The cosmetic outcome in early breast cancer treated with breast conservation

Nipple reconstruction using spiral-peeling technique during oncoplastic breast-conserving surgery for a patient with small breasts

Treatment of early breast cancer using breast-conserving surgery (BCS) commonly leads to local control and acceptable cosmetic results. We report a useful technique to achieve symmetry of the breast shape and nipple-areola, with excellent results. A Japanese patient with early breast cancer located in the inner central area of the breast was enrolled in this study. Intraductal spread of breast cancer to the nipple was suspected; however, no invasion was observed outside the nipple wall. We preserved the cylindrical surface, but resected the inner tissue with the top surface of the nipple. After coring the nipple, the remnant cylindrical surface was cut into a spiral shape. Nipple reconstruction using the spiral-peeling technique during oncoplastic breast-conserving surgery (OPBCS) may be useful for patients who desire nipple preservation.

Long-term follow-up of complex oncoplastic breast-conserving surgery, standard breast conservation and skin-sparing mastectomy in DCIS - a register-based study

BACKGROUND

Few studies evaluate oncological safety in complex oncoplastic breast-conserving surgery(C-OBCS) for DCIS. It still needs to be defined whether it is equivalent to standard breast conservation(S-BCS) or an alternative to skin-sparing mastectomy(SSM). This study compares local recurrence rates(LR), disease-free survival(DFS) and overall survival (OS) between the three surgical techniques.

METHODS

We conducted a retrospective register-based study on LR, DFS and OS of patients operated with S-BCS(n=1388), C-OBCS (n=106) or skin-sparing mastectomy (n=218) for DCIS diagnosed 2007-2020. Data was extracted from the Norwegian Breast Cancer Registry.

RESULTS

In the S-BCS, C-OBCS and SSM groups, median age was 60, 58 and 51 years (p<0.001), median size 15, 25, and 40 mm (p<0.001) and median follow-up 55, 48 and 76 months. At ten years, the overall LR was 12.7%, 14.3% for S-BCS, 11.2% for C-OBCS and 6.8% for SSM. Overall DFS at ten years was 82.3%, 80.5% for S-BCS, 82.4% for C-OBCS and 90.4% for SSM. At ten years, the OS was 93.8%, 93.0% in S-BCS, 93.3% in C-OBCS and 96.6% in the SSM group. Weighted Kaplan Meier plots showed that SSM had a significantly higher DFS than S-BCS (p=0.003) and C-OBCS (p=0.029). DFS in C-OBCS versus S-BCS and the difference in OS was not significant (p=0.264).

CONCLUSION

SSM had a significantly higher DFS than S-BCS and C-OBCS. The difference in DFS between S-BCS and C-OBCS, and OS between the three groups was not statistically significant. Our study suggests that C-OBCS is a safe alternative to S-BCS and SSM.

Long-term course of the changes in the nipple position after breast-conserving surgery

PURPOSE

Even if favorable cosmetic outcomes are obtained shortly after breast-conserving surgery (BCS), cosmetic changes may occur up to several years after BCS. In the present study, we evaluated cosmetic changes while focusing on changes in the nipple position after BCS.

METHODS

We examined the long-term course of changes in the nipple position over time after BCS using the proportion of the distance between the sternal notch and nipple (PDSN) in 196 patients. We also evaluated risk factors for long-term nipple position changes.

RESULTS

The median follow-up period was 9.9 years. Nipple position changes occurred within eight years after BCS and seemed to plateau beyond that point. The body mass index (BMI), breast size, proportion of excision volume and axillary treatment were significantly associated with the nipple position changes within one to five years after BCS. The BMI, breast size, axillary treatment, chemotherapy and hormonal therapy were significantly associated with the nipple position changes within five to eight years after BCS.

CONCLUSIONS

After BCS, the nipple position changes occur within about eight years. Obesity, large breast size, large excision volume, axillary treatment, chemotherapy and hormone therapy were factors that affected the treated breast shrinkage and increase in the left-right difference after BCS.

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

A Novel Validated Breast Aesthetic Scale

BACKGROUND

Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.

METHODS

The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.

RESULTS

Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.

CONCLUSIONS

The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Surgical outcomes of localization using indocyanine green fluorescence in breast conserving surgery: a prospective study

We investigated localization and safe resection margins for breast cancer patients undergoing breast conserving surgery (BCS) using ultrasound-guided indocyanine green fluorescence (ICG-F) marking. From April 2016 to March 2019, we prospectively enrolled 114 patients who underwent BCS using US-guided ICG-F marking and we compared these results with 300 patients who underwent BCS using US-guided skin marking from January 2012 to December 2016. Clinical features, identification rates, status of resection margins, and re-operation rates were analyzed. The ICG-F identification rate was 100% (114/114). The mean approach time for resection of the lesion ICG-F using group was about 13 min. The positive rate of frozen resection margins was 10.5% using ICG-F and 25.0% using sono-guided skin marking (p < 0.01). The rate of additional intraoperative resection was significantly lower in the ICG-F marking group compared to that in the sono-guided skin marking group (8.8% vs. 23.3%, p < 0.01). The rate of final positive resection margins was 3.5% in the ICG-F using group and 14.7% in the sono-guided skin marking group (p < 0.01). The rate of re-operation was 4.4% in the ICG-F using group and 4% in the sono-guided group (p = 0.79). At follow-up after the operation using ICG-F, no complications occurred. Using ICG-F during BCS could be a safe, sophisticated method for localization.

Sub-muscular Reconstruction after NAC Sparing Mastectomy: Direct to Implant Breast Reconstruction with Human ADM Versus Tissue Expander

BACKGROUND

Nipple areola complex (NAC) sparing mastectomy allows good oncological and aesthetic results. The study compares the results, in terms of self-evaluated satisfaction and symmetry, of direct to implant (DTI) sub-muscular breast reconstruction, with the aid of human acellular dermal matrix (ADM) versus two-stage reconstruction with sub-muscular tissue expander, followed by implant.

MATERIALS AND METHODS

This is a retrospective, observational, single-center, non-randomized, case-control study. Inclusion criteria were: unilateral NAC sparing mastectomy at Forlì Hospital between 2014 and 2018; sub-muscular reconstruction; minimum follow-up of 12 months from the reconstructive stage; no history of radiotherapy. Patients were divided into two groups: group A included patients who underwent DTI breast reconstruction with the aid of human ADM; group B were those who underwent a two-stage reconstruction with tissue expander then implant. We collected data on: (1) Self-evaluated satisfaction by Breast Q questionnaire (scores from 0 to 100). (2) Observer-evaluated symmetry. Bi-dimensional photographs were collected and evaluated by 11 breast surgeons blinded to each other, who assigned a score for symmetry (from 0 to 10). (3) Symmetry of anthropometric measures collected by hand and volume estimated by Breast V application.

