Oncoplastic breast-conserving surgery for women with primary breast cancer

Repurposing GnRH-A as a Near-Infrared Fluorescent Probe for Diagnosis and Surgical Navigation of Breast Cancer Tumors and Metastases

Breast cancer, globally the most common cancer in women, presents significant challenges in treatment. Breast-conserving surgery (BCS), a less traumatic and painful alternative to radical mastectomy, not only preserves the breast's appearance but also supports postsurgical functional recovery. However, accurately identifying tumors, precisely delineating margins, and thoroughly removing metastases remain complex surgical challenges, exacerbated by the limitations of current imaging techniques, including poor tumor uptake and low signal contrast. Addressing these challenges, our study developed a series of GnRHR-targeted probes (YQGN-n) for fluorescence imaging and surgical navigation of breast cancer through a drug repositioning strategy. Notably, YQGN-7, with its high cellular affinity (Kd of 217.8 nM), demonstrates exceptional selectivity and specificity for breast cancer tumors, surpassing traditional imaging agents like ICG in tumor uptake and pharmacokinetic properties. Furthermore, YQGN-7's effectiveness in surgical navigation, both for primary breast tumors and metastases, highlights its potential as a revolutionary tool in BCS.

A bibliometric worldview of breast-conserving surgery for breast cancer from 2013 to 2023

Over the last decade, significant advancements have been made in breast-conserving surgery (BCS) for breast cancer. However, there is a lack of analytical and descriptive investigations on the trajectory, essential research directions, current research scenario, pivotal investigative focuses, and forthcoming perspectives. The objective of this research is to provide a thorough update on the progress made in BCS for breast cancer over the preceding decade. Retrieved from the Web of Science database, the data span from January 1, 2013, to November 30, 2023. Utilizing a set of advanced analytical instruments, we conducted comprehensive bibliometric and visual analyses. The findings underscore the predominant influence of the USA, representing 35.77% of the overall publications and playing a pivotal role in shaping research within this field. Notable productivity was evident at various institutions, including the Memorial Sloan Kettering Cancer Center, the University of Texas MD Anderson Cancer Center, and the University of Toronto. Annals of Surgical Oncology contributed the most publications in this field. An examination of keywords indicated a change in the concentration of research attention, transitioning from molecular subtype, ultrasonography, and intraoperative aspects to SEER, male breast cancer, and adjuvant measures. By offering a comprehensive bibliometric assessment, this study enhances our understanding of BCS for breast cancer. Consequently, this benefits both experienced researchers and newcomers alike, providing prompt access to essential information and fostering the extraction of innovative concepts within this specific field.

[Effectiveness of sequential method pure single-port lumpectomy-breast conserving surgery for early-stage breast cancer in different quadrants]

Objective

To compare the effectiveness of sequential method pure single-port lumpectomy-breast conserving surgery (SMPSL-BCS) in treating early-stage breast cancer patients with tumors in different quadrants.

Methods

A retrospective analysis was conducted on 200 early-stage breast cancer female patients admitted between January 2023 and December 2023. According to the quadrant where the tumor was located, the patients were allocated into the upper outer quadrant group (UO group), lower outer quadrant group (LO group), upper inner quadrant group (UI group), and lower inner quadrant group (LI group), with 50 cases in each group. There was no significant difference ( P>0.05) in the baseline data, including age, body mass index, smoking history, marital status, comorbidities, affected breast side, maximum tumor diameter on ultrasound, maximum pathological tumor diameter, clinical tumor stage, molecular subtype, and disease duration. The operation time, intraoperative blood loss, postoperative drainage volume, and extubation time were recorded and compared between groups. Additionally, the occurrence of early-stage complications (1-3 months after operation; including subcutaneous fluid accumulation, incision infection, superficial skin burns) and late-stage complications (>3 months after operation; including pectoralis major muscle adhesion, changes in breast appearance and shape, sensory discomfort) were assessed. At 6 months after operation, the cosmetic outcome of breast-conserving surgery was rated for all groups.

