Non-surgical ablation for breast cancer: an emerging therapeutic option

Non-surgical ablation is emerging as an alternative local therapy option for patients with early-stage breast cancer and encompasses two main types of percutaneous therapeutic procedures: radiofrequency ablation and cryoablation. Both techniques involve obliteration of a spherical lesion and feasibility studies have shown that complete tumour ablation is achievable with good or excellent cosmetic results. Although few clinical studies have directly compared non-surgical ablation with conventional surgical resection, observational studies indicate that clinical outcomes are favourable with acceptable rates of local control and no detriment to long-term survival. There remain outstanding issues with these percutaneous ablative techniques that require resolution before they could be incorporated into routine clinical practice. Hence, a consensus meeting was convened to discuss the challenges of non-surgical ablation and clarify indications for its use alongside clinical management pathways. In this Policy Review we will address some of the broader biological aspects of non-surgical ablation, including immune-modulatory effects and potential novel applications for the future.

Perioperative nursing care speed up recover of a male patient after bilateral endoscopic mastectomy: a case report

Background

Gynecomastia (GYN) is mainly caused by the benign proliferation of mammary glands and adipose tissue. Currently, up to 38% of adult males have GYN. GYN can be caused by systemic diseases, obesity, endocrine disorders (such as liver cirrhosis, which impairs estrogen inactivation), malignant tumors, and medications. Surgical intervention is required after 12 months pharmacological treatment of GYN was no response who have endocrine disorder, or due to psychological and physiological factors, young patients have a higher demand for surgical intervention. Recent advances in minimally invasive endoscopic surgery, with the advantage of rapid rehabilitation, have markedly improved the surgical management of GYN.

Case Description

In November 2021, we admitted a young patient with bilateral GYN whose problem began several years prior and for which he sought surgical intervention. After comprehensive evaluation and psychological consultation, he underwent surgical treatment. The present case report summarizes our experience in nursing this patient.

Conclusions

Perioperative nursing care is essential in the management of patients undergoing endoscopic surgical treatment for GYN. The nursing team must be knowledgeable about the procedure, assess and manage the patient's pain, monitor vital signs, prevent infections, and provide emotional support to the patient. With proper nursing care, patients can recover smoothly and quickly after endoscopic surgical treatment of GYN.

Oncoplastic and reconstructive breast surgery

This article provides an overview of the principles and techniques of oncoplastic and reconstructive breast surgery for patients with early-stage breast cancer. Oncoplastic breast surgery (OPBS) with partial breast reconstruction is a natural evolution in the application of breast conserving surgery and permits wide surgical resection of tumours that might otherwise mandate mastectomy and whole breast reconstruction. These reconstructive techniques must be optimally selected and integrated with ablative breast surgery together with non-surgical treatments such as radiotherapy and chemotherapy that may be variably sequenced with each other. A multidisciplinary approach with shared decision-making is essential to ensure optimal clinical and patient-reported outcomes that address oncological, aesthetic, functional and psychosocial domains. Future practice of OPBS must incorporate routine audit and comprehensive evaluation of outcomes.

The role of irradiation in the management of the axilla in early breast cancer patients

The need for axillary radiotherapy in patients with invasive breast cancer (IBC) has been a topic of great debate in the last decade. Management of the axilla has evolved significantly over the past four decades with a trend towards de-escalation of surgical interventions and the aim of reducing morbidity and enhancing QOL without compromising long-term oncology outcomes. This review article will address the role of axillary irradiation with a focus on the omission of completion axillary lymph node dissection in selected patients with sentinel lymph node (SLN) positive early breast cancer (EBC) with reference to current guidelines based on evidence to date.