RESULTS

Group A included 28 patients; group included B 26 patients. Breast-Q questionnaires reported the following results: satisfaction with breasts in group A 65 ± 12 versus group B 68 ± 14; satisfaction with outcome in group A 88 ± 16 versus group B 93 ± 11; psychosocial well-being in group A 71 ± 20 versus group B 76 ± 17; sexual well-being in group A 63 ± 26 versus group B 60 ± 13; physical well-being in group A 68 ± 15 versus group B 60 ± 12. The average symmetry breast score assigned to group A was 6.9, versus group B 7.2. Regarding the anthropometric measures in group A, the differences between right and left were major to those in group B. Regarding breast volume, the mean difference between right and left in group A was 31.89 cc ± 24.97, whereas in group B was 25.46 cc ± 23.59.

CONCLUSION

Our data show better symmetry and better psychosocial well-being in the two-stage reconstruction, and higher satisfaction with sexual and physical well-being in DTI reconstructions. These aspects should be discussed with the patient while collecting the informed consent.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recurrence and survival after standard versus oncoplastic breast-conserving surgery for breast cancer

Background

Oncoplastic techniques in breast-conserving surgery (BCS) are used increasingly for larger tumours. This large cohort study aimed to assess oncological outcomes after oncoplastic BCS (OPS) versus standard BCS.

Methods

Data for all women who had BCS in three centres in Stockholm during 2010–2016 were extracted from the Swedish National Breast Cancer Register. All patients with T2–3 tumours, all those receiving neoadjuvant treatment, and an additional random sample of women with T1 tumours were selected. Medical charts were reviewed for local recurrences and surgical technique according to the Hoffman–Wallwiener classification. Date and cause of death were retrieved from the Swedish Cause of Death Register.

Results

The final cohort of 4178 breast cancers in 4135 patients was categorized into three groups according to surgical technique: 3720 for standard BCS, 243 simple OPS, and 215 complex OPS. Median duration of follow up was 64 (range 24–110) months. Node-positive and large tumours were more common in OPS than in standard BCS (P < 0.001). There were 61 local recurrences: 57 (1.5 per cent), 1 (0.4 per cent) and 3 (1.4 per cent) in the standard BCS, simple OPS and complex OPS groups respectively (P = 0.368). Overall, 297 patients died, with an unadjusted 5-year overall survival rate of 94.7, 93.1 and 92.6 per cent respectively (P = 0.350). Some 102 deaths were from breast cancer, with unadjusted 5-year cancer-specific survival rates of 97.9, 98.3 and 95.0 per cent respectively (P = 0.056).

Discussion

Oncoplastic BCS is a safe surgical option, even for larger node-positive tumours, with low recurrence and excellent survival rates.

A Three-Dimensional Bioabsorbable Tissue Marker for Volume Replacement and Radiation Planning: A Multicenter Study of Surgical and Patient-Reported Outcomes for 818 Patients with Breast Cancer

Background

Accurate identification of the tumor bed after breast-conserving surgery (BCS) ensures appropriate radiation to the tumor bed while minimizing normal tissue exposure. The BioZorb^® three-dimensional (3D) bioabsorbable tissue marker provides a reliable target for radiation therapy (RT) planning and follow-up evaluation while serving as a scaffold to maintain breast contour.

Methods

After informed consent, 818 patients (826 breasts) implanted with the BioZorb^® at 14 U.S. sites were enrolled in a national registry. All the patients were prospectively followed with the BioZorb^® implant after BCS. The data collected at 3, 6, 12, and 24 months included all demographics, treatment parameters, and provider/patient-assessed cosmesis.

Results

The median follow-up period was 18.2 months (range, 0.2–53.4 months). The 30-day breast infection rate was 0.5 % of the patients (n = 4), and re-excision was performed for 8.1 % of the patients (n = 66), whereas 2.6 % of the patients (n = 21) underwent mastectomy. Two patients (0.2 %) had local recurrence. The patient-reported cosmetic outcomes at 6, 12, and 24 months were rated as good-to-excellent by 92.4 %, 90.6 %, and 87.3 % of the patients, respectively and similarly by the surgeons. The radiation oncologists reported planning of target volume (PTV) reduction for 46.2 % of the patients receiving radiation boost, with PTV reduction most commonly estimated at 30 %.

Conclusions

This report describes the first large multicenter study of 818 patients implanted with the BioZorb^® tissue marker during BCS. Radiation oncologists found that the device yielded reduced PTVs and that both the patients and the surgeons reported good-to-excellent long-term cosmetic outcomes, with low adverse effects. The BioZorb^® 3D tissue marker is a safe adjunct to BCS and may add benefits for both surgeons and radiation oncologists.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-09271-2) contains supplementary material, which is available to authorized users.

Oncoplastic breast surgery combining partial mastectomy with V-rotation mammoplasty for breast cancer on the upper inner area of the breast

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique for obtaining symmetry of the breast shape and a level inframammary line and nipple-areola that achieved excellent results. Four Japanese patients with early breast cancer located on the upper inner area of the breast were enrolled into this study. De-epithelialized skin close to the resected area and skin from the epigastric area with subdermal fatty tissue were moved to repair the defect. Oncoplastic breast surgery (OBS) combining partial mastectomy with the V-rotation mammoplasty technique was useful for patients with breast cancer on the upper inner area of minimal ptotic breasts.

Achieving margin clearance following oncoplastic breast surgery in comparison with simple wide local excision: a three-dimensional specimen assessment

BACKGROUND

Pre-operative breast tumour radial dimensions often determine the choice between simple wide local excision (WLE) and oncoplastic breast surgery (OBS). We reviewed the three-dimensional interplay between tumour and surgical specimen dimensions in the two cohorts.

METHODS

Demographic, tumour and treatment data were collected for all patients undergoing OBS by a single surgeon and compared with a randomly selected cohort of WLE patients treated. The relationship between tumour and specimen medio-lateral, supero-inferior and antero-posterior dimensions were explored in both groups. Subgroup analyses were performed in the OBS cohort (parenchymal displacement versus replacement).

RESULTS

We identified 60 OBS patients (63 breasts), comparing them with 60 WLE patients. Pre-operative tumour estimated size was significantly larger in the OBS cohort and concordant with macroscopic tumour radial dimensions and final microscopic tumour size. Surgical specimen weight was more than 3.5 times higher in the OBS group and its radial dimensions were almost double. No significant difference was observed for the antero-posterior dimensions. The rate of margin re-excisions and completion mastectomies were lower in the OBS cohort. WLE patients with positive margins had a lower tumour-to-specimen ratio, whereas, the requirement for further surgery in the OBS cohort was associated with larger tumour dimensions.

CONCLUSION

Despite larger tumour dimensions, OBS is not inferior to WLE in providing clear surgical margins. Our analysis of the three-dimensional spatial relationship between cancer and surgical specimen, although not completely conclusive, can be helpful in the selection of the most appropriate surgical approach for every patient.