Results

The UO group had the shortest operation time, followed by the UI group, LO group, and LI group, showing significant differences between groups ( P<0.05). The UO group had the least intraoperative blood loss, followed by the LO group, UI group, and LI group; except for the difference between UO group and LO group, which was not significant ( P>0.05), the differences between the other groups were significant ( P<0.05). The UO group had the least postoperative drainage volume, followed by the LO group, UI group, and LI group; except for the difference between LO group and UI group, which was not significant ( P>0.05), the differences between the other groups were significant ( P<0.05). The extubation time of the LI group was significantly longer than that of the other groups ( P<0.05). All patients were followed up 4-12 months, with an average of 8 months. And 193 patients were followed up more than 6 months, including 48 patients in UO group, 47 in LO group, 49 in UI group, and 49 in LI group. In the early-stage period, the LI group had a higher incidence of subcutaneous fluid accumulation after tube removal compared to the UO group and LO group ( P<0.05), while there was no significant difference in the incidences of other early complications between groups ( P>0.05). In the late-stage period, the LI group had significantly higher incidences of pectoralis major muscle adhesion and changes in breast appearance and shape than UO group and LO group ( P<0.05), and a significantly higher incidence of sensory discomfort than UO group ( P<0.05). There was no significant difference in the incidences of other late-stage complications between groups ( P>0.05). At 6 months after operation, the cosmetic outcomes of breast-conserving surgery were significantly better in UO group, LO group, and UI group than in LI group ( P<0.05); there was no significant difference between the other groups ( P>0.05).

Conclusion

In the treatment of early-stage breast cancer using SMPSL-BCS, patients with tumors located in the upper outer quadrant show the best effectiveness. The effectivenesses are similar for patients with tumors in the lower outer and upper inner quadrants. However, patients with tumors in the lower inner quadrant do not experience significant advantages. Therefore, it is recommended that SMPSL-BCS should not be the first-choice surgical method for patients with tumors in the lower inner quadrant.

Impact of surgical types on overall survival in patients with ductal carcinoma in situ: an analysis based on the SEER database

Background

Breast cancer, as one of the most common malignancies among women globally, presents a concerning incidence rate, underscoring the importance of addressing the treatment of its precursor lesion, ductal carcinoma in situ (DCIS). Treatment decisions for DCIS, involving the balance between breast-conserving surgery (BCS) and mastectomy, remain an area requiring further investigation. This study aimed to compare influence of different surgical types on overall survival (OS) of patients with DCIS and identify specific subgroups with improved OS to develop an effective survival nomogram for patients.

Methods

Patient data from the Surveillance, Epidemiology, and End Results (SEER) database for DCIS cohort from 2010 to 2020 were retrieved. Kaplan-Meier (K-M) survival curves were utilized to compare prognostic OS of patients with different surgical methods. Cox regression analysis was employed to determine prognostic factors and establish a nomogram to predict 3-, 5-, and 10-year survival rates. The model was confirmed by Concordance Index (C-index), calibration curves, and receiver operating characteristic (ROC) curves.

Results

A total of 71,675 patients with DCIS were included. Patients who underwent subcutaneous mastectomy (SM) demonstrated the best OS compared to other surgical types. Additionally, adjuvant radiotherapy or chemotherapy in combination with surgery significantly improved OS compared to surgery alone. Among DCIS patients aged ≤74 years, those who underwent SM benefited the most in terms of OS, while in the age group of 63-74 years, patients who underwent BCS had significantly higher OS than those who underwent total (simple) mastectomy (TM)/modified radical mastectomy (MRM). Multiple factors were associated with improved OS in DCIS patients, and these factors were integrated into the nomogram to establish OS predictions. The C-index, calibration curves, and ROC curves indicated that the nomogram was suitable for assessing patient prognosis.

Conclusions

This study demonstrated that SM treatment yielded the best survival rates for DCIS patients, providing important guidance for future surgical decision-making. Moreover, identifying multiple independent factors related to survival and establishing reliable survival nomograms can assist physicians in developing personalized treatment plans and prolonging patient survival.

Understanding decision-making for and against oncoplastic breast-conserving surgery as an alternative to a mastectomy in early breast cancer: UK ANTHEM qualitative study

BACKGROUND

Oncoplastic breast-conserving surgery may allow women with early breast cancer to avoid a mastectomy, but many women undergo more extensive surgery, even when breast-conserving options are offered. The aim of the ANTHEM qualitative study was to explore factors influencing women's surgical decision-making for and against oncoplastic breast-conserving surgery.

