Importance of margin width in breast-conserving treatment of early breast cancer

Impact of Margin Status on Local Recurrence in Patients with Breast Cancer Undergoing Breast-Conserving Surgery After Neoadjuvant Chemotherapy: A Retrospective Multi-Institutional Cohort Study

BACKGROUND

Questions have been raised as to an increased risk of local recurrence with breast-conserving surgery (BCS) post NAC highlighting the uncertainty around optimal margin width in this patient population. We examined the association between margin status and local recurrence-free survival (LRFS) in patients who underwent BCS following NAC.

METHODS

We performed a retrospective cohort study of adult female patients with stage I-III breast cancer who underwent NAC followed by BCS between 2012 and 2021 at two cancer centers. Margins were categorized as "close" if they were < 1 mm.

RESULTS

The full cohort included 544 patients with a median age of 53 years (interquartile range [IQR] 44-64). Pathologic complete response (pCR) was achieved in 41.2% of the overall cohort (n = 224). Of the 320 with residual disease, 29.4% (n = 94) had at least one close margin, and 10.9% (n = 35) had ≥2 close margins. Median follow-up was 55 months (IQR 32-83); 4.8% had an ipsilateral breast recurrence (n = 26). Patients with pCR had a higher 5-year LRFS than those with residual disease (98.0% vs. 91.6%, p = 0.02). There was no difference in 5-year LRFS between the margin categories (clear vs. 1 close margin vs. ≥2 close margins) in those with residual disease (92.2% vs. 88.9% vs. 92.9%) (p = 0.78).

CONCLUSIONS

In patients undergoing BCS post-NAC, those who achieved pCR had a significantly higher LRFS compared with those with residual disease at the time of surgery, but LRFS was not associated with margin width nor the number of close margins.

Surgical treatment of breast cancer

Surgical treatment of breast cancer has changed towards less invasive procedures as summarised in this review. Breast conserving surgery (BCS) and radiotherapy (RT) are now recommended as standard of care. Several flexible marking methods for removal of non-palpable tumours have gradually replaced wire-guided localisation. Neoadjuvant systemic treatment increases tumour shrinkage and BCS and may lead to omission of axillary clearance (AC). The prognostic significance of AC in patients with metastases to 1-2 sentinel nodes at primary surgery is questioned. Results from the SENOMAC trial are expected to change guidelines from AC to axillary RT.

Effect of high-dose radiation therapy on positive margins after breast-conserving surgery for invasive breast cancer

PURPOSE

Positive margins after breast-conserving surgery are associated with poor oncological outcomes and warrant additional surgery. This study aimed to evaluate the effectiveness of high-dose radiation therapy for positive margins by comparing local recurrence between patients with positive and negative margins.

METHODS

We retrospectively evaluated 550 patients treated with adjuvant radiation therapy after breast-conserving surgery for invasive breast cancer between 2013 and 2019. The total equivalent dose in 2 Gy fractions (EQD2) to the tumor bed ranged from 65.81 to 66.25 Gy for positive margins and 59.31-61.81 Gy for negative margins. The differences in local recurrence between the positive and negative margin groups were analyzed.

RESULTS

After a median follow-up of 58 months, the crude local recurrence rate was 7.3% in the positive margin group (n = 55) and 2.4% in the negative margin group (n = 495). Positive margins were associated with higher local recurrence without statistical significance in the entire cohort (p = 0.062). Among patients aged <60 years, those with positive margins had a significantly lower 5-year local recurrence-free survival rate than those with negative margins (89.16% vs. 97.57%, respectively; p = 0.005). In contrast, there was no significant difference in the 5-year local recurrence-free survival rate between patients with positive and negative margins among those aged ≥60 years (100.00% vs. 94.38%, respectively; p = 0.426).

CONCLUSION

In this study, positive margins were not associated with poor local control in older patients after a high-dose boosts. Further prospective studies are needed to verify our findings.