Oncoplastic breast surgery combining partial mastectomy with a triangular skin resection and re-centralization of the nipple-areola

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique to obtain symmetry of the breast shape and a level inframammary line and nipple-areola, which achieved excellent results. Six Japanese patients with early breast cancer located on the upper area of the breast were enrolled into this study. A triangle-shaped area of skin was removed together with cancerous and healthy-surrounding breast tissue. Two crescents were designed and de-epithelialized in the directions of 9 o'clock and 3 o'clock. The width of the crescent was decided to be the same as a half or the length of the base of a triangle to be removed. After partial mastectomy, the inner and outer glandular flaps were horizontally sutured. The operations were simple to perform and were not associated with any postoperative complications. Oncoplastic breast surgery combining partial mastectomy with triangular skin resection and re-centralization of the nipple-areola was useful for patients with breast cancer on the upper quadrant area of non-ptotic breasts.

Association of surgical margins with local recurrence in patients undergoing breast-conserving surgery after neoadjuvant chemotherapy

BACKGROUND

The aim of the current study was to report a single-institution experience using breast-conserving surgery after neoadjuvant chemotherapy (NACT), focusing on the association between microscopic resection margin status and locoregional recurrence (LRR).

METHODS

Our institutional prospectively maintained database was reviewed to identify patients who were treated with NACT between January 2008 and April 2018.

RESULTS

Among the main partial mastectomy specimens available for analysis (n = 161), 28 had margins < 1 mm, 21 had margin width of 1-2 mm and the remaining 112 had margins > 2 mm. LRR occurred in 16 patients (9.9%) and distant metastases were detected in 27 (16.8%) patients. There was no significant difference in the LRR between the > 2 mm margin group with a 60-month cumulative survival of 85.2% compared with 76.2% for the ≤2 mm group (P = 0.335) in the Kaplan-Meier analysis. When we stratified patients by margin widths of ≥1 mm or <  1 mm, there was no LRR-free survival benefit observed for the ≥1 mm pathologic excision margin group in the univariate analysis (hazard ratio = 0.443; 95% confidence interval = 0.142-1.383; P = 0.161) with a 60-month cumulative LRR-free survival of 84.9% compared with 69.5% for the < 1 mm margin cohort (P = 0.150).

CONCLUSIONS

In the absence of multiple scattered microscopic tumour foci, a negative margin of no ink on tumour maybe sufficient for stage I-III invasive breast cancer treated with NACT and breast-conserving surgery.

Expectations of breast-conserving therapy: a qualitative study

Background

Early-stage breast cancer is often treated with breast-conserving therapy (BCT), including lumpectomy with radiation therapy. Patients’ expectations of BCT remain largely unknown. Expectations affect perceptions of treatment-related experiences and health-related quality of life (HR-QOL) outcomes. Our primary aim was to describe expectations of BCT among patients with early breast cancer through qualitative methods. Our secondary aim was to inform preoperative patient education and improve the patient experience through knowledge.

Methods

We used a grounded-theory approach to investigate a convenience sample of 22 women with stage I and II breast cancer who were treated with BCT at a single hospital in New York City between May and August 2016. Semi-structured interviews were conducted in person and by telephone. Open-ended questions covered participants’ expectations of treatment experiences and outcomes. Data was analyzed in a line-by-line approach to identify emergent themes related to patient expectations. Interviews continued until no new themes emerged.

Results

Analysis of data identified the following themes related to patient expectations of BCT: experience of cancer care, recovery, appearance, and HR-QOL. Despite preoperative informed consent and teaching, participants expressed few expectations preoperatively, owing to a lack of knowledge about the process of care. Lack of expectations preoperatively was compensated with available care and resources postoperatively.

Conclusions

Patients in our sample had a surprisingly limited understanding of what to expect during treatment with BCT. Despite available information and preoperative teaching, patients have a clear knowledge gap regarding BCT. These findings suggest patients often undergo cancer treatment with trust rather than complete understanding of the process. This data may be used to enhance preoperative discussions aimed at preparing patients for surgery and treatment.

Cosmetic assessment in brachytherapy (interventional radiotherapy) for breast cancer: A multidisciplinary review

PURPOSE

This review was to focus on breast brachytherapy cosmetic assessment methods state of the art and to define the advantages and disadvantages related to.

METHODS AND MATERIALS

We conducted a literature review of the major experience on breast brachytherapy cosmetic assessment methods in several databases (PubMed, Scopus, and Google Scholar databases). To identify the relevant works, a task force screened citations at title and abstract level to identify potentially relevant paper. An expert board reviewed and approved the text. The assessment systems were classified into three main groups: (1) the Oncological Toxicity Scales, (2) the Independent Patients Perspective Measures, (3) the Patient-Related Outcome Measures. Each cosmetic assessment method was evaluated following six parameters: (1) anatomical site, (2) advantages, (3) disadvantages, (4) subjective/objective, (5) quantitative/qualitative, (6) computers or pictures needs.

RESULTS

Eleven assessment methods were selected. Three methods were classified as Oncological Toxicity Scale, six in the Independent Patients Perspective Measures classification, and two as Patient-Related Outcome Measures. Six methods are subjective, while eight are objective. Four systems are classified as quantitative, four as qualitative while three both. Five systems need informatics support. Moreover, each method was discussed individually reporting the main characteristics and peculiarities.

CONCLUSIONS

Cosmesis is one major end point for the patient who has a malignancy of low lethal potential. In modern personalized medicine, there is a need for standardized cosmetic outcome assessments to analyze and compare the results of treatments. No gold standard methods currently exist. The result of this review is to summarize the various cosmesis methods, defining the strengths and weaknesses of each one and giving a line in research and clinical practice.

Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™

Background

Oncoplastic breast-conserving surgery allows larger resections in unfavorable locations, with an improved chance of preserving esthetics. Indications and timing for potential contralateral surgery to obtain symmetry are not clear. The aim of this study was to evaluate patient satisfaction after unilateral oncoplastic volume displacement surgery, to investigate potential risk factors for lower patient satisfaction and to assess patient wish for contralateral surgery.

Method

A cohort of 144 women, consecutively treated for breast cancer with unilateral breast-conserving oncoplastic volume displacement surgery, followed by radiotherapy and with an unoperated contralateral breast, was sent the BREAST-Q™ breast-conserving therapy (BCT) and a study-specific questionnaire. In all, 120 women (83%) responded. For these women, the median value for resected specimen weight was 92 g (range 14–345) and for the estimated percentage of the breast volume excised 15% (range 3–35%).

Results

The median patient-reported score for “Satisfaction with breast” (BREAST-Q™ BCT) was 74/100. Factors associated with a score below median value in a simple logistic regression model adjusted for age and BMI were axillary clearance (OR 2.46, 95% CI 1.09–5.56), neoadjuvant chemotherapy (OR 3.26, 95% CI 1.15–9.24), and low breast density (OR 2.32 95% CI 1.02–5.29). Thirteen women (11%) were interested in contralateral surgery.