METHODS

Semi-structured interviews were conducted with a purposive sample of women who had received either oncoplastic breast-conserving surgery or a mastectomy with or without immediate breast reconstruction to explore their rationale for procedure choice. Interviews were transcribed verbatim and analysed thematically. Trial registration number: ISRCTN18238549.

RESULTS

A total of 27 women from 12 centres were interviewed. Out of these, 12 had chosen oncoplastic breast-conserving surgery and 15 had chosen a mastectomy with or without immediate breast reconstruction. Overwhelmingly, women's decisions were guided by their surgical teams. Decision-making for and against oncoplastic breast-conserving surgery was influenced by three key inter-related factors: perceptions of oncological safety; the importance of maintaining/restoring femininity and body image; and practical issues. Oncological safety was paramount. Women who reported feeling reassured that oncoplastic breast-conserving surgery was oncologically safe were happy to choose this option. Those who were not reassured were more likely to opt for a mastectomy, as a perceived 'safer' option. Most women wished to maintain/restore femininity, with the offer of immediate breast reconstruction essential to make a mastectomy an acceptable option. Practical issues such as the perceived magnitude of the surgery were a lesser concern.

CONCLUSION

Decision-making is complex and heavily influenced by the surgical team. High-quality, accurate information about surgical options, including appropriate reassurance about the short- and long-term oncological safety of oncoplastic breast-conserving surgery is vital if women are to make fully informed decisions.

Health-related quality of life by type of breast surgery in women with primary breast cancer: prospective longitudinal cohort study

BACKGROUND

Health-related quality of life and patient-related outcome measures for patients with cancer have gained increased interest over the last decade. However, few prospective studies with longitudinal data evaluated health-related quality of life in patients with breast cancer. This study aimed to investigate how health-related quality of life changed from the time of diagnosis to 1 year after breast cancer surgery for the main surgical techniques.

METHODS

This prospective longitudinal single-centre study included patients with primary breast cancer diagnosed in 2019-2020 who underwent surgery. Patients completed a health-related quality of life questionnaire (Breast-Q) at baseline. One year after surgery, they completed the Breast-Q a second time, the EORTC (European Organization for Research and Treatment of Cancer) quality of life questionnaire-C30 and the quality of life questionnaire-BR23. Analysis of variance and Kruskal-Wallis tests were used to evaluate the differences in health-related quality of life between surgical groups. Analysis of covariance with robust standard errors was used to adjust for confounders.

RESULTS

In total, 340 patients were included in the study; 160 patients received oncoplastic partial mastectomy, 112 received partial mastectomy, 42 received mastectomy and 26 had mastectomy with immediate reconstruction. Patients that had partial mastectomy or oncoplastic partial mastectomy were more satisfied with their breasts (P < 0.001), had a better body image (P = 0.006) and higher sexual functioning scores (P = 0.027) than patients who had a mastectomy with/without reconstruction. The oncoplastic and mastectomy with reconstruction groups had more breast symptoms than other groups (P < 0.001), and the mastectomy group had the least symptoms from the chest area.

CONCLUSION

Partial mastectomy and oncoplastic partial mastectomy have the best outcomes in terms of breast satisfaction, body image and sexual functioning. This highlights the importance of preserving the breast when feasible and underscores that breast reconstruction is not equal to breast conservation. Registration number: NCT04227613 (http://www.clinicaltrials.gov).

Evolution of breast conserving surgery-current implementation of oncoplastic techniques in breast conserving surgery: a literature review

Background and Objective

De-escalation in breast cancer surgery has been a natural evolution since breast conserving surgery (BCS) was introduced in the early 1980s. From Halsted mastectomies to wide local excisions, we are facing nowadays the next trend in form of oncoplastic breast surgery. Oncoplastic breast surgery combines oncological principles with plastic surgery techniques to preserve the breast shape and appearance. The aim of this work is to review recent oncological and quality of live outcomes derived from oncoplastic techniques as well as offer a perspective about its implementation in breast cancer units.

Methods

A literature review was conducted to explore the landscape of oncoplastic breast surgery. Key terms related to oncoplastic techniques and breast cancer were used in searches across databases such as PubMed, Embase and Cochrane Library. Inclusion criteria focused on recent articles discussing oncological and quality of life (QoL) outcomes, as well as perspectives on the role of oncoplastic surgery.