Diffuse reflectance spectroscopy for accurate margin assessment in breast-conserving surgeries: importance of an optimal number of fibers

During breast-conserving surgeries, it remains challenging to accomplish adequate surgical margins. We investigated different numbers of fibers for fiber-optic diffuse reflectance spectroscopy to differentiate tumorous breast tissue from healthy tissue ex vivo up to 2 mm from the margin. Using a machine-learning classification model, the optimal performance was obtained using at least three emitting fibers (Matthew's correlation coefficient (MCC) of 0.73), which was significantly higher compared to the performance of using a single-emitting fiber (MCC of 0.48). The percentage of correctly classified tumor locations varied from 75% to 100% depending on the tumor percentage, the tumor-margin distance and the number of fibers.

Breast-Conserving Surgery or Mastectomy?: Impact on Survival

The early randomized controlled trials revealed no differences in survival between breast-conserving surgery (BCS) and mastectomy. However, breast cancer treatment has undergone changes, and the results of recent population-based registry studies suggest superior long-term survival after BCS. To explore the current evidence, a systematic review and meta-ana lysis of population-based observational studies from 2010 and onward was conducted.

Methods

A literature search was conducted in the PubMed, Embase, and Cochrane databases to identify relevant literature. Keywords included "mastectomy," "breast conserving surgery," and "survival." The identified studies were narratively reviewed and effect sizes (hazard ratios [HRs]) for overall (OS) and breast cancer-specific survival (BCSS) were combined with random-effects models.

Results

A total of 30 reports were included in the review, and results from 25 studies were included in the meta-analyses. Compared with mastectomy, BCS was associated with better OS (HR = 1.34 [1.20-1.51]; N = 1,311,600) and BCSS (HR = 1.38 [1.29-1.47]; N = 494,267). Selected subgroups of patients, based on lymph node status, age (<50 years/≥50 years), and radiation therapy after mastectomy (±), all showed better overall survival after BCS. The number (range 4-12) and type of prognostic variables adjusted for in the survival analyses of the studies did not statistically significantly moderate the differences in survival between BCS and mastectomy.

Conclusions

The combined findings from large population-based studies indicate that BCS is associated with survival benefit compared with mastectomy, suggesting that BCS be the recommended treatment of early breast cancer (T1-2N0-1M0) if a radical lumpectomy can be performed.

Margin status and survival outcomes after breast cancer conservation surgery: prospectively registered systematic review and meta-analysis

OBJECTIVE

To determine if margin involvement is associated with distant recurrence and to determine the required margin to minimise both local recurrence and distant recurrence in early stage invasive breast cancer.

DESIGN

Prospectively registered systematic review and meta-analysis of literature.

DATA SOURCES

Medline (PubMed), Embase, and Proquest online databases. Unpublished data were sought from study authors.

ELIGIBILITY CRITERIA

Eligible studies reported on patients undergoing breast conserving surgery (for stages I-III breast cancer), allowed an estimation of outcomes in relation to margin status, and followed up patients for a minimum of 60 months. Patients with ductal carcinoma in situ only or treated with neoadjuvant chemotherapy or by mastectomy were excluded. Where applicable, margins were categorised as tumour on ink (involved), close margins (no tumour on ink but <2 mm), and negative margins (≥2 mm).

RESULTS

68 studies from 1 January 1980 to 31 December 2021, comprising 112 140 patients with breast cancer, were included. Across all studies, 9.4% (95% confidence interval 6.8% to 12.8%) of patients had involved (tumour on ink) margins and 17.8% (13.0% to 23.9%) had tumour on ink or a close margin. The rate of distant recurrence was 25.4% (14.5% to 40.6%) in patients with tumour on ink, 8.4% (4.4% to 15.5%) in patients with tumour on ink or close, and 7.4% (3.9% to 13.6%) in patients with negative margins. Compared with negative margins, tumour on ink margins were associated with increased distant recurrence (hazard ratio 2.10, 95% confidence interval 1.65 to 2.69, P<0.001) and local recurrence (1.98, 1.66 to 2.36, P<0.001). Close margins were associated with increased distant recurrence (1.38, 1.13 to 1.69, P<0.001) and local recurrence (2.09, 1.39 to 3.13, P<0.001) compared with negative margins, after adjusting for receipt of adjuvant chemotherapy and radiotherapy. In five studies published since 2010, tumour on ink margins were associated with increased distant recurrence (2.41, 1.81 to 3.21, P<0.001) as were tumour on ink and close margins (1.44, 1.22 to 1.71, P<0.001) compared with negative margins.