Conclusion

Most patients in this study cohort, who had undergone breast-conserving therapy with oncoplastic volume displacement techniques, were satisfied with their breasts without surgery to the contralateral breast. This indicates that contralateral surgery to achieve symmetry only should be performed after individual evaluation and as a delayed procedure.

Breast Reduction and Mastopexy for Repair of Asymmetry After Breast Conservation Therapy: Lessons Learned

BACKGROUND

Breast conservation therapy (BCT) can cause breast distortion and asymmetry. Repair of this asymmetry by means of breast reduction or mastopexy procedures can be challenging and harbor considerably high rates of complications.

METHODS

In this retrospective study, we describe our experience in repairing post-BCT breast asymmetry by performing breast reduction or mastopexy. The surgical protocol we followed consisted of stringent patient selection, thorough surgical planning, basic surgical refinements, and patient education for enhancing the likelihood of achieving a good outcome with minimal surgical complications.

RESULTS

Our search of the departmental database identified 25 patients with breast asymmetry who had undergone breast reduction or mastopexy between 2009 and 2017. Corrective surgery was performed 4 years on average after the completion of radiotherapy, and those patients included eleven who had undergone breast reduction and fourteen who had undergone mastopexy on the radiated side. Two patients (8%) had major complications that required further surgery (major fat necrosis, wound infection, and breast deformation), and five patients (20%) had minor complications (infection, minor fat necrosis, wound dehiscence, and nipple congestion). All complications developed on the radiated breast. There was no correlation between the occurrence of complications and patients' demographics, tumor type, tumor location, and breast tissue resection (p > 0.05).

CONCLUSION

Only two of our 25 patients had major complications following breast reduction and mastopexy for the repair of asymmetry post-BCT. Following our four-step protocol was instrumental in leading to the successful performance of these procedures.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Single incision for oncologic breast conserving surgery and sentinel node biopsy in early stage breast cancer: A minimally invasive approach

INTRODUCTION

Breast conserving surgery (BCS) has a postoperative morbidity up to 30%. We report the feasibility of a single-incision approach for tumor excision and axillary sentinel node biopsy (SNB) sampling intended to minimize patient morbidity and complications.

MATERIALS AND METHODS

A tertiary surgical oncology single surgeon database was retrospectively reviewed for all patients undergoing BCS and SNB between January 2013 and December 2015. The single-incision approach used a single breast incision to resect the tumor and the Lymphazurin-tagged SNB. The multi-incision group used a breast incision and a separate axillary incision.

RESULTS

The single-incision approach was associated with shorter operative time (56 vs 64 minutes, P = 0.026). Sentinel node retrieval was achieved in 100% in both groups. The single-incision technique was used primarily in the upper outer quadrant (N = 41, 85.4%), but was also selectively applied in other quadrants (N = 5). There was no significant difference in complication rates between the two procedures (P = 0.425), and there were no instances of conversion from single-incision to standard BCS-SNB.

CONCLUSIONS

Minimally invasive breast conserving surgery is feasible for patients with early breast cancer located in the upper outer quadrants. This technique may reduce postoperative morbidity and improved cosmetic result.

Does intra-operative margin assessment improve margin status and re-excision rates? A population-based analysis of outcomes in breast-conserving surgery for ductal carcinoma in situ

BACKGROUND AND OBJECTIVES

Using a 2 mm margin criteria, we evaluated the effect of intra-operative margin assessment on margin status and re-excisions following breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS).

METHODS

We identified patients undergoing BCS for DCIS from a prospective, population-based database. Multivariable logistic regression was used to determine the effect of specimen mammography, ultrasound and macroscopic assessment by a pathologist on margins and re-excision rates.

RESULTS

In 588 patients, 52% (95% confidence interval [CI], 48%-56%) had positive margins (<2 mm), 39% (95% CI, 35%-43%) had a re-excision and 15% (95% CI, 12%-18%) had completion mastectomy. There were few re-excisions for margins ≥2 mm (2%). Adjusting for confounders, any margin assessment versus wire localization alone did not reduce positive margins (odds ratio [OR], 0.75; P = 0.202) or re-excisions (OR, 1.14; P = 0.564), however both outcomes varied by type of technique ( P < 0.001). Individually, only macroscopic assessment by pathologist reduced positive margins (OR, 0.54; P = 0.002) and re-excisions (OR, 0.61; P = 0.036).

CONCLUSIONS

Despite adherence to a 2 mm margin criteria, re-excision rates remain high following BCS for DCIS, with 39% converted to mastectomy when re-excision is required. Intra-operative margin assessment does not appear to reduce re-excisions; in particular, surgeons should be aware of the limitations of specimen mammography for margin assessment in DCIS.

Multi-institutional evaluation of the reproducibility and the accuracy of the objective breast cosmesis scale

PURPOSE

The aim of the present work is to assess the Objective Breast Cosmesis Scale (OBCS) in a patient cohort that was treated in two hospitals. Their treatment-related cosmetic changes were recorded on nonstandardized photographs.

METHODS AND MATERIALS

Nineteen female patients were enrolled in two radiation oncology centers (Nice, France, and Perugia, Italy). All patients had undergone breast-conserving surgery (BCS) and received adjuvant accelerated partial breast irradiation using interstitial fractionated multicatheter high-dose-rate brachytherapy. One photograph before and another after accelerated partial breast irradiation was taken for each patient to record changes in breast cosmesis. Using the OBCS, before and after photographs were analyzed by measuring distances between anatomic features. OBCS scores from four doctors (two males [one radiation oncologist and one post-grad trainee] and two females [one radiation oncologist and one post-grad trainee]) were compared.

RESULTS

Agreement was high between trainees and specialist, and males and females before and after treatment. The intraclass correlation coefficient ranged from 0.867 to 0.950 before treatment and from 0.876 to 0.952 afterward. The coefficient of variation ranged from 12% to 26.5% before treatment, and from 13% to 21.4% afterward.

CONCLUSIONS

The OBCS is easy, time-efficient, reproducible, cost-effective, and reliable. Its potential practical applications merit further investigation in future studies.

Factors influencing reoperation following breast-conserving surgery

BACKGROUND

Reoperation rates after breast-conserving surgery are highly variable and the best techniques for optimizing margin clearance are being evaluated. The aim was to identify the reoperation rate at our centre and identify influential factors, including a change in guidelines on margin recommendations and the introduction of in-theatre specimen X-ray.

METHODS

A retrospective review of medical records was undertaken to identify 562 patients who underwent breast conservation at The Royal Melbourne Hospital and Royal Women's Hospital between 2013 and 2015. All cases that underwent subsequent re-excision or total mastectomy were captured and factors influencing margin excision recorded.