Key Content and Findings

The research aims to contribute valuable insights into the efficacy and impact of oncoplastic surgery in the context of breast cancer treatment. In this new era of precision medicine, it is more than just healing patients; it is about improving their well-being. We ought to consider specific oncoplasty role in leading this paradigm shift. It is also relevant to define whether these new technical-demanding surgical options can be applied to all patients and if professional training performs adequately to current demands of personalized treatments.

Conclusions

The global adoption of oncoplastic BCS is recommended due to its oncological safety and improvement in QoL compared to standard procedures. Emphasizing the need for skilled surgeons in complex cases, collaboration between breast surgeons and scientific societies is urged to certify ongoing educational training in oncoplastic techniques.

The Utility of a Novel Bidirectional Lateral Intercostal Artery Perforator Flap for Reconstructing Partial Mastectomy Defects

Smaller breasts require volume replacement to allow for breast conservation for large tumor to breast size ratios. The lateral intercostal artery perforator (LICAP) flap is one of the most commonly used approaches to replace volume as it readily fills lateral breast defects where most cancers typically arise. The LICAP flap was initially described with the bulk of its tissue volume oriented posteriorly, lateral to the breast footprint. Recently, the "reverse LICAP" flap was described, which uses the same perforators but recruits tissue instead from below the inframammary fold. Here, we combine these two approaches, preserving the same perforators, but harvesting tissue from both below the inframammary fold and lateral to the breast footprint, to create a single, larger, bidirectional LICAP flap. This modified flap replaces more volume than previously described for uni-directional approaches allowing us to potentially avoid mastectomy or more extensive flap reconstructions. Here, we describe 10 consecutive patients where the bidirectional LICAP flap was used to facilitate oncoplastic breast conservation.

A clinical perspective on oncoplastic breast conserving surgery

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.

Oncoplastic breast-conserving surgery improves cosmetic outcomes without increasing recurrence risk compared to modified radical mastectomy in early breast cancer patients: development and validation of a recurrence risk prediction model

In the quest for effective treatment of early-stage breast cancer, this study aimed to compare the clinical efficacy of modified radical mastectomy (MRM) and oncoplastic breast-conserving surgery (OBCS). Breast cancer remains a major health concern globally, where early detection and effective treatment strategies are crucial for improving the outcomes of patients. MRM and OBCS are two primary treatment modalities for breast cancer, each with its distinct benefits and challenges. Through a retrospective analysis, we found that although the patients in the OBCS group experienced a longer operation time, they had significantly less intraoperative bleeding, postoperative drainage, and hospitalization time compared to the MRM group. Furthermore, patients in the OBCS group demonstrated higher subjective satisfaction and quality of life scores, along with better objective outcomes. In terms of postoperative complications and recurrence rates, no significant difference was identified between the two groups. However, our multivariate Cox regression analysis identified lymph node metastasis and molecular type as independent prognostic factors for disease-free survival (DFS). Subsequently, we constructed a risk model based on these variables, which was proven to be effective in predicting recurrence, with an area under the risk score curve for recurrence prediction being 0.852. The group with a lower risk score demonstrated a significantly higher DFS rate. Our study suggests that compared with MRM, OBCS can significantly reduce surgical incision, improve patient satisfaction, and does not increase the risk of complications or recurrence. Our risk model, developed using Cox regression, also demonstrated high clinical value in predicting breast cancer recurrence, thereby aiding in personalized patient management and treatment planning.

Feasibility analysis of treating breast cancer patients with breast-conserving surgery via a periareolar incision combined with non-lipolytic suspension-type mastoscopy