CONCLUSIONS

Involved or close pathological margins after breast conserving surgery for early stage, invasive breast cancer are associated with increased distant recurrence and local recurrence. Surgeons should aim to achieve a minimum clear margin of at least 1 mm. On the basis of current evidence, international guidelines should be revised.

SYSTEMATIC REVIEW REGISTRATION

CRD42021232115.

Machine Learning to Discern Interactive Clusters of Risk Factors for Late Recurrence of Metastatic Breast Cancer

Simple Summary

Breast cancer is the most frequently diagnosed cancer and second leading cause of cancer-related death among women worldwide. After initial tumor resection, breast cancer may recur locally and/or in distant organs within several months to years or even decades. Multiple methods exist to prognosticate disease progression in the early months and years after diagnosis. However, further efforts are needed to identify risk factors that relate to recurrence beyond the initial 5-year window. In this study, we applied machine learning to retrieve single and interactive clinical and pathological risk factors of 5-, 10- and 15-year metastases.

Abstract

Background: Risk of metastatic recurrence of breast cancer after initial diagnosis and treatment depends on the presence of a number of risk factors. Although most univariate risk factors have been identified using classical methods, machine-learning methods are also being used to tease out non-obvious contributors to a patient’s individual risk of developing late distant metastasis. Bayesian-network algorithms can identify not only risk factors but also interactions among these risks, which consequently may increase the risk of developing metastatic breast cancer. We proposed to apply a previously developed machine-learning method to discern risk factors of 5-, 10- and 15-year metastases. Methods: We applied a previously validated algorithm named the Markov Blanket and Interactive Risk Factor Learner (MBIL) to the electronic health record (EHR)-based Lynn Sage Database (LSDB) from the Lynn Sage Comprehensive Breast Center at Northwestern Memorial Hospital. This algorithm provided an output of both single and interactive risk factors of 5-, 10-, and 15-year metastases from the LSDB. We individually examined and interpreted the clinical relevance of these interactions based on years to metastasis and reliance on interactivity between risk factors. Results: We found that, with lower alpha values (low interactivity score), the prevalence of variables with an independent influence on long-term metastasis was higher (i.e., HER2, TNEG). As the value of alpha increased to 480, stronger interactions were needed to define clusters of factors that increased the risk of metastasis (i.e., ER, smoking, race, alcohol usage). Conclusion: MBIL identified single and interacting risk factors of metastatic breast cancer, many of which were supported by clinical evidence. These results strongly recommend the development of further large data studies with different databases to validate the degree to which some of these variables impact metastatic breast cancer in the long term.

The Incidence of Breast Cancer Recurrence 10-32 Years after Primary Diagnosis

Background

Extended, more effective breast cancer treatments have increased the prevalence of long-term survivors. We investigated the risk of late breast cancer recurrence (BCR), 10 years or more after primary diagnosis, and associations between patient and tumor characteristics at primary diagnosis and late BCR up to 32 years after primary breast cancer diagnosis.

Methods

Using the Danish Breast Cancer Group clinical database, we identified all women with an incident early breast cancer diagnosed during 1987-2004. We restricted to women who survived 10 years without a recurrence or second cancer (10-year disease-free survivors) and followed them from 10 years after breast cancer diagnosis date until late recurrence, death, emigration, second cancer, or December 31, 2018. We calculated incidence rates per 1000 person-years and cumulative incidences for late BCR, stratifying by patient and tumor characteristics. Using Cox regression, we calculated adjusted hazard ratios for late BCR accounting for competing risks.

Results

Among 36 924 women with breast cancer, 20 315 became 10-year disease-free survivors. Of these, 2595 developed late BCR (incidence rate = 15.53 per 1000 person-years, 95% confidence interval = 14.94 to 16.14; cumulative incidence = 16.6%, 95% confidence interval = 15.8% to 17.5%) from year 10 to 32 after primary diagnosis. Tumor size larger than 20 mm, lymph node–positive disease, and estrogen receptor–positive tumors were associated with increased cumulative incidences and hazards for late BCR.