Abstract P6-05-44: REASONS FOR CHOOSING DELAYED RATHER THAN IMMEDIATE CONTRALATERAL PROPHYLACTIC MASTECTOMY IN PATIENTS WITH UNILATERAL BREAST CANCER

Background: Rates of contralateral prophylactic mastectomy (CPM) have more than doubled in the past decade amongst breast cancer patients irrespective of inherited genetic predisposition related to high penetrance genes. Increasing numbers of women with unilateral breast cancer are opting for removal of both the affected ipsilateral and unaffected contralateral ‘normal’ breast even when suitable for breast conserving surgery. Reasons for requesting CPM include prevention of recurrence, peace of mind and moving on after breast cancer. Some women seek CPM as a delayed procedure but factors influencing this are poorly understood. Methods: A retrospective analysis examined patients undergoing CPM as either an immediate or delayed procedure with or without breast reconstruction (BR) at a single tertiary referral centre between January 2009 and December 2019. A cross-sectional survey was undertaken that was compiled and based on validated questionnaires and responses to defined statements generated using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) with calculation of mean scores and standard deviation (SD). This questionnaire explored patient’s decision-making process in terms of timing of CPM and any BR and was supported by subjective free-text boxes to gauge qualitative and quantitative aspects of the patient-related decision-making process. Those patients who consented to participate were provided with access to an online questionnaire. Results: Amongst this cohort of 39 delayed CPM patients, there were 6 decliners and therefore questionnaires were issued to the remaining 33 patients. The response rate was 67% (22/33) and the most common reason for seeking delayed CPM was to allow completion of adjuvant treatment recommendations (including radiotherapy/chemotherapy) before surgery on the unaffected breast [mean score 2.91; SD 1.0]. This avoided risk of delay in commencement of adjuvant treatment consequent to potential complications of contralateral surgery (especially with BR). The second most important reason for choosing delayed CPM was unavailability of genetic test results at the time of therapeutic mastectomy [mean score 2.64; SD 1.4]. The third most common reason was a subsequent change in family history cancer history after their personal breast cancer diagnosis that often prompted genetic testing [mean score 2.55; SD 2.7]. Several patients cited a shorter recovery time as a strong reason for requesting delayed CPM. Conclusion: Factors determining delayed CPM are patient-driven and this accords with documented reasons for women seeking CPM in general. Patients tend to make decisions about CPM based on two main themes relating to either ‘fear’ of cancer or a desire to ‘take control’. Temporal factors are important in the context of a delayed procedure and relate to subsequent availability of genetic test results and changes in family history in relatives who were otherwise unaffected at the time of initial diagnosis. Completion of all cancer treatments prior to delayed CPM (with BR) can be advantageous when implant-based BR is planned at the time of an immediate CPM. Radiotherapy can increase capsular contracture rates and surgical complications can delay start of chemotherapy. CPM should be offered as a potentially delayed option with informed discussion of risks and benefits.

Citation Format: Chien Lin Soh, Samantha Muktar, Charles M Malata, John R Benson. REASONS FOR CHOOSING DELAYED RATHER THAN IMMEDIATE CONTRALATERAL PROPHYLACTIC MASTECTOMY IN PATIENTS WITH UNILATERAL BREAST CANCER. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-44.

Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre

INTRODUCTION

Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends.

METHODS

A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications.

RESULTS

A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001).

CONCLUSION

This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

Does pre-operative breast MRI have an impact on surgical outcomes in high-grade DCIS?

OBJECTIVES

High-grade DCIS (HG DCIS) is associated with upgrade to invasive disease but few studies evaluate the role of MRI in this subset of DCIS. This study compared surgical outcomes of females with HG DCIS on biopsy who had pre-operative MRI with those that proceeded directly to surgery.

METHODS

This single-centre retrospective, observational study identified patients with pure HG DCIS on pre-operative biopsy from the pathology database. Surgical outcomes, clinicopathological and radiological features were obtained for all patients.