The purpose is to analyze and compare postoperative recovery and complication incidence between a periareolar incision combined with Suspension-type Mastoscopic Axillary Lymph Node Dissection (SMALND) and traditional inflated Mastoscopic Axillary Lymph Node Dissection (MALND). This was a randomized trial conducted from June 1, 2020, to April 30, 2022, in the Department of Second Breast Surgery, Shengjing Hospital of China Medical University, and the Department of Thyroid and Breast Surgery, Zibo Central Hospital, in accordance with the criteria of inclusion and exclusion. Overall, 126 patients diagnosed and treated for early-stage breast cancer were selected to undergo periareolar-incision breast-conserving surgery. Those patients who underwent periareolar-incision surgery combined with SMALND formed the observation group (SMALND Group), while those who underwent periareolar-incision surgery combined with traditional inflation became MALND Group. In the two groups, paired data "t" was used to examine, analyze, and compare the postoperative daily drainage volume and drain removal time, while paired data "χ²" was used to examine, analyze, and compare the incidences of postoperative upper limb edema and paresthesia. There were 64 cases in the SMALND Group and 62 cases in the MALND Group. Between the two clusters, no differences were found in age, clinical staging, BMI, and breast cancer classification (P > 0.05). The intraoperative surgery time of the SMALND Group was 43.37 ± 6.27 min while that of the MALND Group was longer: 45.72 ± 4.25 min (P < 0.05). The intraoperative hemorrhage volume of the SMALND Group was 88.33 ± 16.79 ml, less than that of the MALND Group: 96.76 ± 26.85 ml (P < 0.05). The postoperative axillary mean daily drainage volume of the SMALND Group was 38.17 ± 5.55 ml, less than that of the MALND Group: 40.72 ± 7.25 ml (P < 0.05). The drain removal time of the SMALND Group was 7.50 ± 1.60, less than that of the MALND Group: 9.00 ± 1.80 (P < 0.05). The upper limb edema incidence rate of the SMALND Group was 3.12% (2/64) and had no obvious difference from the MALND Group, which was 4.83% (3/62) (P = 0.62). The paresthesia incidence rate of the SMALND Group was 18.75% (12/64), while that of the MALND Group was 17.7% (11/62), without an obvious difference (P = 0.88). For axillary lymph node dissection, the use of non-lipolytic suspension-type mastoscopy has reduced the intraoperative hemorrhage volume of patients, shortened surgery time and postoperative recovery time, saved treatment expenses for patients, and avoided complications such as hypercapnia and subcutaneous emphysema caused by traditional inflated mastoscopic surgery. Moreover, it has not increased the incidence of postoperative upper limb edema and paresthesia, supporting its safety and effectiveness.

Oncoplastic level II volume displacement surgery for breast cancer: oncological and aesthetic outcomes

Oncoplastic breast-conserving surgery (OBCS) is increasingly used to treat breast cancer with the dual purpose of performing a radical oncological resection while minimizing the risk of post-operative deformities. The aim of the study was to evaluate the patient outcomes after Level II OBCS as regards oncological safety and patient satisfaction. Between 2015 and 2020, a cohort of 109 women consecutively underwent treatment for breast cancer with bilateral oncoplastic breast-conserving volume displacement surgery; patient satisfaction was measured with BREAST-Q questionnaire. The 5-year overall survival and disease-free survival were 97% (95%CI 92, 100) and 94% (95%CI 90, 99), respectively. In two patients (1.8%), mastectomy was finally performed due to margin involvement. The median patient-reported score for "satisfaction with breast" (BREAST-Q) was 74/100. Factors associated with a lower aesthetic satisfaction index included: location of tumour in central quadrant (p = 0.007); triple negative breast cancer (p = 0.045), and re-intervention (p = 0.044). OBCS represents a valid option in terms of oncological outcomes for patients otherwise candidate to more extensive breast conserving surgery; the high satisfaction index also suggests a superiority in terms of aesthetic outcomes.

Remodeling the Tumor Microenvironment with Core-Shell Nanosensitizer Featuring Dual-Modal Imaging and Multimodal Therapy for Breast Cancer

To improve the efficiency of radiation therapy (RT) for breast cancer, a designable multifunctional core-shell nanocomposite of FeP@Pt is constructed using Fe(III)-polydopamine (denoted as FeP) as the core and platinum particles (Pt) as the shell. The hybrid structure is further covered with hyaluronic acid (HA) to give the final nanoplatform of FeP@Pt@HA (denoted as FPH). FPH exhibits good biological stability, prolongs blood circulation time, and is simultaneously endowed with tumor-targeting ability. With CD44-mediated endocytosis of HA, FPH can be internalized by cancer cells and activated by the tumor microenvironment (TME). The redox reaction between Fe³⁺ in FPH and endogenous glutathione (GSH) or/and hydrogen peroxide (H₂O₂) initiates ferroptosis therapy by promoting GSH exhaustion and •OH generation. Moreover, FPH has excellent photothermal conversion efficiency and can absorb near-infrared laser energy to promote the above catalytic reaction as well as to achieve photothermal therapy (PTT). Ferroptosis therapy and PTT are further accompanied by the catalase activity of Pt nanoshells to accelerate O₂ production and the high X-ray attenuation coefficient of Pt for enhanced radiotherapy (RT). Apart from the therapeutic modalities, FPH exhibits dual-modal contrast enhancement in infrared (IR) thermal imaging and computed tomography (CT) imaging, offering potential in imaging-guided cancer therapy. In this article, the nanoplatform can remodel the TME through the production of O₂, GSH- and H₂O₂-depletion, coenhanced PTT, ferroptosis, and RT. This multimodal nanoplatform is anticipated to shed light on the design of TME-activatable materials to enhance the synergism of treatment results and enable the establishment of efficient nanomedicine.