Conclusions

Recurrences continued to occur up to 32 years after primary diagnosis. Women with high lymph node burden, large tumor size, and estrogen receptor–positive tumors had increased risk of late recurrence. Such patients may warrant extended surveillance, more aggressive treatment, or new therapy approaches.

A multi-center investigation of breast-conserving surgery based on data from the Chinese Society of Breast Surgery (CSBrS-005)

Background:

Although breast-conserving surgery is one of the standard treatments for breast cancer, few studies have assessed its recent implementation in China. We aimed to clarify the current real-world status of breast-conserving surgery in China.

Methods:

This cross-sectional survey relied on data collected by the Chinese Society of Breast Surgery (CSBrS) to examine patients who underwent this surgery between January 2018 and December 2018. The survey was conducted using a uniform electronic questionnaire to collect information, including clinical and pathological data on these patients.

Results:

Overall, 4459 breast-conserving surgeries were performed in 34 member units of CSBrS, accounting for 14.6% of all breast cancer surgeries performed in these units during the study period. In patients who underwent breast-conserving surgery with information on tumor size available, more than half (61.2%) of the tumors were smaller than 2 cm in diameter, and only 87 (3.2%) tumors were larger than 4 cm in diameter. Among patients who underwent breast-conserving surgeries, 457 (10.2%) patients received neoadjuvant therapy before the surgery. Among patients with a reported margin width, 34 (2.0%) patients had a margin of ≤2 mm, and 1530 (88.2%) of them had a margin of >5 mm.

Conclusions:

This study demonstrated the rates of breast-conserving surgery in member units of the CSBrS, and introduced the characteristics and surgical margins of patients who underwent this surgery. This information helps describe the real-world status of breast-conserving surgery in China.

Trial registration

chictr.org.cn, ChiCTR1900026841; http://www.chictr.org.cn/showproj.aspx?proj=42783

10-Year Survival after Breast-Conserving Surgery Compared with Mastectomy in Louisiana Women with Early-Stage Breast Cancer: A Population-Based Study

BACKGROUND

Louisiana has the third highest breast cancer mortality in the US, despite ranking 30th in incidence. Whether surgical approach contributes to such a poor outcome is unknown. We compared outcomes of breast-conserving surgery plus radiation (BCT) vs mastectomy (MST) for Louisiana women with early-stage breast cancer.

STUDY DESIGN

Data on women diagnosed with Stage I-II breast cancer from 2004 to 2016 were analyzed from the Louisiana Tumor Registry. Overall survival (OS) and breast cancer-specific survival (CSS) were compared between BCT and MST. Kaplan-Meier method and log-rank test were used to compare survival curves, and logistic regression was used to examine the association of sociodemographic and clinical factors with the type of breast cancer surgery. Values of p < 0.05 were considered significant.

RESULTS

Of the 18,260 patients, 9,968 patients (54.6%) had BCT and 8,292 patients (45.4%) had MST. Compared with BCT, the MST group tended to be underinsured/Medicare/Medicaid, more impoverished, had higher stage 2 disease, were more likely to reside in rural regions, travel ≥25 miles to radiation treatment facility, be treated at low volume centers, and have T3, node positive, and poorly differentiated tumors. Ten-year OS and CSS were significantly better among those who had BCT (OS: 80.0%; 95% CI: 79.0%-81.1%; CSS: 92.7%; 95% CI: 92.1%-93.4%) than those having MST (OS: 69.3%; 95% CI: 68.0%-70.5%; CSS: 88.8%:95% CI: 87.9%-89.7%) (p < 0.05). Even after controlling for sociodemographic and clinical variables, MST was associated with a 28.6% increased risk of death from all causes (hazard ratio [HR]:1.286; 95% CI:1.197-1.380) and a 29.8% increased risk of breast-cancer specific death (HR:1.298; 95% CI: 1.150-1.465).

CONCLUSIONS

Surgical approach, a factor that is within the control of the surgeon, has an impact on mortality for Louisiana women with early-stage breast cancer.