RESULTS

From August 2015 to February 2020, 217 patients had HG DCIS on biopsy. Pre-operative MRI was performed in 40 (MRI group) and not in 88 (No MRI group) patients. Initial mastectomy was performed in 25/40 (63%) women in the MRI group and 20/88 (23%) women in the no MRI group (p < 0.0001). No difference was observed in re-operation rate between the two groups, 15% in MRI group vs 22% in No MRI group (p = 0.4749). Mean tumour size on histology was larger in mastectomy cases in the MRI group (73.4 mm, range 6-140 mm), than the total MRI group, (58.3 mm, range 0-140 mm) or no MRI group (30.7 mm, range 0-130 mm) (p < 0.0001).

CONCLUSIONS

Pre-operative MRI in HG DCIS is associated with higher mastectomy rates, possibly due to patient selection for MRI, as tumours on final histology were significantly larger. Fewer re-operations were observed in the MRI group although this was not significant.

ADVANCES IN KNOWLEDGE

Breast MRI performed pre-operatively in HG DCIS is associated with higher mastectomy rates and fewer re-operation rates.

O050 A ten-year review of methodological trends and outcomes in riskreducing mastectomy and associated reconstruction at a tertiary referral centre

Introduction

Risk-reducing mastectomy (RRM) is the removal of breast tissue to substantially decrease the risk of developing breast cancer in individuals with higher breast cancer susceptibility due to strong family history or genetic mutations. This retrospective study evaluates cases of RRM, and subsequent reconstruction performed at a tertiary referral centre over the last decade, with emphasis on mastectomy and reconstructive trends.

Methods

A retrospective review of all cases of RRM performed between January 2010 and January 2020, divided into two groups corresponding to the first half (group 1) and second half (group 2) of the decade was conducted. Data collected included demographics, genetic test results, family and personal history of breast cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and complications.

Results

A total of 167 patients (group 1=76, group 2=91) underwent RRM, with a significant increase in cases of RRM despite negative genetic test results (p=0.047). The proportion of nipple sparing techniques for RRM compared to more traditional skin-sparing techniques. Concomitantly, post-RRM reconstruction has progressively become solely implant-based, to coincide with a rise in ADM usage. This is consistent with national trends towards fewer complex autologous procedures.

Take-home message

Emergent trends in risk-reducing mastectomy and reconstructive techniques are occurring against a background of broadened indications for RRM and more frequent patient requests for RRM in the absence of any documented pathogenic gene mutation. As breast surgery continues to evolve, it is important to evaluate specific trends such as more conservative forms of mastectomy and novel techniques/devices for breast reconstruction to ensure optimal patient care and levels of satisfaction.

Role of early post-operative breast MRI: how helpful is it in deciding the next step for women who may have residual disease?

Objectives

Positive resection margins following breast conserving surgery are a risk factor for local disease recurrence. Subsequent management of patients is often not straightforward, with post-operative breast MRI increasingly used to aid decision-making. Interpretation of MRI after surgery can prove challenging due to local inflammatory enhancement. We reviewed our experience of post-operative breast MRIs to determine their ability to detect residual disease and to evaluate how they changed initial patient management from re-excision to an alternative.

Methods:

A search of breast MRIs performed from August 2014 to December 2019 was undertaken, to identify those performed post-operatively within 4 months of breast conserving surgery. Electronic patient records and imaging were evaluated to determine additional work-up, pathology and surgical outcomes.

Results:

Of the 2274 breast MRIs during the study period, 44 (2%) were performed post-operatively to evaluate 47 breasts. MRI was normal in 20 cases (43%), suspicious findings at surgical cavity only in 13 (28%), suspicious ipsilateral distant breast findings only in 6 (13%), and both cavity and distant findings in 7 cases (15%). Contralateral abnormalities were identified in 3 cases. Following MRI, mastectomy was performed in 11 cases, re-excision in 25, with 2 subsequent mastectomies, and multidisciplinary team accepted margins in 11 cases, 10 of whom underwent post-operative radiotherapy. MRI altered initial patient management from re-excision to an alternative in 25 cases (45%).

Conclusion:

Post-operative breast MRI, although potentially challenging to interpret, can prove useful in planning the next step in patient management, particularly in its ability to evaluate the whole breast.