Determination of Oncologic Outcomes, Satisfaction, and Psychosocial Well-being in Patients with Breast Cancer after Oncoplastic and Conventional Breast Conserving Surgery

Background

Breast cancer is the most common cancer in women and surgery is necessary for its treatment. We aimed to determine the oncologic outcomes, satisfaction with breasts, and psychosocial well-being in the patients with breast cancer, after oncoplastic and conventional breast conserving surgery (BCS).

Method

The patients with breast cancer from Shahid Motahari Clinic affiliated to Shiraz University of Medical Sciences, Shiraz, Iran from December 2020 to December 2021 were allocated to two groups, one who had undergone BCS alone and the patients who had undergone oncoplastic BCS. For all the patients, demographic data, data about surgery, oncologic outcomes, wound complications, and BREAST-Q© questionnaire score were collected and compared between two groups.

Result

The mean age of the patients in the oncoplastic BCS and BCS group was 48.13±9.73 (median=48), and 50.01±8.47 (median=50) years, respectively. The mean score of psychosocial well-being was higher in the oncoplastic BCS group in comparison with BCS alone. (P-value< 0.0001). Also, the mean score of satisfaction with breast was higher among the oncoplastic BCS group in comparison with the BCS group (P-value< 0.0001).

Conclusion

Replacing traditional BCS with oncoplastic BCS does not adversely affect the oncologic results of surgery but improves the consequent psychosocial well-being and satisfaction in the patients.

Development of a Novel Immune-Related Gene Prognostic Index for Breast Cancer

Objective

To construct an immune-related gene prognostic index (IRGPI) for breast cancer (BC) and investigate its prognostic specificity and the molecular and immune characteristics.

Methods

BC hub genes were identified from The Cancer Genome Atlas and immune-related databases using weighted gene co-expression network analysis (WGCNA). IRGPI was constructed using univariate, LASSO, and multivariate regression analyses, and was validated with GSE58812 and GSE97342 in the Gene Expression Omnibus database (GEO). At the same time, we evaluated the predictive ability of IRGPI for different BC subtypes. Subsequently, the molecular and immune characteristics, clinical relevance, and benefits of immune checkpoint inhibitor treatment were analyzed for different IRGPI subgroups.

Results

IRGPI consisted of six genes: SOCS3, TCF7L2, TSLP NPR3, ANO6, and HMGB3. The IRGPI 1-, 5-, and 10-years area under curve (AUC) values were 0.635, 0.752, and 0.753, respectively, indicating that IRGPI has good potential in predicting the long-term survival of BC patients, consistent with the results in the GEO cohort. IRGPI showed good predictive power in four different breast cancer subtypes: ER positive, PR positive, HER2 positive and triple-negative (P<0.01). Compared with the low-IRGPI group, the high-IRGPI group had a worse prognosis and a lower degree of immune infiltrating cells (p < 0.05). IRGPI showed specificity in distinguishing age, TNM stage, ER, and HER2 statuses, and our study found that the high-IRGPI group had low tumor immune dysfunction and exclusion (TIDE), microsatellite instability (MSI), and T cell dysfunction scores (p < 0.05). In addition, compared with the TIDE and TIS models, showed that the AUCs of IRGPI were better during the 5-year follow-up.

Conclusion

IRGPI can be used as an independent prognostic indicator of breast cancer, providing a method for monitoring the long-term treatment of BC.

Oncoplastic breast-conserving surgery for women with primary breast cancer

BACKGROUND

Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

OBJECTIVES

Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

DATA COLLECTION AND ANALYSIS

Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

MAIN RESULTS

We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

AUTHORS' CONCLUSIONS

The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.