Characterization and imaging of surgical specimens of invasive breast cancer and normal breast tissues with the application of Raman spectral mapping: A feasibility study and comparison with randomized single-point detection method

A mapping technique was used in the present study to explore the biological and imaging characteristics of invasive breast cancer and normal breast tissues in Raman examination data and construct a diagnostic model for breast cancer. Raman examination data reflect the biochemical or molecular characteristics of the target tissues. A total of 45 specimens from patients with breast cancer who underwent surgery and 25 adjacent normal breast tissue specimens were included in the present study. Using the specimens, a total of 53 sets of mapping data and 2,597 pieces of Raman spectral data were obtained. The collected spectra were corrected and fitted, the Raman spectra were analyzed by robust statistical methods, and a diagnostic model was constructed using the k-Nearest Neighbor (KNN) method. The KNN classification method was applied to analyze the characteristics of the mapping test application. The percentage of outliers in the mapping data for malignant and normal breast tissues was 12.7 and 6.6%, respectively. The percentage of outlier data in the conventional single-point detection data for malignant and normal breast tissues was 24.5 and 26.0%, respectively. Analysis using a t-test identified a significant difference in the number of outliers between mapping and single-point detection for malignant (t=−6.169; P<0.001) and normal breast tissues (t=−8.873; P<0.001). Based on the mapping data, the accuracy, sensitivity and specificity for breast cancer detection by the diagnostic model constructed using the KNN method was 99.56, 96.6 and 98.48%, respectively. The positive and negative predictive value of this model was 99.56 and 89.04%, respectively. The data obtained by mapping technology demonstrated improved stability and contained less outliers compared with single-point detection. The diagnostic model constructed using the mapping data demonstrated excellent diagnostic performance and good correspondence with pathological results. The findings of the present study demonstrated the feasibility of the application of the diagnostic model for intraoperative real-time imaging for patients with breast cancer. This study provided the foundation of Raman spectroscopy-based diagnostic imaging at the molecular level.

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Background

There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting.

Methods

In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias.

Results

A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching.

Conclusion

A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.

The Diminishing Impact of Margin Definitions and Width on Local Recurrence Rates following Breast-Conserving Therapy for Early-Stage Invasive Cancer: A Meta-Analysis

BACKGROUND

The optimal tumor-free margin definition and width following breast-conserving therapy (BCT) for early-stage invasive cancers has been evaluated in previous meta-analyses and guidelines. We performed an updated meta-analysis to assess how improvements in treatment over time have affected the impact of margins on local recurrence (LR) rates over time.

METHODS

A systematic literature review identified 38 eligible studies comprising 54,502 patients treated between 1968 and 2010. Inclusion criteria included patients treated with BCT and minimum follow-up of 50 months, pathologic definitions of margin status explicitly stated, and LR data in relation to margin status. Data were pooled using a Bayesian logistic regression model to evaluate the risk of LR in relation to both margin status and study enrollment periods.

RESULTS

Median follow-up was 7.25 years. Absolute LR rates decreased over time for each margin width cohort, with maximum differences between negative margin groups of less than 1% for the most recent enrollment period. However, relative rates of LR between different margin groups remained stable over time.

CONCLUSIONS

With an additional 22,000 patients compared with the previous meta-analysis, this updated meta-analysis supports the consensus guideline of "no tumor on ink" for the majority of patients. Additionally, while concerns exist regarding a benefit with wider margins from previous studies, the analysis demonstrates the impact of margin width on LR rates has declined substantially over time, with very small differences between the narrowest and widest margin groups in the most recent cohort. Hence, older studies appear to have limited value to inform current management guidelines.

Partial chest wall radiation therapy for positive or close surgical margins after modified radical mastectomy for breast cancer without lymph node metastasis

Aim

Whole‐breast radiation therapy after breast‐conserving surgery can control local recurrence with a long‐term survival rate equivalent to that of radical mastectomy for patients with early breast cancer. However, the significance of radiation therapy for patients with positive/close margins after mastectomy remains controversial. Following radical mastectomy, no residual breast parenchyma remains, and thus radiation therapy of the entire chest wall may represent overtreatment in the patients, especially those without lymph node metastasis (N0). We therefore implemented partial chest wall radiation therapy for patients with N0 breast cancer and positive and/or close margins after mastectomy.