Advances in knowledge

Post-operative breast MRI is increasingly requested at multidisciplinary team following breast conserving surgery with positive surgical margins on histology, however interpretation is challenging. The value of these studies lie in assessment of the distant breast rather than the surgical resection cavity and can alter patient management guiding the most appropriate next step for definitive treatment.

Extended endocrine therapy in early breast cancer: how long and who for?

Endocrine therapy for early stage breast cancer is currently in a state of flux with much uncertainty about choice of agents and duration of therapy. The standard treatment span of 5 years usually incorporates an aromatase inhibitor in the majority of postmenopausal patients. Hormonal therapy has a cytostatic action that provides a biological rationale for continuing treatment for more prolonged periods to reduce risk of late recurrence in estrogen receptor-positive disease. Several trials of extended endocrine therapy for periods varying from 7.5 to 10 years have shown mixed results for gains in disease-free survival. The challenge is to assimilate available data and apply clinical judgment to tailor therapies taking account of intrinsic risk of disease recurrence, patient preference, tolerability to date, and co-morbidities.

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

BACKGROUND

Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017.

METHODS

Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements.

RESULTS

The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22).

CONCLUSION

Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.

Genomic and Transcriptomic Landscape of Triple-Negative Breast Cancers: Subtypes and Treatment Strategies

We comprehensively analyzed clinical, genomic, and transcriptomic data of a cohort of 465 primary triple-negative breast cancer (TNBC). PIK3CA mutations and copy-number gains of chromosome 22q11 were more frequent in our Chinese cohort than in The Cancer Genome Atlas. We classified TNBCs into four transcriptome-based subtypes: (1) luminal androgen receptor (LAR), (2) immunomodulatory, (3) basal-like immune-suppressed, and (4) mesenchymal-like. Putative therapeutic targets or biomarkers were identified among each subtype. Importantly, the LAR subtype showed more ERBB2 somatic mutations, infrequent mutational signature 3 and frequent CDKN2A loss. The comprehensive profile of TNBCs provided here will serve as a reference to further advance the understanding and precision treatment of TNBC.

Abstract P3-03-07: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Benson JR, Gnanakumar S, Dumitru D, Provenzano E. Withdrawn [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 P3-03-07.

Tailoring breast cancer therapies to reduce mortality and improve quality of life: San Antonio Breast Cancer Symposium 2017 (part 2)

The 40th annual San Antonio Breast Cancer Symposium was convened in San Antonio, TX, USA on 5-9 December 2017. More than 7500 clinicians and scientists from around the world participated in the symposium which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, loco-regional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with part 1 focusing on dose-intense radiotherapy, perioperative endocrine therapy, duration of bisphosphonates, immunotherapy, ovarian function suppression and acupuncture. The second part of this report will discuss a range of topics related to de-escalation of loco-regional therapies, the significance of complete pathological response, older patients and CDK 4/6 inhibitors, circulating tumor cells and plasma DNA as a tumor marker.

Tailoring breast cancer therapies to reduce mortality and improve quality of life: San Antonio Breast Cancer Symposium 2017 (part 1)

The 40th annual San Antonio Breast Cancer Symposium was convened in San Antonio, TX, USA on 5-9 December 2017. More than 7500 clinicians and scientists from around the world participated in the symposium which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, loco-regional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with part 1 focusing on dose-intense radiotherapy, perioperative endocrine therapy, duration of bisphosphonates, immunotherapy, ovarian function suppression and acupuncture. The second part of this report will discuss a range of topics related to de-escalation of loco-regional therapies, the significance of complete pathological response, older patients and CDK 4/6 inhibitors, circulating tumor cells and plasma DNA as a tumor marker.

Hypothesis: can the abscopal effect explain the impact of adjuvant radiotherapy on breast cancer mortality?

