Locoregional recurrence in breast carcinoma patients

Considerable Long-Term Aesthetic Outcomes and Oncologic Safety of Breast-Conserving Surgery Via a Periareolar Incision: A Retrospective Study

BACKGROUND

To investigate the application effect of periareolar incision breast-conserving surgery in patients with early breast cancer.

METHODS

From January 2017 to November 2021, a clinician in our research center performed a total of 533 breast-conserving surgery. After screening, we collected the information of 209 patients through telephone, online questionnaires, and outpatient follow-up. One hundred seventeen patients with early breast cancer underwent breast-conserving surgery under the periareolar incision, while 92 patients underwent surgery through the tumor surface incision. We compared the differences between the 2 groups in the length of stay, postoperative complications, adjuvant therapy, and other clinical indicators, as well as the subjective and objective evaluation of the long-term postoperative breast aesthetic outcome, local recurrence, distant metastasis, and survival.

RESULTS

With a mean follow-up of 3.9 years, patients in the periareolar incision group (PAIG) and tumor surface incision group (TSIG) had no significant differences in clinical indicators, local recurrence, distant metastasis, and survival. However, PAIG patients had better subjective satisfaction with postoperative breast appearance. In the evaluation of objective aesthetic outcomes, PAIG was significantly better than TSIG in texture and elasticity, symmetry, sunken degree of the operative side, skin color, surgical scar, and breast compliance difference.

CONCLUSION

By observing and comparing the clinical indicators, postoperative recurrence, and metastasis of the enrolled patients, this study found that periareolar incision surgery could achieve radical therapeutic effects similar to those achieved through tumor surface incision, and had advantages in improving postoperative aesthetic outcomes, which could provide certain references for clinical practice.

Feasibility and safety of breast-conserving surgery via a periareolar incision for cancers located far from the nipple-areolar complex: a retrospective study

Purpose

We performed breast-conserving surgery (BCS) using periareolar incisions for cancers located far from the nipple–areolar complex (NAC) and examined if BCS via a periareolar incision maximized cosmesis and maintained oncologic safety. One of the most important goals of BCS is to improve cosmesis after surgery and quality of life, but the skin incision can affect cosmesis based on the tumor location.

Methods

Fifty-five patients with breast cancers located far from the NAC underwent BCS via periareolar incisions between January 2017 and April 2018. If a sentinel lymph node biopsy was required, another skin incision was created in the axilla using the conventional technique. Medical records of patients were reviewed retrospectively.

Results

The mean patient age was 48.1 ± 10.6 years. The mean tumor size was 1.8 ± 1.0 cm (range 0.2–4.5 cm) on preoperative magnetic resonance imaging (MRI); the mean distance from the NAC to the tumor was 5.9 ± 1.9 cm (range 4.0–12.3 cm). Patients with cancers in the subareolar area were excluded even though the distance from the nipple was > 4 cm on MRI. Negative microscopic margins were obtained in all patients. There was no surgical complication such as seroma, bleeding, or infection. Re-operation was not needed. All patients received whole breast radiation therapy. After surgery and radiation therapy, periareolar incision scars were nearly invisible.

Conclusion

For cancers located far from the NAC, BCS via periareolar incisions is feasible and leads to superior cosmesis in selective patients. Moreover, BCS seems oncologically safe, although long-term outcomes need to be evaluated.

Clinical Safety of Stromal Vascular Fraction Separation at the Point of Care

INTRODUCTION

Pluripotential cells in adipose tissue may be important in long-term volume retention and regenerative effects of fat grafting. Unfortunately, graft harvest with lipoaspiration significantly depletes the population of stromal vascular cells, which includes adipose stem cells. Stromal vascular fraction (SVF) cells may be isolated from excess lipoaspirate at the point of care and used to replenish fat grafts, a technique termed cell-assisted lipotransfer (CAL). Preclinical and clinical evidence supports the rationale of CAL but clinical adoption of the strategy requires evidence of clinical safety. This prospective, level 1 study reports clinical safety of SVF-enhanced fat grafting using a manual, collagenase-based separation process to isolate autogenous progenitor cells from lipoaspirate at the point of care.

