Comparison of breast-conserving surgery and mastectomy in early breast cancer using observational data revisited: a propensity score-matched analysis

Can We Do Breast-Conserving Surgery Without Intraoperative Frozen Section of Margin?

PURPOSE

This study was a retrospective and nonrandomized study to assess the safety and reliability of identifying the surgical margin in breast cancer breast-conserving surgery (BCS) by using intraoperative ultrasonic location and specimen mammography instead of traditional intraoperative frozen pathological section.

METHODS

Among the patients who underwent BCS from May 2019 to October 2021, according to the different methods of evaluating the intraoperative margin, 104 breast cancer patients were included in the frozen edge group, 53 breast cancer patients were included in the freeze-free group, and the surgeon judged whether extended resection was needed based on the results of pathological section or evaluation of intraoperative ultrasound and mammography. The surgical margins of the two groups were judged by postoperative pathological results as the gold standard.

RESULTS

The median waiting pathology results time in the frozen edge group was 64 minutes, while the waiting time in the freeze-free group was 30 minutes, and the difference was statistically significant (P < .0001). The postoperative pathological results showed that the positive rate of the surgical margin in the frozen edge group was 0.96%. The coincidence rate of intraoperative frozen and postoperative pathological results was 99.04%. The coincidence rate between intraoperative mammography and postoperative pathological results was 100%.

CONCLUSIONS

In BCS, the method of using intraoperative staining markers combined with mammography to evaluate the resection margin is highly accurate, reliable, economical and convenient, and at the same time reduces the waiting time of the operator during the operation. However, this was not a randomized controlled study, and there was patient selection bias, and its safety needs to be confirmed by long-term follow-up. In the future, it is expected to become the mainstream means of evaluating.

Comparison of breast-conserving surgery without radiotherapy and mastectomy in the treatment of elderly patients with early breast cancer: A PSM and SEER database study

BACKGROUND

At present, there is no research on which surgical method can lead to a better prognosis in elderly patients with early breast cancer. The purpose of this study was to establish a nomogram to predict the survival outcome of elderly patients with early breast cancer and to compare the prognosis of the breast-conserving surgery (BCS) group who did not receive postoperative radiotherapy and the mastectomy group through risk stratification.

METHODS

This study included patients with early breast cancer aged ≥70 years from the Surveillance, Epidemiology, and End Results database (n = 20,520). The group was randomly divided into a development cohort (n = 14,363) and a validation cohort (n = 6157) according to a ratio of 7:3. Risk factors affecting overall survival (OS) and breast-cancer-specific survival (BCSS) were analyzed using univariate and multivariate Cox regression. Present results were obtained by constructing nomograms and risk stratifications. Nomograms were evaluated by the concordance index and calibration curve. Kaplan-Meier curves were established based on BCSS and analyzed using the log-rank test.

RESULTS

Multivariate Cox regression results showed that age, race, pathological grade, T and N stages, and progesterone receptor (PR) status were independent risk factors for OS and BCSS in the BCS group and mastectomy group. Subsequently, they were incorporated into nomograms to predict 3- and 5-year OS and BCSS in patients after BCS and mastectomy. The concordance index was between 0.704 and 0.832, and the nomograms also showed good calibration. The results of risk stratification showed that there was no survival difference between the BCS group and the mastectomy group in the low-risk and high-risk groups. In the middle-risk group, BCS improved the BCSS of patients to a certain extent.

CONCLUSION

This study constructed a well-performing nomogram and risk stratification model to assess the survival benefit of BCS without postoperative radiotherapy in elderly patients with early breast cancer. The results of the study can help clinicians analyze the prognosis of patients and the benefits of surgical methods individually.

Radiomic and clinical data integration using machine learning predict the efficacy of anti-PD-1 antibodies-based combinational treatment in advanced breast cancer: a multicentered study

BACKGROUND

Immune checkpoint inhibitors (ICIs)-based therapy, is regarded as one of the major breakthroughs in cancer treatment. However, it is challenging to accurately identify patients who may benefit from ICIs. Current biomarkers for predicting the efficacy of ICIs require pathological slides, and their accuracy is limited. Here we aim to develop a radiomics model that could accurately predict response of ICIs for patients with advanced breast cancer (ABC).