Radiotherapy is an integral component of loco-regional therapy for breast cancer. Randomized controlled trials indicate that increasing the extent of extirpative surgery primarily reduces the risk of local recurrences, while the addition of radiotherapy to surgery can also reduce the risk of distant recurrences, thereby lowering breast cancer-specific mortality. This may suggest an “abscopal” effect beyond the immediate zone of loco-regional irradiation that favorably perturbs the natural history of distant micrometastases. Immunological phenomena such as “immunogenic cell death” provide a plausible mechanistic link between the local and systemic effects of radiation. Radiotherapy treatment can stimulate both pro-immunogenic and immunosuppressive pathways with a potential net beneficial effect on anti-tumor immune activity. Upregulation of programmed cell death ligand (PD-L1) by radiotherapy is an immunosuppressive pathway that could be approached with anti-PD-L1 therapy with potential further improvement in survival. The world overview of randomized trials indicates that the breast cancer mortality reduction from adjuvant radiotherapy is delayed relative to that of adjuvant systemic treatments, and similar delays in the separation of survival curves are evident in the majority of randomized immunotherapy trials demonstrating treatment efficacy. In this article, we hypothesize that an abscopal effect may explain the benefit of radiotherapy in reducing breast cancer mortality, and that It might be possible to harness and augment this effect with systemic agents to reduce the risk of late recurrences.

Axillary surgery in breast cancer: the beginning of the end

Axillary surgery in breast cancer patients has shifted from more extensive to minimalist approaches with re-evaluation of the risks versus benefits of available treatment options which are increasingly tailored to individual patient characteristics. A radical axillary node dissection is rarely indicated nowadays due to several factors including screening with detection of small node negative cancers, introduction of targeted node sampling, less reliance on information from nodal staging for adjuvant therapy decision making and evidence that non-surgical treatments such as systemic therapies (chemotherapy, hormonal therapy, biological therapy) together with radiotherapy can safely treat low burden axillary disease. Sentinel lymph node biopsy (SLNB) alone with omission of further axillary surgery for nodal macrometastases (>2 mm) might be sufficiently extirpative to achieve local control when combined with adjuvant treatments. There remain unanswered questions on the safety of SLNB post chemotherapy in patients with biopsy-proven nodal disease at presentation and whether omission of axillary node dissection is feasible in selected cases. Emerging evidence suggests that a complete radiological response with removal of at least 3 nodes (including clipped nodes at time of biopsy) can yield false negative rates of <10% and be a safe option. New technologies involving percutaneous biopsy of sentinel nodes under radiological guidance are under investigation and could potentially replace surgical staging of the axilla in the future. Moreover, omission of any type of node biopsy might be a potential option in more favorable tumors and could herald the beginning of the end for histological axillary sampling in selected cases.

Surgical treatment of multiple ipsilateral breast cancers

Abundant research

Novel techniques for intraoperative assessment of margin involvement

Breast conserving surgery (BCS) is now the standard of care for the majority of women with early stage breast cancer. There is a finite rate of ipsilateral breast tumour recurrence (IBTR) for breast conserving therapy (BCT) with annual rates of less than 1% for specialist breast practices. There has been recent consensus on the definition of an adequate resection margin for both invasive and noninvasive breast cancer treated with BCS, although some variation in margin policy persists with definitions of 'no tumour at ink', 1 and 2 mm margin mandates. Despite the development of methods for intraoperative assessment of margins, up to 20% of patients require further surgery (cavity re-excision or completion mastectomy) to achieve clear surgical margins. In the past decade, several novel technologies for intraoperative margin assessment have been explored with the aim of reducing rates of re-operation and its attendant patient anxiety, inconvenience and additional cost. Ongoing studies are addressing the safety, feasibility and cost-effectiveness of these novel technologies relative to methods in routine clinical usage.

