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Falade IO, Switalla KM, Baxter ME, Quirarte A, Record H, Rothschild HT, Clelland EN, Mukhtar RA. Variation in surgical treatment by body mass index in patients with invasive lobular carcinoma of the breast. Breast Cancer Res Treat 2024:10.1007/s10549-024-07452-1. [PMID: 39127971 DOI: 10.1007/s10549-024-07452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE Patients with invasive lobular carcinoma (ILC) face high rates of positive margins and completion mastectomy, which can be improved with the use of specific techniques, such as oncoplastic surgery. However, prior studies have shown that type of breast cancer surgery performed is also associated with patient factors such as elevated body mass index (BMI). Thus, this study investigates whether BMI impacts the type of surgical interventions in patients with ILC. METHODS A retrospective analysis of 705 patients with stage I-III ILC from an institutional database was conducted. Patients were stratified by BMI (underweight, normal weight, overweight, obese). Pearson's Chi-square, ANOVA, and multivariable logistic regression were used to evaluate the relationship between BMI and surgical procedures. RESULTS Breast-conserving surgery (BCS) was the initial operation in 60% of patients, with no significant difference by BMI. Among those undergoing BCS, patients with obese BMI were significantly more likely to undergo oncoplastic surgery (46.9% vs. 7.7%, 37.3%, and 33.6% for underweight, normal, and overweight, respectively, p = 0.032). Obese BMI patients undergoing mastectomy were less likely to have reconstruction compared to those with underweight, normal weight, and overweight BMI (44.2% vs. 50%, 71.1%, and 64.1%, p = 0.002). CONCLUSION Overweight/obese BMI patients with ILC underwent different surgical interventions compared to those with lower BMI. While initial BCS rates were similar, overweight/obese patients had higher oncoplastic surgery rates in BCS and lower reconstruction rates in mastectomy. Further research is needed to understand BMI's impact on surgical decisions and outcomes in ILC.
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Affiliation(s)
- Israel O Falade
- School of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - Kayla M Switalla
- Medical School, University of Minnesota - Twin Cities, Minneapolis, MN, USA
- Department of Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Molly E Baxter
- Department of Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Astrid Quirarte
- Department of Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Helena Record
- Department of Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Harriet T Rothschild
- School of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - Elle N Clelland
- School of Medicine, University of California - San Francisco, San Francisco, CA, USA
| | - Rita A Mukhtar
- Department of Surgery, University of California - San Francisco, San Francisco, CA, USA.
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2
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Riis MLH. The Challenges of Lobular Carcinomas from a Surgeon's Point of View. Clin Breast Cancer 2024:S1526-8209(24)00172-1. [PMID: 39033066 DOI: 10.1016/j.clbc.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/13/2024] [Indexed: 07/23/2024]
Abstract
Invasive lobular breast cancer (ILC) presents unique challenges and considerations in the realm of surgical management. Characterized by its distinct histological features, including the loss of E-cadherin expression and dys-cohesive growth pattern, ILC often poses diagnostic and therapeutic dilemmas for clinicians. This abstract explores the surgical landscape of ILC, focusing on its epidemiology, clinical presentation, diagnostic modalities, and surgical interventions. Emphasizing the importance of individualized treatment strategies, this narrative delves into the nuances of surgical decision-making, including the role of breast-conserving surgery versus mastectomy, axillary staging, and the significance of margin status. Additionally, advancements in surgical techniques, such as oncoplastic approaches and sentinel lymph node biopsy, are examined in the context of optimizing oncologic outcomes and preserving cosmesis. Through a comprehensive review of current literature and clinical guidelines, this overview aims to provide a nuanced understanding of the surgical considerations inherent to the management of invasive lobular breast cancer.
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Affiliation(s)
- Margit L H Riis
- Department of Breast and Endocrine Surgery, Oslo University Hospital, Oslo, Norway.
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3
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Falade I, Mukhtar RA. ASO Author Reflections: The Oncologic Safety of Immediate Oncoplastic Approaches in Invasive Lobular Carcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15384-9. [PMID: 38735901 DOI: 10.1245/s10434-024-15384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024]
Affiliation(s)
- I Falade
- School of Medicine, University of California San Francisco, San Francisco, USA.
