option increasingly used by women who wish to reduce their risk of breast cancer or its local recurrence. There is limited data on demographic differences among patients who choose to undergo this procedure. Methods: The population-based Florida cancer registry, Florida’s Agency for Health Care Administration (AHCA) data, and U.S. census data were linked and queried for patients diagnosed with invasive breast cancer from 1996 to 2009. The main outcome variable was the rate of CPM in those with a single unilateral cancer diagnosis. Primary predictors were race, ethnicity, socioeconomic status (SES), marital status, and insurance status. Results: The rates of CPM rose from 2% in 1996 to 4.8% in 2006 up to 8% in 2009. The population studied was 91.1% white and 7.5% black; 89.1% non-Hispanic and 10.9% Hispanic. Out of 21,608 included patients, 837 (3.9%) underwent CPM. Significantly more white than black (3.9 versus 2.8%; p < 0.001) and more Hispanic than non-Hispanic (4.5 versus 3.8%; p = 0.0909) underwent CPM. Those in the highest SES category had higher rates of CPM compared to the lowest SES category (5.3 versus 2.9%; p < 0.001). In multivariate analyses, Blacks and uninsured patients had significantly less CPM compared to whites and private patients (OR = 0.59, 95% CI 0.42- 0.83, p = 0.002) and (OR = 0.60, 95% CI 0.36- 0.98, p = 0.043), respectively. Conclusions: CPM rates are significantly increasing; these rates were significantly different among patients of different race, socioeconomic class, and insurance coverage. This observation is not accounted for by population distribution, incidence or disease stage. More in-depth study of the causes of this increase and the disparities in healthcare delivery is critically needed.
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Affiliation(s)
- Danny Yakoub
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Eli Avisar
- University of Miami, Miller School of Medicine, Miami, FL
| | - Tulay Koru-Sengul
- Department of Epidemiology and Public Health and Sylvester Comprehensive Cancer Center of University of Miami Miller School of Medicine, Miami, FL
| | - Feng Miao
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
| | | | | | | | - Alan S Livingstone
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
| | - Dido Franceschi
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
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Abstract
103 Background: The presence of positive internal mammary nodes has historically been associated with a significant worse prognosis. Recent studies have also demonstrated a worse prognosis associated with drainage to the internal mammary nodes. Intense search for those nodes, biopsy, appropriate staging and modern treatment for positive IMSN might improve outcome. We sought to study the prognosis of pathologically positive IMSN at our institution. Methods: A retrospective analysis of a prospectively collected database including all breast cancer patients identified with an IMSN that was biopsied between 2005 and 2012 was performed. Demographics, histologic markers, patterns of recurrence as well as survival data were collected. Univariate and multivariate analysis were performed. Results: Thirteen of 82 patients with a biopsied IMSN were metastatic (16%). In 8 of those (62%), the biopsy resulted in a change in staging. In all cases of positive IMSN additional radiation to the internal mammary chain was added. Eighteen percent (18%) of positive nodes did not show drainage to the internal mammary basin during Lymphoscintigraphy. There was no statistical difference in regional and distant recurrences between the patients with positive IMSN and those with negative IMSN. Furthermore there was no difference in disease specific survival. Conclusions: Intense search for IMSN presence and biopsy of those nodes is associated with changes in staging and treatment for metastatic IMSN. In our study, pathologically positive IMSN were associated with a non- inferior prognosis than negative IMSN.
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Affiliation(s)
- Eli Avisar
- University of Miami, Miller School of Medicine, Miami, FL
| | | | - Eduardo Perez
- Miller School of Medicine, University of Miami, Miami, FL
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48
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Cox CE, Blumencranz PW, Saez RA, Wesolowski R, Dooley WC, Stork L, De Snoo F, Gibson J, Avisar E. MINT: Multi-institutional, neoadjuvant therapy MammaPrint project. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.tps1137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Charles E. Cox
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | | | | | | | | | | | | | - Eli Avisar
- University of Miami School of Medicine, Miami, FL
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Alazhri J, Koru-Sengul T, Miao F, Tannenbaum SL, Byrne MM, Alghamdi H, Franceschi D, Avisar E. Predictors of surgery types after neoadjuvant therapy for advanced stage breast cancer. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Tulay Koru-Sengul
- Department of Epidemiology and Public Health and Sylvester Comprehensive Cancer Center of University of Miami Miller School of Medicine, Miami, FL
| | - Feng Miao
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
| | | | | | | | - Dido Franceschi
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL
| | - Eli Avisar
- University of Miami School of Medicine, Miami, FL
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Cox CE, Blumencranz P, Saez R, Wesolowski R, Stork-Sloots L, Gibson J, de Snoo F, Avisar E. Abstract OT1-2-01: MINT I: Multi-institutional neo-adjuvant therapy, MammaPrint project I. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-ot1-2-01] [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: Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomic assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. ASCO 2012].
Trial design: MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict response to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.
Eligibility: The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.
Objectives: The objectives of the study are to:
1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.
2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.
3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.
4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.
5. Compare BluePrint with IHC-based subtype classification.
Statistical methods: Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.
Accrual: A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2013), 57 patients have been enrolled.
Clinical trial registry number: NCT01501487.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-2-01.
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Affiliation(s)
- CE Cox
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - P Blumencranz
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - R Saez
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - R Wesolowski
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - L Stork-Sloots
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - J Gibson
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - F de Snoo
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
| | - E Avisar
- University of South Florida, Tampa, FL; Morton Plant Hospital, Clearwater, FL; Plano Cancer Institute, Plano, TX; Ohio State University, Columbus, OH; Agendia NV, Amsterdam, Netherlands; Agendia Inc, Irvine, CA; Miller School of Medicine, University of Miami, Miami, FL
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