Highlights of the San Antonio Breast Cancer Symposium 2016: Part 2

The 39th annual San Antonio Breast Cancer Symposium (SABCS) was convened in San Antonio, Texas, on 9-13 December 2016. More than 7000 clinicians and scientists from around the world participated in the symposium which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, locoregional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with Part 1 focusing onmetastatic breast cancer, extended endocrine therapy and the prognostic significance of BRCA1/2 gene mutations. The second part of this report will discuss a range of topics including anti-HER2 directed treatments, the impact of radiotherapy on implant and autologous flap based reconstruction, biological risk predictors for ductal carcinoma-in situ (DCIS), longer term effects of dietary fat modification and the influence of aromatase inhibitors on endothelial cell function.

Coming of age of oncoplastic breast surgery

For every breast surgeon's toolbox

Highlights of the San Antonio Breast Cancer Symposium 2016

The 39th annual San Antonio Breast Cancer Symposium (SABCS) was convened in San Antonio, Texas, on 9-13 December 2016. More than 7000 clinicians and scientists from around the world participated in the symposium which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, locoregional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with Part 1 focusing onmetastatic breast cancer, extended endocrine therapy and the prognostic significance of BRCA1/2 gene mutations. The second part of this report will discuss a range of topics including anti-HER2 directed treatments, the impact of radiotherapy on implant and autologous flap based reconstruction, biological risk predictors for ductal carcinoma-in situ (DCIS), longer term effects of dietary fat modification and the influence of aromatase inhibitors on endothelial cell function.

Treatment of low-risk ductal carcinoma in situ: is nothing better than something?

The heterogeneous nature of ductal carcinoma in situ has been emphasised by data for breast-cancer screening that show substantial increases in the detection of early-stage non-invasive breast cancer but no noteworthy change in the incidence of invasive and distant metastatic disease. Indolent non-progressive forms of ductal carcinoma in situ are managed according to similar surgical strategies as high-risk disease, with extent of resection dictated by radiological and pathological estimates of tumour dimensions. Although adjuvant treatments might be withheld for low-risk lesions, surgical treatments incur potential morbidity, especially when mastectomy and breast reconstruction are done for widespread low-grade or intermediate-grade ductal carcinoma in situ. Low rates of deaths from breast cancer coupled with overdiagnosis within screening programmes have prompted a fundamental rethink of approaches to the management of both low-risk and high-risk ductal carcinoma in situ. Changes include active surveillance for low-risk lesions and a watchful waiting policy with intervention when invasive local recurrence after breast-conserving surgery is detected. Prediction of ipsilateral invasive recurrence is likely to be improved by integration of molecular biomarkers with conventional histopathological parameters. Moreover, further genetic interrogation of ductal carcinoma in situ might lead to a reclassification of some low-grade lesions as non-cancerous entities.

Abstract P1-11-09: The impact of a change in margin width on rates of re-excision following breast conserving surgery

Background: Surgical margin status is a predictor of ipsilateral breast tumor recurrence but the definition of an adequate surgical margin following breast conserving surgery (BCS) remains controversial despite published recommendations for acceptance of 'no tumor at ink'. BCS can be compromised by the need for a re-excision procedure which incurs inconvenience to patients and additional healthcare costs. We have previously shown that reducing the margin mandate from 5mm to 2mm does not influence rates of re-excision and the impact of adopting a more stringent margin policy of 'no tumor at ink' is now reported.

Methods:A retrospective analysis examined rates of re-excision amongst patients undergoing BCS for both invasive carcinoma with or without admixed ductal carcinoma in situ (DCIS) or pure DCIS over two sequential 12 month time periods either prior to (GROUP 1; n=225) or immediately following (GROUP 2; n=238) a change in minimum margin policy from 2mm to 'no tumor at ink' when the latter was deemed an adequate definition of a negative margin. A total of 611 patients underwent non-reconstructive breast surgery for symptomatic and screen-detected cancers during these time periods among whom 463 received BCS. Wire-localization was undertaken in 51% (114/225) and 42% (101/238) of patients in groups 1 and 2 respectively. Data was extracted from electronic patient records of histopathology reports and clinic letters with further information available from documentation of MDT discussions. Statistical analysis used Fisher-Exact test.