METHODS

One hundred sixty-four subjects underwent 174 SVF-enhanced autologous fat grafting procedures at the university stem cell center between August 2009 and November 2014 for a variety of cosmetic and reconstructive indications.

RESULTS

Cell-assisted lipotransfer was performed for a variety of cosmetic and reconstructive indications. The mean time of the SVF isolation process was 91 minutes. Because of the frequent concomitant procedures, the average operating room time increased by only 11 minutes. Mean follow-up was 19.9 months. There were no major complications and 6 minor complications. No collagenase or neutral protease related complications were observed.

CONCLUSIONS

This series of 174 CAL cases demonstrates that SVF cell isolation using a standardized, manual, collagenase-based process at the POC is equivalent in safety compared to nonenhanced fat grafting. These results support expanded use of CAL in the clinical research setting.

Safe negative margin width in breast conservative therapy: results from a population with a high percentage of negative prognostic factors

BACKGROUND

There remains a controversy in the literature regarding adequate width of negative surgical margins in breast conservative therapy (BCT). It is now advocated that no tumor on an inked margin is a safe negative margin. Majority of studies on the outcomes of BCT had patients with favorable prognostic factors. Pakistani population has a high expression of unfavorable prognostic factors. The objective of this study was to determine a safe negative margin width in Pakistani population that undergoes BCT.

METHODS

A total of 603 patients with identifiable surgical margins underwent BCT from 1997 to 2009 in Shaukat Khanum Cancer Hospital. Patients were divided into close (≤2 mm), free (>2-10 mm), and wide (>10 mm) margin groups. Locoregional recurrence was defined as recurrence within the operated breast, ipsilateral axilla, or supraclavicular or internal mammary lymph nodes. Locoregional recurrence-free survival was calculated from the date of surgery to the date of locoregional recurrence. Five-year locoregional recurrence-free survival was determined for margin groups. Univariate and multivariate Cox proportional hazard analyses were performed to determine independent predictors of locoregional recurrence.

RESULTS

A total of 415 (69 %) patients were <50 years of age. There were 82 (15 %) T3/T4, 337 (56 %) poorly differentiated, and 238 (39 %) ER/PR -ve tumors. Nodal positivity was present in 314 (52 %) patients. The actual number of locoregional recurrences was 16 (12 %), 8 (3 %), and 10 (4.6 %), respectively (P = 0.002). Expected 5-year locoregional recurrence-free survival was 90, 97, and 96 %, respectively (P = 0.002). On multivariate analysis, tumor size, nodal involvement, and negative margin width were independent predictors of locoregional recurrence.

CONCLUSION

A negative margin width of 2 mm might represent an adequate negative margin width in the Pakistani population undergoing breast conservative therapy.

How to identify patients with increased risk of breast cancer relapse?

A cohort of 362 breast cancer patients had subtype classification accomplished using 4 immunohistochemical markers: luminal A (ER or PR positive, HER2 negative, Ki-67<14%), luminal B (ER or PR positive, HER2 negative, Ki-67≥14%), luminal HER2 (ER or PR positive, HER2 positive), HER2 enriched (ER or PR negative, HER2 positive) or triple negative (ER, PR, and HER2 negative). Multivariable Cox analysis was used to determine the risk of local (LR) or distant (DR) relapse associated with the intrinsic subtypes, adjusting for standard clinicopathologic factors. There have been a total of 124 recurrences. Triple-negative patients were associated with increased risk of LR. Luminal B subtype showed statistical tendency (P=0.053) to LR. For patients undergoing breast conservation surgery, luminal B and HER2-enriched subtypes demonstrated an increased risk to LR, and this was statistically significant on multivariable analysis. After mastectomy, there was no statistical difference between subtypes of LR or DR on multivariable analysis. Luminal A tumors are associated with a low risk of LR or DR. Despite the existence of gene expression profiling, in the current study we demonstrate that analysis of 4 immunohistochemical markers is equally effective and less expensive alternative to identify higher recurrence risk patients.

US screening for detection of nonpalpable locoregional recurrence after mastectomy

PURPOSE

To assess the value of screening ultrasonography (US) in the detection of nonpalpable locoregional recurrence following mastectomy for breast cancer and to describe the US appearances of occult recurrent cancers.