RESULTS

Reoperation was undertaken in 19.5% of patients (110; 86 re-excisions and 24 total mastectomies). There was a reduction in reoperation rate from 25% to 17% (P = 0.01) with adoption of the margin guidelines in 2014, but no significant reduction with the introduction of in-theatre specimen X-ray in 2015 (21% versus 16%, P = 0.14). On multivariate analysis, factors that significantly influenced reoperation rates were the presence of multifocality on mammogram (odds ratio (OR): 5.3, 95% confidence interval (CI): 1.6-16.7, P < 0.01); lesion size on mammogram (OR: 2.2 per 10 mm, 95% CI: 1.4-3.6, P < 0.01); smaller excision specimen weight (OR: 0.5 per 25 g of resection, 95% CI: 0.3-0.8, P < 0.01); and pure ductal carcinoma in situ on final pathology (OR: 5.9, 95% CI: 1.9-16.7, P < 0.01).

CONCLUSION

Optimizing reoperation rates following breast-conserving surgery remains a surgical challenge, particularly in patients with in situ or multifocal disease. Adoption of international margin guidelines reduced reoperation rates at our centre; however, introduction of intraoperative specimen X-ray had no influence.

The COSMAM TRIAL a prospective cohort study of quality of life and cosmetic outcome in patients undergoing breast conserving surgery

Background

Cosmetic result in breast cancer surgery is gaining increased interest. Currently, some 30–40% of the patients treated with breast conserving surgery (BCS) are dissatisfied with their final cosmetic result. In order to prevent disturbing breast deformity oncoplastic surgical techniques have been introduced. The extent of different levels of oncoplastic surgery incorporated in breast conserving surgery and its value with regard to cosmetic outcome, patient satisfaction and quality of life remains to be defined. The aim of this prospective cohort study is to investigate quality of life and satisfaction with cosmetic result in patients with breast cancer, undergoing standard lumpectomy versus level I or II oncoplastic breast conserving surgery.

Methods

Female breast cancer patients scheduled for BCS, from 18 years of age, referred to our outpatient clinic from July 2015 are asked to participate in this study. General, oncologic and treatment information will be collected. Patient satisfaction will be scored preceding surgery, and at 1 month and 1 year follow up. Photographs of the breast will be used to score cosmetic result both by the patient, an independent expert panel and BCCT.Core software. Quality of life will be measured by using the BREAST-Q BCT, EORTC-QLQ and EQ-5D-5 L questionnaires.

Discussion

The purpose of this prospective study is to determine the clinical value of different levels of oncoplastic techniques in breast conserving surgery, with regard to quality of life and cosmetic result. Analysis will be carried out by objective measurements of the final cosmetic result in comparison with standard breast conserving surgery. The results of this study will be used to development of a clinical decision model to guide the use oncoplastic surgery in future BCS.

Trial registration

Central Commission of Human Research (CCMO), The Netherlands: NL54888.015.15.

Medical Ethical Commission (METC), Maxima Medical Centre, Veldhoven, The Netherlands: 15.107.

Dutch Trial Register: NTR5665, retrospectively registered, 02-25-2016.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4368-8) contains supplementary material, which is available to authorized users.

Batwing Mastopexy as Oncoplastic Surgical Approach to Periareolar Tumors in Upper Quadrants

Aims and background

Batwing mastopexy (BWM) is an oncoplastic technique most commonly used in the treatment of 12 o'clock periareolar tumors. The aim of this study was to assess the early cosmetic results of BWM performed for periareolar lesions located in the upper quadrants, i.e. from 10 to 2 o'clock position.

Methods and study design

A prospective analysis of a preliminary group of 35 women with periareolar intraductal or invasive breast cancer in the upper quadrants was done. All patients underwent wide lumpectomy with clear margins followed by BWM in order to obtain favorable cosmesis. For invasive cancers axillary biopsy or dissection was performed by separate incision. Cosmetic outcome was assessed 4 weeks after surgery by the patient with reference to breast shape, nipple-areola complex (NAC) position and scar arrangement. The result was rated as poor, medium or good for each parameter.

Results

There were no poor ratings of cosmetic outcome. The result was rated as medium by 5 women (14%) regarding breast shape and by 3 regarding NAC position (9%). The remaining women evaluated these parameters as good (86% and 91%, respectively). In contrast, scar arrangement was assessed as good by 26 patients (74%), medium by 8 (23%), and poor by 1 (3%). All women rating scar arrangement as other than good had a lesion located in the upper lateral quadrant. Considering the reasons for the relatively low scar acceptance by these women, the only important cause of disappointment was the placement of one of the radial parts of the scar in the area of decolletage in the upper medial quadrant.

Conclusions

BWM allows to achieve favorable breast shape and NAC position for lesions located in the upper quadrants regardless of the medial or lateral side. However, when performed in the lateral quadrant it produces a scar that can be hard to accept for some women.

Intraoperative Ultrasound Guidance in Breast-Conserving Surgery Improves Cosmetic Outcomes and Patient Satisfaction: Results of a Multicenter Randomized Controlled Trial (COBALT)

Background

Ultrasound-guided breast-conserving surgery (USS) results in a significant reduction in both margin involvement and excision volumes (COBALT trial).

Objective

The aim of the present study was to determine whether USS also leads to improvements in cosmetic outcome and patient satisfaction when compared with standard palpation-guided surgery (PGS).

Methods

A total of 134 patients with T1–T2 invasive breast cancer were included in the COBALT trial (NTR2579) and randomized to either USS (65 patients) or PGS (69 patients). Cosmetic outcomes were assessed by a three-member panel using computerized software Breast Cancer Conservative Treatment cosmetic results (BCCT.core) and by patient self-evaluation, including patient satisfaction. Time points for follow-up were 3, 6, and 12 months after surgery. Overall cosmetic outcome and patient satisfaction were scored on a 4-point Likert scale (excellent, good, fair, or poor), and outcomes were analyzed using a multilevel, mixed effect, proportional odds model for ordinal responses.

Results

Ultrasound-guided breast-conserving surgery achieved better cosmetic outcomes, with 20 % excellence overall and only 6 % rated as poor, whereas 14 % of PGS outcomes were rated excellent and 13 % as poor. USS also had consistently lower odds for worse cosmetic outcomes (odds ratio 0.55, p = 0.067) than PGS. The chance of having a worse outcome was significantly increased by a larger lumpectomy volume (p_trend = 0.002); a volume >40 cc showed odds 2.78-fold higher for a worse outcome than a volume ≤40 cc. USS resulted in higher patient satisfaction compared with PGS.

Conclusion

Ultrasound-guided breast-conserving surgery achieved better overall cosmetic outcomes and patient satisfaction than PGS. Lumpectomy volumes >40 cc resulted in significantly worse cosmetic outcomes.

Minimally invasive ablative techniques in the treatment of breast cancer: a systematic review and meta-analysis

PURPOSE

Breast-conserving surgery is effective for breast cancer treatment but is associated with morbidity in particular high re-excision rates. We performed a systematic review and meta-analysis to assess the current evidence for clinical outcomes with minimally invasive ablative techniques in the non-surgical treatment of breast cancer.