Results: Rates of re-excision were significantly lower for group 2 (32/238=13%) compared with group 1 48/225=21%). Re-excision encompassed cavity re-excision alone, cavity re-excision followed by mastectomy and completion mastectomy. Residual disease in re-excision specimens was significantly higher for group 2 (40.6%) compared with group 1 (16.6%) [p=0.02] with more than one-third of cases of residual disease in group 2 being exclusively DCIS. Three patients in each group required 2 additional operations to achieve negative margins. For groups 1 and 2, three-quarters or more cases (87% and 77% respectively) had only 1 or two margins positive and 2 cases in group 2 were re-excised for reasons other than a positive margin (e.g. tumor type). For group 1, re-excision cases were prompted by margin categories of 0mm (n=22), &lt;1mm (n=18) and ≥1mm; &lt;2mm (n=8) whilst for group 2 all re-excisions were prompted by tumor at ink (0mm). A hypothetical minimum margin of 1mm would have reduced the re-excision rate for group 1 to 40/225 or 17.7%.

Conclusion: Re-excision was usually prompted by margins of &lt;2mm when a 5mm margin policy prevailed. A more relaxed margin mandate of 'no tumor at ink' has led to halving of re-excision rates from 21% to 13% as opposed to 17.7% for a minimum margin of 1mm. This reduction in rates of re-excision is accompanied by an increase in the proportion of cases with residual disease in re-operation specimens. Longer-term follow up is essential to monitor in-breast local recurrence.

Citation Format: Jiwa NE, Ayyar S, Provenzano E, Benson JR. The impact of a change in margin width on rates of re-excision following breast conserving surgery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-11-09.

Management of women with a hereditary predisposition for breast cancer

Women with a hereditary breast cancer predisposition have three management options: screening, chemoprevention (risk-reducing medication) and risk-reducing surgery. However, no randomized trials have addressed the effect of these strategies in mutation carriers. In the general population, randomized trials failed to demonstrate a benefit for screening in premenopausal women. Moreover, although chemoprevention reduces breast cancer incidence in high-risk populations, this benefit is potentially confined to estrogen receptor-positive tumors. Finally, observational studies suggest that prophylactic mastectomy and even prophylactic salpingo-ophorectomy reduces breast cancer risk in BRCA mutation carriers, but there are systematic biases associated with such studies. Therefore, women with a hereditary predisposition for breast cancer should be informed of the three risk-reducing strategies, and that their benefits are not fully understood.

Contralateral prophylactic mastectomy

Fashion is not science

Idiopathic granulomatous mastitis: presentation, investigation and management

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory condition of the breast which although benign can mimic carcinoma. Establishing a diagnosis can be challenging and requires a high index of suspicion with exclusion of infective and autoimmune breast diseases. IGM is characterized histologically by noncaseating granulomas which are of a lobulo-centric pattern and often associated with microabscess formation. Management of confirmed cases remains controversial with proponents of initial surgical or medical therapies - each has its associated problems which can be worse than the original symptoms of IGM. However, many patients require more than one modality of treatment to completely resolve IGM lesions and careful judgment is necessary to ensure optimal type and sequencing of treatments.

Highlights of the San Antonio Breast Cancer Symposium 2015: part 2

38th San Antonio Breast Cancer Symposium (SABCS), San Antonio, TX, USA, 8-12 December 2015 The 38th annual San Antonio Breast Cancer Symposium was convened in San Antonio (TX, USA) on 8-12 December 2015. More than 7000 clinicians and scientists from around the world participated in the symposium, which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, loco-regional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with part 1 focusing on radiotherapy treatment, translational approaches to immunotherapy and longer term cardiotoxicity from anti-HER2 therapies. The second part of this report will discuss a range of topics including de-escalation of chemotherapy regimens in luminal A tumors, the prognostic relevance of circulating tumor cells, the optimum treatment of triple-negative breast cancer and shifting attitudes to primary surgical treatment.