METHODS

Pretreatment contrast-enhanced CT (CECT) image and clinicopathological features of 240 patients with ABC who underwent ICIs-based treatment in three academic hospitals from February 2018 to January 2022 were assigned into a training cohort and an independent validation cohort. For radiomic features extraction, CECT images of patients 1 month prior to ICIs-based therapies were first delineated with regions of interest. Data dimension reduction, feature selection and radiomics model construction were carried out with multilayer perceptron. Combined the radiomics signatures with independent clinicopathological characteristics, the model was integrated by multivariable logistic regression analysis.

RESULTS

Among the 240 patients, 171 from Sun Yat-sen Memorial Hospital and Sun Yat-sen University Cancer Center were evaluated as a training cohort, while other 69 from Sun Yat-sen University Cancer Center and the First Affiliated Hospital of Sun Yat-sen University were the validation cohort. The area under the curve (AUC) of radiomics model was 0.994 (95% CI: 0.988 to 1.000) in the training and 0.920 (95% CI: 0.824 to 1.000) in the validation set, respectively, which were significantly better than the performance of clinical model (0.672 for training and 0.634 for validation set). The integrated clinical-radiomics model showed increased but not statistical different predictive ability in both the training (AUC=0.997, 95% CI: 0.993 to 1.000) and validation set (AUC=0.961, 95% CI: 0.885 to 1.000) compared with the radiomics model. Furthermore, the radiomics model could divide patients under ICIs-therapies into high-risk and low-risk group with significantly different progression-free survival both in training (HR=2.705, 95% CI: 1.888 to 3.876, p<0.001) and validation set (HR=2.625, 95% CI: 1.506 to 4.574, p=0.001), respectively. Subgroup analyses showed that the radiomics model was not influenced by programmed death-ligand 1 status, tumor metastatic burden or molecular subtype.

CONCLUSIONS

This radiomics model provided an innovative and accurate way that could stratify patients with ABC who may benefit more from ICIs-based therapies.

Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscopy 'Histolog® scanner' for breast margin assessment in comparison with conventional specimen radiography

PURPOSE

The Histolog® Scanner (SamanTree Medical SA, Lausanne, Switzerland) is a large field-of-view confocal laser scanning microscope designed to allow intraoperative margin assessment by the production of histological images ready for assessment in the operating room. We evaluated the feasibility and the performance of the Histolog® Scanner (HS) to correctly identify infiltrated margins in clinical practice of lumpectomy specimens. It was extrapolated if the utilization of the HS has the potential to reduce infiltrated margins and therefore reduce re-operation rates in patients undergoing breast conserving surgery (BCS) due to a primarily diagnosed breast cancer including ductal carcinoma in situ.

METHODS

This is a single-center, prospective, non-interventional, diagnostic pilot study including 50 consecutive patients receiving BCS. The complete surface of the specimen was scanned using the HS intraoperatively. The surgery and the intraoperative margin assessment of the specimen was performed according to the clinical routine consisting of conventional specimen radiography as well as the clinical impression of the surgeon. Three surgeons and an experienced pathologist assessed the scans produced by the HS for cancer cells on the surface. The potential of the HS to correctly identify involved margins was compared to the results of the conventional specimen radiography alone as well as the clinical routine. The histopathological report served as the gold standard.

RESULTS

50 specimens corresponding to 300 surfaces were scanned by the HS. The mean sensitivity of the surgeons to identify involved margins with the HS was 37.5% ± 5.6%, the specificity was 75.2% ± 13.0%. The assessment of resection margins by the pathologist resulted in a sensitivity of 37.5% and a specificity of 81.0%, while the local clinical routine resulted in a sensitivity of 37.5% and a specificity of 78.2%.

CONCLUSION

Acquisition of high-resolution histological images using the HS was feasible in clinical practice. Sensitivity and specificity were comparable to clinical routine. With more specific training and experience on image interpretation and acquisition, the HS may have the potential to enable more accuracy in the margin assessment of BCS specimens.