Methods

A total of 22 patients with N0 status but positive/close margins underwent partial chest wall radiation therapy to irradiate the predetermined clinical target volume, which had margins of at least 2 cm medial, lateral, superior, and inferior to the primary tumor bed. With reference to chest wall thickness, 4‐10‐MV photons or 5‐8‐MeV electrons with/without a bolus were delivered. The total dose was 50‐66 Gy. We compared the results with those from 18 nonradiation therapy patients using Pearson's χ² test.

Results

All patients in the partial chest wall radiation therapy group achieved good local control despite having a significantly higher proportion of positive margins (77.3%) compared with the nonradiation therapy group (27.8%) (P = 0.002). Both groups showed 100% recurrence‐ and disease‐free survival.

Conclusion

Partial chest wall radiation therapy may offer recurrence‐ and disease‐free survival without local recurrence in N0 mastectomy patients with positive/close surgical margins.

Towards the use of diffuse reflectance spectroscopy for real-time in vivo detection of breast cancer during surgery

Background

Breast cancer surgeons struggle with differentiating healthy tissue from cancer at the resection margin during surgery. We report on the feasibility of using diffuse reflectance spectroscopy (DRS) for real-time in vivo tissue characterization.

Methods

Evaluating feasibility of the technology requires a setting in which measurements, imaging and pathology have the best possible correlation. For this purpose an optical biopsy needle was used that had integrated optical fibers at the tip of the needle. This approach enabled the best possible correlation between optical measurement volume and tissue histology. With this optical biopsy needle we acquired real-time DRS data of normal tissue and tumor tissue in 27 patients that underwent an ultrasound guided breast biopsy procedure. Five additional patients were measured in continuous mode in which we obtained DRS measurements along the entire biopsy needle trajectory. We developed and compared three different support vector machine based classification models to classify the DRS measurements.

Results

With DRS malignant tissue could be discriminated from healthy tissue. The classification model that was based on eight selected wavelengths had the highest accuracy and Matthews Correlation Coefficient (MCC) of 0.93 and 0.87, respectively. In three patients that were measured in continuous mode and had malignant tissue in their biopsy specimen, a clear transition was seen in the classified DRS measurements going from healthy tissue to tumor tissue. This transition was not seen in the other two continuously measured patients that had benign tissue in their biopsy specimen.

Conclusions

It was concluded that DRS is feasible for integration in a surgical tool that could assist the breast surgeon in detecting positive resection margins during breast surgery.

Trail registration NIH US National Library of Medicine–clinicaltrails.gov, NCT01730365. Registered: 10/04/2012 https://clinicaltrials.gov/ct2/show/study/NCT01730365

Factors predicting local relapse and survival in patients treated with surgery for breast cancer

BACKGROUND

Assessment of local relapse in patients treated with surgery for breast cancer.

MATERIALS AND METHODS

This observational study included 673 patients treated with surgery for breast cancer between 2005 and 2010, who were monitored for a 7-year minimum follow-up period. The study was concluded on 2017 and yielded a total of 31 cases of local relapse.

RESULTS

4.6% of patients presented local relapse, most of them during the first 3 years of follow-up; 45% of patients with local relapse subsequently presented the disease at distant points. The association between the occurrence of local relapse and later onset of the disease at distant points was significant. The Kaplan-Meier survival analysis revealed that negative results for the presence of progesterone receptors, the use of neoadjuvant chemotherapy and the presence of the disease at distant points were factors that significantly influenced patient survival.

CONCLUSIONS

Almost half of the patients suffering relapse subsequently present the disease at distant points. Certain factors increase the aggressiveness of the disease, predict higher risk of relapse and determine its prognosis.