Highlights of the San Antonio Breast Cancer Symposium 2015: part 1

38th San Antonio Breast Cancer Symposium, San Antonio, TX, USA, 8-12 December 2015 The 38th annual San Antonio Breast Cancer Symposium (SABCS) was convened in San Antonio (TX, USA) on 8-12 December 2015. More than 7000 clinicians and scientists from around the world participated in the symposium, which featured a range of presentations and keynote talks pertaining to breast cancer screening, prevention, loco-regional and systemic therapies. This two-part report highlights a selection of important studies presented at this premier breast cancer event with part 1 focusing on radiotherapy treatment, translational approaches to immunotherapy and longer term cardiotoxicity from anti-HER2 therapies. The second part of this report will discuss a range of topics including de-escalation of chemotherapy regimens in luminal A tumors, the prognostic relevance of circulating tumor cells, the optimum treatment of triple-negative breast cancer and shifting attitudes to primary surgical treatment.

Abstract P3-01-01: Fluorescence navigation system using indocyanine green (ICG) instead of radioisotope for sentinel lymph node (SLN) biopsy in early breast cancer

Background: Dual localisation methods with blue dye and radioisotope are commonly employed for SLN identification but potential drawbacks include allergic reactions, staining of cutaneous/surgical breast tissue, radiation exposure and mandatory licencing. A majority of studies have reported near 100% identification rates using the fluorescent tracer ICG in combination with standard tracer agents. A feasibility study (ICG-10) has confirmed high sensitivity of ICG fluorescence mapping for SLN detection in early breast cancer with 95% of nodes both blue and fluorescent. This follow-on study has specifically evaluated a combination of ICG with blue dye for SLN localization.

Methods: As an observational cohort study, 50 consecutive patients (49 female; 1 male) with core biopsy proven unilateral invasive (37 cases) or non-invasive (13 cases) breast cancer underwent SLN biopsy with blue dye and ICG. All patients were clinically and sonographically node negative. Axillary surgery (SLN biopsy) followed neoadjuvant chemotherapy in 5 patients (10%). The median patient age was 48 years and for primary surgical patients median tumor size was 19mm. Patients received a dual peri-areolar/intradermal injection of blue dye [2ml 2.5% Patent Blue] and ICG [2mls 0.5%] after induction of anaesthesia. The number of sentinel nodes for each patient was recorded numerically and whether blue, fluorescent or both. Subcutaneous lymphatics were visualised with a photodynamic eye camera and nodal and procedural detection rates calculated for ICG alone and in combination with blue dye.

Results: Final analysis was performed on a total of 87 nodes retrieved from 50 patients with an average nodal count of 1.8 per patient (range 1 – 4). Eighty-four nodes were blue and fluorescent and 3 nodes fluorescent only with no harvesting of non-blue, non-fluorescent nodes. At least one transcutaneous lymphatic channel was visible in all cases. Nodal detection rates for ICG alone and combined with blue dye were 100% (87/87) and 96% (84/87) respectively. Metastases (&gt;0.2mm) were present in 18 nodes which were all blue and fluorescent and a total of 10 patients had at least one positive node (node positivity rate = 20%). The procedural detection rate was 96% (48/50) for blue dye and 100% (50/50) for ICG with 2 patients having fluorescent only nodes which were deemed sentinel (4%). No serious adverse reactions were noted.

Conclusion: ICG fluorescence navigation system permits real-time visualization of lymphatic tissues and provides an additional dimension to SLN biopsy using methodology which is sensitive, valuable and safe. These results confirm accuracy of ICG fluorescence for SLN identification with nodal sensitivity of 96% for a combination of blue dye and ICG. With further refinements of the technique, use of ICG as a sole tracer may be possible agent without concerns about excessive nodal yield but improved patient convenience and costs.

Citation Format: Benson JR, Pitsinis V, Provenzano E, Wishart GC. Fluorescence navigation system using indocyanine green (ICG) instead of radioisotope for sentinel lymph node (SLN) biopsy in early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-01.