METHODS

A systematic search of the literature was performed using PubMed and Medline library databases to identify all studies published between 1994 and May 2016. Studies were considered eligible for inclusion if they evaluated the role of ablative techniques in the treatment of breast cancer and included ten patients or more. Studies that failed to fulfil the inclusion criteria were excluded.

RESULTS

We identified 63 studies including 1608 patients whose breast tumours were treated with radiofrequency (RFA), high intensity focussed ultrasound (HIFU), cryo-, laser or microwave ablation. Fifty studies reported on the number of patients with complete ablation as found on histopathology and the highest rate of complete ablation was achieved with RFA (87.1%, 491/564) and microwave ablation (83.2%, 89/107). Short-term complications were most often reported with microwave ablation (14.6%, 21/144). Recurrence was reported in 24 patients (4.2%, 24/570) and most often with laser ablation (10.7%, 11/103). The shortest treatment times were observed with RFA (15.6 ± 5.6 min) and the longest with HIFU (101.5 ± 46.6 min).

CONCLUSION

Minimally invasive ablative techniques are able to successfully induce coagulative necrosis in breast cancer with a low side effect profile. Adequately powered and prospectively conducted cohort trials are required to confirm complete pathological ablation in all patients.

Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin

Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1-2N0-1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20-66) vs 56 (38-94) cm(3); p = 0.001] and median calculated resection ratio [1.7 (1.0-2.9) vs 2.8 (1.4-4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2-5 mm) vs 2 mm (1-4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23-2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.

Magnetic resonance imaging appearance of oxidized regenerated cellulose in breast cancer surgery

PURPOSE

To describe magnetic resonance imaging (MRI) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in surgical cavity.

MATERIALS AND METHODS

We retrospectively reviewed 51 MRI examinations performed between January 2009 and January 2014 in 51 patients who underwent BCS with ORC implantation.

RESULTS

In 29/51 (57 %) cases, MRIs showed abnormal findings with three main MRI patterns: (1) complex masses: hyperintense collections on T2-weighted (w) images with internal round hypointense nodules without contrast enhancement (55 %); (2) completely hyperintense collections (17 %); and (3) completely hypointense lesions (28 %). All lesions showed rim enhancement on T1w images obtained in the late phase of the dynamic study with a type 1 curve. Diffusion-weighted imaging was negative in all MRIs and, in particular, 22/29 (76 %) lesions were hyperintense but showing ADC values >1.4 × 10(-3) mm(2)/s, while the remaining 7/29 (24 %) lesions were hypointense. In four cases, linear non-mass-like enhancement was detected at the periphery of surgical cavity; these patients were addressed to a short-term follow-up, and the subsequent examinations showed the resolution of these findings.

CONCLUSION

When applied to surgical residual cavity, ORC can lead alterations in surgical scar. This could induce radiologists to misinterpret ultrasonographic and mammographic findings, addressing patients to MRI or biopsy; so knowledge of MRI specific features of ORC, it is essential to avoid misdiagnosis of recurrence.

Do LORIS Trial Eligibility Criteria Identify a Ductal Carcinoma In Situ Patient Population at Low Risk of Upgrade to Invasive Carcinoma?

BACKGROUND

The Surgery Versus Active Monitoring for Low-Risk DCIS (LORIS) trial is studying the safety of monitoring core-biopsy diagnosed low-risk ductal carcinoma in situ (DCIS) without excision. We sought to determine the incidence and characteristics of synchronous invasive carcinoma found in LORIS-eligible women who underwent excision, as this knowledge is essential in assessing the safety of observation alone.

METHODS

Women meeting LORIS eligibility criteria (age ≥46 years, screen-detected calcifications, non-high-grade DCIS diagnosed by core biopsy, absence of nipple discharge, or strong family history of breast cancer) who underwent surgical excision from 2009 to 2012 were identified. Histologic findings of excision specimens were reviewed.

RESULTS

Overall, 296 LORIS-eligible cases were identified; 58 (20 %) had invasive carcinoma on final pathology (90 % invasive ductal, 78 % >1 mm in size, 21 % high grade, 3 % triple negative, 9 % HER2 amplified). Of these, 18 (31 %) were pT1b or larger and 3 (5 %) were pN1. Among eligible upgraded cases, 90 % received radiation, 89 % received endocrine therapy, and 18 % were recommended chemotherapy. Women upgraded to invasive carcinoma were more likely to have intermediate-grade DCIS on core biopsy and to have undergone mastectomy.

CONCLUSIONS

Among LORIS-eligible women, 20 % had invasive carcinoma at surgical excision that was heterogeneous in grade, size, and receptor status. Information gained from surgical excision influenced receipt of adjuvant radiation and endocrine therapy in most patients, and indicated benefit from chemotherapy in 18 % of patients. Surgical excision is warranted until additional risk stratification is available to identify a cohort of DCIS patients at lower risk for clinically significant synchronous invasive carcinoma.

Oncoplastic Breast Surgery: What, When and for Whom?

Oncoplastic surgery is integral to all breast cancer surgeries. The use of an aesthetic approach to breast conservation or mastectomy greatly enhances the range of options that can be offered to women with breast cancer and facilitates better outomes from it. It should be the standard of care. However, a structured approach to selecting appropriate techniques is essential, and although many operative procedures are reported, this article sets out to describe a set of principles and an algorithm by which the what, when and for whom for oncoplastic surgery can be defined.

A nationwide pathology study on surgical margins and excision volumes after breast-conserving surgery: There is still much to be gained

AIM OF THE STUDY

The current study aims to assess margin status in relation to amount of healthy breast tissue resected in breast-conserving surgery (BCS) on a nationwide scale.

METHODS

Using PALGA (a nationwide network and registry of histology and cytopathology in the Netherlands), all patients who underwent BCS for primary invasive carcinoma in 2012-13 were selected (10,058 excerpts). 9276 pathology excerpts were analyzed for a range of criteria including oncological margin status and distance to closest margin, specimen weight/volume, greatest tumor diameter, and with or without localization method. Calculated resection ratios (CRR) were assessed to determine excess healthy breast tissue resection.

RESULTS

Margins for invasive carcinoma and in situ carcinoma combined were tumor-involved in 498 (5.4%) and focally involved in 1021 cases (11.0%) of cases. Unsatisfactory resections including (focally) involved margins and margins ≤ 1 mm were reported in 33.8% of patients. The median lumpectomy volume was 46 cc (range 1-807 cc; SD 49.18) and median CRR 2.32 (range 0.10-104.17; SD 3.23), indicating the excision of 2.3 the optimal resection volume.

CONCLUSION

The unacceptable rate of tumor-involved margins as well as margins ≤ 1 mm in one third of all patients is also achieved at the expense of healthy breast tissue resection, which may carry the drawback of high rates of cosmetic failure. These data clearly suggest the need for improvement in current breast conserving surgical procedures to decrease tumor-involved margin rates while reducing the amount of healthy breast tissue resected.

Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome

BACKGROUND

The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival.

MATERIALS AND METHODS

251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery.

RESULTS

The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups.

CONCLUSIONS

Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.

Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients

BACKGROUND

Immediate volume replacement using a free dermal fat graft (FDFG) has been proven safe with early postoperative benefits. The aims of the present study were to clarify adequate indications and risk factors associated with operative morbidity.

PATIENTS AND METHODS

A multi-institutional analysis of partial mastectomy with immediate volume replacement with FDFG was undertaken in 14 hospitals specializing in breast cancer treatment. Clinical and oncological variables were analyzed to identify factors associated with postoperative complications.

RESULTS

A total of 262 cases were analyzed. Considering the observation period and overlap of patients, 13 (5.4%) out of 242 patients had complications within 1 month of surgery while 7 (4.6%) out of 151 patients developed complications 1-12 months after surgery. Two hundred and eleven out of 242 patients were statistically examined using a multivariate analysis, which revealed that the weight of resected breast tissue, size of implanted FDFG (cranio-caudal length), and weight of implanted FDFG were associated with a higher likelihood of postoperative complications.

CONCLUSIONS

Immediate breast volume replacement using a FDFG after breast cancer surgery should be done for selected patients with breast cancer to avoid postoperative complications. The prospective and larger investigations are warranted for the establishment of appropriate guidelines.

Interrogating a multifactorial model of breast conserving therapy with clinical data

Most women with early stage breast cancer do not require removal of the entire breast to treat their cancer; instead, up to 70% of women can be effectively and safely treated by breast conserving therapy (BCT) with surgical removal of the tumor only (lumpectomy) followed by radiation treatment of the remaining breast tissue. Unfortunately, the final contour and cosmesis of the treated breast is suboptimal in approximately 30% of patients. The ability to accurately predict breast contour after BCT for breast cancer could significantly improve patient decision-making regarding the choice of surgery for breast cancer. Our overall hypothesis is that the complex interplay among mechanical forces due to gravity, breast tissue constitutive law distribution, inflammation induced by radiotherapy and internal stress generated by the healing process play a dominant role in determining the success or failure of lumpectomy in preserving the breast contour and cosmesis. We have shown here from a first patient study that even in the idealistic situation of excellent cosmetic outcome this problem requires multiscale modeling. We propose a method to decide which component of the model works best for each phase of healing and what parameters should be considered dominant and patient specific. This patient study is part of a clinical trial registered on ClinicalTrial.gov, identifier NCT02310711.

Mammographic and Ultrasonographic Findings of Oxidized Regenerated Cellulose in Breast Cancer Surgery: A 5-Year Experience

BACKGROUND

The purpose of this study was to describe the ultrasonographic (US) and mammographic (MX) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in the surgical cavity and their size variations in follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 417 MX and 743 US images performed between January 2009 and January 2014 for 262 women who underwent breast-conserving surgery. All patients underwent US, only 203 women underwent MX examination.

RESULTS

In 170 of 262 patients, US examinations showed abnormal findings. Three main US patterns were identified: (1) complex masses: well-encapsulated ipoisoechoic lesions with circumscribed margins with internal hyperechoic nodules (56%); (2) hypoanechoic lesions without internal hyperechoic nodules (24%); and (3) completely anechoic collections (20%). Moreover, Doppler ultrasound examination was performed on all of the patients. In 95 of 203 patients, MX examinations showed abnormalities. Four main MX patterns were identified: (1) round or oval opacity with circumscribed margins (58%); (2) round or oval opacity with indistinct or ill-defined margins (17%); (3) irregular opacity with indistinct or spiculated margins (9%); and (4) architectural distortion or focal asymmetry (15%). Most of the lesions showed a decrease in size at US and MX follow-up examination and the decrease was statistically significant (P < .01).

CONCLUSION

When applied to the surgical residual cavity, ORC aids to control local hemorrhage and reduce the risk of postoperative infections, but can lead to alterations in surgical scar. Thus, knowledge of the radiological findings might allow avoidance of misdiagnosis of tumor recurrence or unnecessary diagnostic examinations.

Systematization of Oncoplastic Surgery: Selection of Surgical Techniques and Patient-Reported Outcome in a Cohort of 1,035 Patients

Introduction

Functional and aesthetic outcome after breast-conserving surgery are vital endpoints for patients with primary breast cancer. A large variety of oncoplastic techniques exist; however, it remains unclear which techniques yield the highest rates of local control at first surgery, omission of reexcision or subsequent mastectomy, and merits the highest degree of patient satisfaction.

Methods

In this retrospective case cohort trial with a customized investigational questionnaire for assessment of patient satisfaction with the surgical result, we analyzed 1,035 patients with primary, unilateral breast cancer and oncoplastic surgery from 2004 to 2009.

Results

Analysis of patient reported outcome (PRO) revealed that 88 % of the cohort was satisfied with their aesthetic result using oncoplastic techniques following the concept presented. These results also were achieved in difficult tumor localizations, such as upper inner and lower inner quadrant. Conversion rate from breast-conserving therapy to secondary mastectomy was low at 7.2 % (n = 68/944 patients). The systematization of oncoplastic techniques presented—embedded in a multimodal concept of breast cancer therapy—facilitates tumor control with a few number of uncomplicated techniques adapted to tumor site and size with a median resection of 32 (range 11–793) g. Five-year recurrence rate in our cohort was 4.0 %.

Conclusions

Patient´s satisfaction was independent from age, body mass index, resection volume, tumor localization, and type of oncoplastic surgery (p > 0.05). We identified postoperative pain as an important negative impact factor on patient´s satisfaction with the aesthetic result (p = 0.0001).

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4396-4) contains supplementary material, which is available to authorized users.

A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique

When immediate reconstruction is applied to breast conservation therapy (BCT), the benefits extend well beyond the minimization of poor cosmetic results. The purpose of this analysis was to compare literature outcomes between BCT alone and BCT with the oncoplastic approach.

METHODS

A meta-analysis was performed in PubMed using key words "oncoplastic," "partial breast reconstruction," and "breast conservation therapy." Case reports, series with less than 10 patients, and those with less than 1-year follow-up were excluded from the analysis. The 3 comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C).

RESULTS

Comparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%, P < 0.0001). Reexcision was more common in the BCT alone group (14.6% vs 4%, P < 0.0001), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%, P < 0.0001). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%, P < 0.001).

CONCLUSIONS

The oncoplastic approach to BCT allows a generous resection with subsequent reduction in positive margins. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used.

Re-excision rates of invasive ductal carcinoma with lobular features compared with invasive ductal carcinomas and invasive lobular carcinomas of the breast

BACKGROUND

Invasive ductal carcinoma (IDC) with lobular features (IDC-L) is not recognized as a subtype of breast cancer. We previously showed that IDC-L may be a variant of IDC with clinicopathological characteristics more similar to invasive lobular carcinoma (ILC). We sought to determine the re-excision rates of IDC-L compared with ILC and IDC, and the feasibility of diagnosing IDC-L on core biopsies.