Evolution of radiotherapy techniques in breast conservation treatment

Radiation therapy (RT) is an important component of breast cancer treatment that reduces local recurrence and improves survival after breast conservation. Breast conservation rates have increased significantly since the late 1980s and techniques have improved with greater awareness of the impact of radiation on the heart. An overview of randomized controlled trials of breast conservation using standard whole breast irradiation, whole breast hypofractionation, accelerated partial breast irradiation (APBI) and intraoperative radiation are reviewed. Selection criteria for breast conservation and the utility of adding a boost dose to the primary tumor site are reviewed. Modern dose constraints are documented and 10 different radiation techniques from the 1980s through to modern volumetric modulated arc therapy (VMAT) are compared for a patient where the breast and internal mammary nodes are treated. A radiation boost reduces the risk of a recurrence for most, but not all patients. Short courses of RT over 3-4 weeks are generally as effective as longer courses. Short-term follow-up of trials of APBI show promise for selected good prognosis subgroups. The role of intraoperative radiation remains controversial. In the last 30 years, there have been significant advances in radiation techniques. Modern radiotherapy equipment and techniques will reduce complications and improve survival rates.

Can invasive breast carcinoma with close or positive margins be managed without a new surgery?

We present the long-term outcome (FU 127 months) of a prospective study with 248 breast cancer patients with close or positive surgical margin, treated with 50 Gy whole breast irradiation plus high-dose-rate boost, 3 × 4.4 Gy. Actuarial breast failure at 10/15 years was 6.5%/11.6%; with positive margin (120) 6.8%/14.8%, with margin ≤2 mm (76) 9.8%/9.8%, with margin >2 mm <5 mm (52) 2%/2%. In 90 patients aged ≤50 was 11.9%/17.8%, between 51 and 70, 3.8%/8.2%, >70, 0%. Fibrosis appeared in 26.7%. Cosmetic outcome was excellent/good in 85.8%. This approach avoids a second surgery in women >50 with positive surgical margin, or with close margins in all ages.

The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy

OBJECTIVES

Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB.

METHODS

This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days-whichever occurred first.

RESULTS

In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P < .001). Mean incremental commercial payments were US $13 190 greater among patients with 1 open procedure vs PCNB alone (US $17 125 vs US $3935, P < .001), and US $4767 greater with re-excision (US $21 892) relative to 1 procedure. Mean patient OOP cost was US $858 greater for 1 open procedure vs PCNB alone (US $1527 vs US $669), and US $247 greater for re-excision vs 1 procedure.

CONCLUSIONS

A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision.

Breast conserving surgery versus mastectomy: overall and relative survival-a population based study by the Danish Breast Cancer Cooperative Group (DBCG)

BACKGROUND

Observational studies have pointed at a better survival after breast conserving surgery (BCS) compared with mastectomy. The aim of the present study was to evaluate whether this remains true when more extensive tumor characteristics and treatment data were included.

METHODS

The cohort included patients registered after primary surgery for early invasive breast cancer in the database of the Danish Breast Cancer Cooperative Group, in the period 1995-2012. The cohort was divided into three groups: (i) patients who primarily had a mastectomy, (ii) patients treated by BCS, and (iii) patients who primarily had BCS and then mastectomy [intention to treat (ITT) by BCS]. The association between overall mortality and standard mortality ratio (SMR) and risk factors was analyzed in univariate and multivariate Poisson regression models.

RESULTS

A total of 58,331 patients were included: 27,143 in the mastectomy group, 26,958 in the BCS group, and 4230 in the BCS-ITT group. After adjusting for patient and treatment characteristics, the relative risk (RR) was 1.20 (95% CI: 1.15-1.25) after mastectomy and 1.08 (95% CI: 1.01-1.15) after BCS first and then mastectomy, as compared to BCS. Statistically significant interactions were not observed for age, period of treatment, and nodal status, but patients with Charlson's Comorbidity Index (CCI) score 2+ had no increased mortality after mastectomy, as opposed to patients with CCI 0-1. Loco-regional radiation therapy (RT) in node positive patients did not reduce the increased risk associated with mastectomy [RR = 1.28 (95% CI 1.19-1.38)].