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

Long-term Survival Comparison of Repeated Breast-conserving Surgery Versus Mastectomy for Patients with DCIS with Ipsilateral Breast Tumor Recurrence: A Real-world Longitudinal Study

BACKGROUND

Although patients diagnosed with ductal carcinoma in situ (DCIS) harbor excellent overall survival (OS) after breast-conserving therapy, the evidence regarding to surgical management for ipsilateral breast tumor recurrence (IBTR) is scarce. This study aimed to assess the prognosis of repeated breast-conserving surgery (BCS) versus mastectomy for IBTR in DCIS survivors.

MATERIALS AND METHODS

Herein, 5344 DCIS cases with IBTR were identified during 702,748 person-years of follow-up, 3532 (66.09%) received mastectomy, and 1812 (33.91%) received repeated BCS. Cox regression and competing risk regression were employed to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for OS and breast cancer-specific survival (BCSS), which was respectively calculated within spontaneous and matched cohorts.

RESULTS

After adjustment for confounders, no statistically significant survival difference was observed between the repeated BCS and mastectomy for patients with DCIS with IBTR. The stratified analyses further revealed that patients with DCIS with IBTR receiving repeated BCS combined with radiation therapy were associated with both superior OS (HR, 0.79; CI, 0.64-0.98; P = .04) and BCSS (HR, 0.54; CI, 0.33-0.90; P = .02) compared with counterparts undergoing mastectomy. Furthermore, patients with DCIS who were age older than 60 years at IBTR diagnosis benefit from repeated BCS with radiotherapy (HR, 0.44; CI, 0.24-0.84; P = .01) than mastectomy.

CONCLUSION

We suggest that repeated BCS with radiation therapy deserves consideration when DCIS survivors suffered IBTR. The choice of surgical management should be tailored based on patients' age at IBTR diagnosis and size of recurrent disease.

The prognostic and predictive value of the 8th American Joint Committee on Cancer (AJCC) staging system among early breast cancer patients aged <50 years

Background

This study respectively analyzed the prognostic value and the role in treatment decision-making [breast-conserving surgery (BCS) + radiotherapy (RT) or mastectomy (MAST)] of the 8th American Joint Committee on Cancer (AJCC) pathological prognostic staging system compared with the 7th AJCC anatomical staging system among early breast cancer patients aged <50 years.

Methods

Patients with T1-2N0M0 breast cancer aged <50 years were extracted from the Surveillance, Epidemiology, and End Results database between 2010 and 2014. Breast cancer-specific survival (BCSS) was used as the primary endpoint. Chi-squared test, receiver operating characteristics analysis, Kaplan-Meier method, and multivariate Cox proportional models were used to conduct statistical analysis.

Results

A total of 22,640 female patients were identified, and 24.4% of them reallocated to new stage groups from the 7th to the 8th AJCC staging. Among them, 46.2% (n=10,450) and 53.8% (n=12,190) of patients received BCS + RT and MAST, respectively. The 8th AJCC staging system was an independent prognostic factor for BCSS. Patients treated with BCS + RT had better BCSS compared to those treated with MAST (P<0.001). According to the 8th AJCC staging, BCS + RT could improve 5-year BCSS compared with MAST in patients with stage IA (P=0.006) and stage IB (P=0.001) diseases, while comparable BCSS was found between the two treatment arms in patients' stage IIA disease (P=0.366). Multivariate analyses replicated similar findings after stratification by the 8th AJCC stages.

Conclusions

In patients with T1-2N0 breast cancer and aged <50 years, the 8th AJCC pathological staging system provides accurate prognostic information than the 7th anatomical staging. BCS + RT is the optimal local management for stage IA and IB diseases, while it is the optional management in stage IIA disease according to the 8th AJCC staging.

Triple-negative breast cancer: new treatment strategies in the era of precision medicine

Triple-negative breast cancer (TNBC) remains the most aggressive cluster of all breast cancers, which is due to its rapid progression, high probabilities of early recurrence, and distant metastasis resistant to standard treatment. Following the advances in cancer genomics and transcriptomics that can illustrate the comprehensive profiling of this heterogeneous disease, it is now possible to identify different subclasses of TNBC according to both intrinsic signals and extrinsic microenvironment, which have a huge influence on predicting response to established therapies and picking up novel therapeutic targets for each cluster. In this review, we summarize basic characteristics and critical subtyping systems of TNBC, and particularly discuss newly found prospective targets and relevant medications, which were proved promising in clinical trials, thus shedding light on the future development of precision treatment strategies.