METHODS

Surgical procedure, multiple tumor foci, tumor size, and residual invasive carcinoma on re-excision were recorded for IDC-L (n = 178), IDC (n = 636), and ILC (n = 251). Re-excision rates were calculated by excluding mastectomy as first procedure cases and including only re-excisions for invasive carcinoma. Slides of correlating core biopsies for IDC-L cases initially diagnosed as IDC were re-reviewed.

RESULTS

For T2 tumors (2.1-5.0 cm), re-excision rates for IDC-L (76 %) and ILC (88 %) were higher than that for IDC (42 %) (p = 0.003). Multiple tumor foci were more common in IDC-L (31 %) and ILC (26 %) than IDC (7 %) (p < 0.0001), which was a significant factor in higher re-excision rates when compared with a single tumor focus (p < 0.001). Ninety-two of 149 patients (62 %) with IDC-L were diagnosed on core biopsies. Of the 44 patients initially diagnosed as IDC, 30 were re-reviewed, of which 24 (80 %) were re-classified as IDC-L.

CONCLUSIONS

Similar to ILC, re-excision rates for IDC-L are higher than IDC for larger tumors. Patients may need to be counseled about the higher likelihood of additional procedures to achieve negative margins. This underscores the importance of distinguishing IDC-L from IDC on core biopsies.

["V" axillary incision for the management of tumors of upper outer quadrant and axillary tail of the breast: retrospective study and technical description]

INTRODUCTION

Tumors of the upper outer quadrant of the breast represent the most common location of breast malignant tumors. Although the choice of surgical approach should be dictated primarily by an imperative of oncological safety, esthetic and practical considerations of the surgeon as well as the esthetic demands of patients have become increasingly important with the development of breast conservative surgery.

MATERIALS AND METHODS

In this retrospective study, we reviewed 30 patients (mean age: 62.3 years) who were operated for a tumor of the upper outer quadrant (50 %) or the axillary tail (50 %) of the breast and who received a "V" axillary incision between 2008 and 2012. The incision draws a "V" that comprises a horizontal incision in an axilla fold associated with a vertical arcuate incision in a Langer line of the breast. The number and type of postoperative complications were collected. Patients were asked about the quality of their scar, position of the areola and breast shape was notified during consultations control.

RESULTS

The mean follow-up of patients was 32.7 months. No postoperative complications were observed. A percentage of 86.6 % of patients rated their scar result as excellent. We found no areolar malposition and no morphological deformation of the breast. The surgeons who performed this technique were very pleased with the wide exposure and the uniqueness of this incision fully respecting the architecture of the breast.

CONCLUSION

"V" axillary incision is a useful and easily reproducible technical option for the management of tumors of the upper outer quadrant and the axillary tail of the breast.

Effect of margin width on local recurrence in triple-negative breast cancer patients treated with breast-conserving therapy

BACKGROUND

The effect of increasing negative margin width after breast-conserving therapy (BCT) on local recurrence (LR) is controversial. LR rates vary by subtype, with the highest rates seen in triple-negative breast cancer (TNBC). This study examined LR rates in relationship to margin width in TNBC treated with BCT.

METHODS

Women with TNBC who underwent BCT between 1999 and 2009 were identified. Margins were defined as positive (ink on tumor), 0.1-2.0, and 2 mm. Patients with positive margins were excluded. Statistical comparisons were by t test, Fisher's exact test, and Wilcoxon rank sum test. Cumulative incidence of LR was compared by competing-risks methodology.

RESULTS

Of 535 cancers, 71 had margins ≤2 mm and 464 had margins >2 mm. At a median follow-up of 84 months (range 8-165 months), there were 37 local, 18 regional, and 77 distant recurrences or deaths as first events. Ten patients had a locoregional recurrence before planned radiotherapy and were excluded from cumulative incidence analyses. The cumulative incidence of LR at 60 months for margins ≤2 mm was 4.7 % (95 % confidence interval 0-10.0) and for >2 mm was 3.7 % (1.8, 5.5) (p = 0.11). After controlling for chemotherapy and tumor size, there was no difference in LR between the two margin groups (p = 0.06). A difference in the risk of distant recurrence or death was not observed (p = 0.53).

CONCLUSIONS

Margin width of >2 mm was not associated with reduced LR rates. These data support a negative margin definition of no ink on tumor, even in this high-risk TNBC cohort.

Image and pathological changes after radiofrequency ablation of invasive breast cancer: a pilot study of nonsurgical therapy of early breast cancer

BACKGROUND

The surgical treatment of early breast cancer has proceeded to less invasive approaches with better cosmetic results. The current study was undertaken to evaluate the clinical and pathological findings after radiofrequency ablation (RFA) without resection for a longer period of time.

METHOD

A total of 14 patients with breast cancer were enrolled. All patients were diagnosed to have invasive ductal carcinoma, and the median breast tumor size was 12 mm (range, 6-20 mm). Six patients received RFA treatment followed by immediate resection and eight patients without resection. The patients without resection were evaluated by ultrasound, MRI, and the pathological findings of a core needle biopsy after RFA. The removed specimens were examined by hematoxylin-eosin (HE) staining and nicotinamide adenine dinucleotide (NADH) diaphorase staining. The median follow-up of the patients was 39.9 months.

RESULTS

NADH staining was necessary to diagnose complete tumor cell death in the tissue for 3 months after RFA. However, HE staining alone could confirm the effect without NADH staining more than 6 months after RFA. Post-RFA, MRI scans clearly demonstrated the area as a complete ablated lesion in all patients without resection. The ablated area detected by MRI or ultrasound became gradually smaller. All patients that underwent RFA with no resection were alive without relapse.

CONCLUSION

RFA therefore could be an effective alternative to partial mastectomy for early breast cancer. Further research will be necessary to establish the standardization of the indications, as well as the optimal techniques and post treatment evaluation modalities.

Ultrasound-guided surgery for palpable breast cancer is cost-saving: results of a cost-benefit analysis

Ultrasound-guided surgery (USS) has recently been proven to result in a significant reduction of tumour-involved surgical margins, for patients with palpable invasive breast cancer. The objective of this economic evaluation alongside a randomised trial was to evaluate the costs and benefits of USS compared to palpation-guided surgery (PGS). The hospital perspective was used. On the cost side of the analysis, resource use related to baseline treatment was taken into account and on the benefit side, resource use related to additional treatments was included. On the cost side, the difference in costs per patient was €193 (95% CI €153-€233) with higher costs in the USS group. On the benefit side, the difference in costs per patient was -€349 (95% CI -€591 to -€103) with higher costs in the PGS group. This resulted in a cost decrease of -€154 (95% CI -€388 to €81) in the USS group compared to the PGS group. Intra-operative use of a US system during BCS reduces the rate of tumour-involved margins and thereby the costs of additional treatments.