CONCLUSION

Patients assigned to BCS have a better survival than patients assigned to mastectomy. Residual confounding after adjustment for registered characteristics presumably explained the different outcomes, thus consistent with selection bias. Diversities in RT did not appear to explain the observed difference in survival after BCS and mastectomy.

Radiation therapy and early breast cancer: current controversies

Radiation therapy (RT) is an important component of breast cancer treatment. RT reduces local recurrence and breast cancer mortality after breast conservation for all patients and for node-positive patients after a mastectomy. Short courses of RT over 3-4 weeks are generally as effective as longer courses. A patient subgroup where RT can be avoided after conservative surgery has not been consistently identified. A radiation boost reduces the risk of a recurrence in the breast but may be omitted for older patients with good prognosis tumours with clear margins. Axillary recurrences can take a long time to appear, with 35% occurring after 5 years. Leaving disease untreated in regional nodes is associated with reduced survival. Not all patients require radiation after neoadjuvant chemotherapy and a subsequent mastectomy. Modern RT equipment and techniques will further improve survival rates.

Indications and Controversies in Partial Mastectomy Defect Reconstruction

Breast cancer surgical treatment nowadays includes oncoplastic surgery. It is a reliable oncologic surgical treatment, which also prevents functional and aesthetic sequelae, thus improving the patient's quality of life and satisfaction. Numerous techniques have been described, with different levels of complexity and technicality. Their indications differ depending on the global breast volume and the degree of ptosis, on the tumor volume compared with the breast volume, and on the tumor location. This article describes the authors' many years of experience of breast cancer treatment using oncoplastic surgery. They also established a decision-making guide, whose implementation enables treatment of every patient.

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

BACKGROUND

The Society of Surgical Oncology and American Society of Radiation Oncology consensus statement was the first professional guideline in breast oncology to declare "no ink on tumor" as a negative margin in patients with stages I/II breast cancer undergoing breast-conservation therapy. We sought to analyze the financial impact of this guideline at our institution using a historic cohort.

STUDY DESIGN

We identified women undergoing re-excision after breast-conserving surgery for invasive breast cancer from 2010 through 2013 using a prospectively maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis.

RESULTS

Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with ductal carcinoma in situ. A subcohort of 83 patients (32.7%) who underwent breast-conservation therapy for stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure, per the Society of Surgical Oncology and American Society of Radiation Oncology guideline. The majority had invasive ductal carcinoma (n = 70 [84.3%]) and had invasive disease (n = 45 [54.2%]), and/or ductal carcinoma in situ (n = 49 [59.0%]) within 1 mm of the specimen margin. Seventy-nine patients underwent 1 re-excision and 4 patients underwent 2 re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations.

CONCLUSIONS

Implementation of the Society of Surgical Oncology and American Society of Radiation Oncology consensus guideline holds great potential to optimize resource use. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Additional analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

Comparison of two different types of oxidized regenerated cellulose for partial breast defects

BACKGROUND

A defect after partial mastectomy, sometimes, is hard to be filled with patient's own breast tissue. Two different types of oxidized regenerated cellulose (ORC) for filling of partial defects in small-sized breasts were compared with respect to clinicopathologic factors and outcomes.

METHODS

A total of 45 patients with breast cancer underwent conventional partial mastectomy with insertion of an ORC filling material. The two filling materials used were a hemostasis-purposed ORC and adhesion barrier-purposed ORC. Clinical factors were compared between these two ORC materials. Both the surgeon and patient assessed the cosmetic outcomes using the Harvard/NSABP/RTOG Breast Cosmesis Grading Scale.

RESULTS

Partial mastectomy with filling material insertion technique was not inferior to partial mastectomy-only technique in many clinical aspects. And most of the clinicopathologic factors showed no significant difference between the two groups. However, the mean operation time was significantly shorter in the hemostasis-purposed ORC group (P = 0.027). In addition, the infection rate was significantly higher in the adhesion barrier-purposed ORC group (P = 0.040).

CONCLUSIONS

Reconstructive surgery using a hemostasis-purposed ORC was associated with a shorter operation time and lower incidence of postoperative infection than that using an adhesion barrier-purposed ORC. However, both types of ORC were feasible as filling compounds for partial defects of the breast.