MATERIALS AND METHODS

During a 36-month period, 1180 consecutive US screenings were performed for mastectomy sites and ipsilateral axillary fossae in 468 asymptomatic women who had undergone mastectomy for breast cancer. All US results were divided into three groups: negative findings, probably benign nodules, and suspicious for malignant nodules. The final diagnoses were based on pathology results and clinical or sonographic follow-up for more than 12 months. The diagnostic performance of US for detecting nonpalpable locoregional recurrence was assessed. The US appearances of occult recurrent cancers were retrospectively reviewed.

RESULTS

Of the 468 patients assessed, 19 (4.1%) showed "suspicious for malignant nodules"; of these lesions, 10 were malignant. One false-negative case was identified. The sensitivity and specificity were 90.9% and 98.0%, respectively. A biopsy positive predictive value of 52.6% was observed. Cancer detection rates were 2.1% with US screenings of mastectomy sites and ipsilateral axillary fossae. The common US features of occult recurrences at the mastectomy sites were irregular shaped, not-circumscribed marginated, and hypoechoic masses with intratumoral vascularities. The most common location was within the deep muscle layer.

CONCLUSION

Although locoregional recurrence infrequently occurs after mastectomy for breast cancer, screening US enables detection of nonpalpable cancer before it can be detected by clinical examination. Routine follow-up US can be advocated for early detection of nonpalpable locoregional recurrent cancer.

Locoregional recurrence risk factors in breast cancer patients with positive axillary lymph nodes and the impact of postmastectomy radiotherapy

BACKGROUND

Locoregional recurrence (LRR) after mastectomy reduces the patient's quality of life and survival. There is a consensus that postmastectomy radiotherapy (PMRT) helps establish locoregional control and reduces LRR in patients with ≥4 metastatic nodes. However, in patients with 1-3 metastatic nodes, the incidence of LRR and the role of PMRT have been the subject of substantial controversy. This study assessed the risk factors for LRR and the efficacy of PMRT in Japanese breast cancer patients with metastatic nodes.

METHODS

This study analyzed 789 cases of invasive breast carcinoma with metastatic nodes from 1998 to 2008. We divided the study population into 4 groups: 1-3 positive nodes with/without chemotherapy and ≥4 positive nodes with/without chemotherapy. Risk factors for LRR were identified and the relationship between LRR and PMRT was analyzed.

RESULTS

During the median follow-up of 59.6 months, 61 (7.7%) patients experienced LRR. In patients who received chemotherapy, independent LRR risk factors were high nuclear grade, severe lymphatic invasion, vascular invasion, and progesterone receptor-negative status in patients with 1-3 positive nodes, and severe lymphatic invasion and estrogen receptor-negative status in patients with ≥4 nodes. Although patients treated with PMRT had good outcomes, there was no significant difference, and PMRT did not significantly improve the outcome of the patients with all risk factors.

CONCLUSIONS

With systemic therapy and adequate dissection, PMRT by itself was of limited value in establishing locoregional control. The indication for PMRT in patients with 1-3 positive nodes remains controversial.

Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions

Inadequate surgical margins represent a high risk for adverse clinical outcome in breast-conserving therapy (BCT) for early-stage breast cancer. The majority of studies report positive resection margins in 20% to 40% of the patients who underwent BCT. This may result in an increased local recurrence (LR) rate or additional surgery and, consequently, adverse affects on cosmesis, psychological distress, and health costs. In the literature, various risk factors are reported to be associated with positive margin status after lumpectomy, which may allow the surgeon to distinguish those patients with a higher a priori risk for re-excision. However, most risk factors are related to tumor biology and patient characteristics, which cannot be modified as such. Therefore, efforts to reduce the number of positive margins should focus on optimizing the surgical procedure itself, because the surgeon lacks real-time intraoperative information on the presence of positive resection margins during breast-conserving surgery. This review presents the status of pre- and intraoperative modalities currently used in BCT. Furthermore, innovative intraoperative approaches, such as positron emission tomography, radioguided occult lesion localization, and near-infrared fluorescence optical imaging, are addressed, which have to prove their potential value in improving surgical outcome and reducing the need for re-excision in BCT.