| | - R A Mukhtar
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
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4
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Falade I, Switalla K, Quirarte A, Baxter M, Soroudi D, Rothschild H, Abe SE, Goodwin K, Piper M, Wong J, Foster R, Mukhtar RA. Oncologic Safety of Immediate Oncoplastic Surgery Compared with Standard Breast-Conserving Surgery for Patients with Invasive Lobular Carcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15326-5. [PMID: 38713388 DOI: 10.1245/s10434-024-15326-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/01/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, resulting in a high risk of positive margins at surgical resection. Oncoplastic approaches have been shown to reduce this risk, but concerns persist around the safety of immediate oncoplastic surgery for those with ILC. This study evaluated the short- and long-term oncologic outcomes of immediate oncoplastic surgery for patients with ILC. METHODS This study retrospectively analyzed an institutional database of stages I to III ILC patients who underwent breast-conserving surgery (BCS) with or without immediate oncoplastic surgery (oncoplastic closure or oncoplastic reduction mammoplasty [ORM]). The study compared positive margin rates, rates of successful BCS, and recurrence-free survival (RFS) by type of surgery. RESULTS For 494 patients the findings showed that the use of immediate ORM was associated with significantly lower odds of positive margins (odds ratio [OR], 0.34; 95 % confidence interval [CI], 0.17-0.66; p = 0.002). Both lumpectomy with oncoplastic closure and ORM were significantly associated with higher rates of successful BCS than standard lumpectomy (94.2 %, 87.8 %, and 73.9 %, respectively; p < 0.001). No difference in RFS was observed between those undergoing immediate oncoplastic surgery and those undergoing standard lumpectomy alone. CONCLUSIONS The patients with stages I to III ILC who underwent immediate oncoplastic surgery had significant benefits including lower odds of positive margins and higher rates of successful BCS, with both types of immediate oncoplastic surgery showing similar RFS compared with lumpectomy alone. This supports the oncologic safety of immediate oncoplastic surgery for diffusely growing tumors such as ILC, providing it an ideal option for patients desiring BCS.
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Affiliation(s)
- Israel Falade
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA.
| | - Kayla Switalla
- University of Minnesota Medical School, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Astrid Quirarte
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Molly Baxter
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Daniel Soroudi
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Harriet Rothschild
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Shoko Emily Abe
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Karen Goodwin
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Merisa Piper
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Jasmine Wong
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Robert Foster
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Rita A Mukhtar
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
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5
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Jochelson MS, Mukhtar RA. Editorial: Contrast mammography-a promising tool for the pre-operative evaluation of lobular breast cancer. Eur J Radiol 2023; 166:110982. [PMID: 37523873 DOI: 10.1016/j.ejrad.2023.110982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Maxine S Jochelson
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Rita A Mukhtar
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA 94158, USA.
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6
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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist. METHODS A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis. RESULTS A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies). CONCLUSIONS On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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Fernandez-Pacheco M, Ortmann O, Ignatov A, Inwald EC. Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review. Arch Gynecol Obstet 2023; 307:1295-1309. [PMID: 35593951 PMCID: PMC10023760 DOI: 10.1007/s00404-022-06512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review. METHODS A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review. RESULTS The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors. CONCLUSION CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.
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Affiliation(s)
- M Fernandez-Pacheco
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - O Ortmann
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - A Ignatov
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - E C Inwald
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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8
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Fernández-Pacheco M, Gerken M, Ortmann O, Ignatov A, Klinkhammer-Schalke M, Hatzipanagiotou ME, Inwald EC. Impact of cavity shaving on residual tumor rates in patients with primary invasive carcinoma and carcinoma in situ in breast conserving surgery. Arch Gynecol Obstet 2022; 307:1573-1583. [PMID: 36282347 PMCID: PMC10110683 DOI: 10.1007/s00404-022-06803-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Several international studies reported relatively high re-excision rates due to residual tumor in breast conserving surgery (BCS). Cavity shaving (CS) is a surgical strategy to reduce re-excision rates. This study aimed to investigate the effect of circumferential cavity shaving during BCS to reduce residual tumor.
Material and Methods
A total of 591 patients with early invasive carcinoma or carcinoma in situ of the breast (ICD-10, C50 or D05) who were diagnosed between 01/01/2017 and 31/12/2019 and underwent BCS in a certified breast cancer center of the University Regensburg were analyzed regarding surgical excision methods. Patients with CS during BCS and patients with targeted re-excision in a specific direction depending on the result of intraoperative mammography or sonography during BCS were compared. The risk of pathologic residual tumor (R1) was compared between both groups by means of a multivariable binary logistic regression model to determine if there is a benefit of a certain surgical method to avoid a second intervention for re-excision. We adjusted for age, tumor size, nodal status, histologic type, surgeon, breast side, and neoadjuvant chemotherapy.
Results
80 (n = 13.54%) patients had CS and 511 (n = 86.46%) had a targeted re-excision in a specific direction during BCS according to intraoperative mammography or sonography. After comparing both techniques in a multivariable regression model, there was no significant difference regarding risk of residual tumor (p = 0.738) in the total cohort. However, CS showed a tendency to be favorable regarding rates of residual tumor in patients with invasive breast cancer between 60 and 70 years (p = 0.072) and smaller T1-tumors (p = 0.057) compared to targeted intraoperative re-excision following mammographic or sonographic assessment.
Conclusion
CS showed a tendency to reduce residual tumor compared to the standard technique of intraoperative re-excision in specific subgroups, although no statistical significance was reached. Further studies are needed to overcome potential limitations like surgeon-based bias and missing standardized definitions of CS to reduce residual tumor rates.
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Affiliation(s)
- Miriam Fernández-Pacheco
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany.
| | - Michael Gerken
- Tumor Center - Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany
| | - Atanas Ignatov
- Department of Gynecology and Obstetrics, Otto-Von-Guericke University, Magdeburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center - Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | | | - Elisabeth C Inwald
- Department of Gynecology and Obstetrics, University Medical Center Regensburg, Regensburg, Germany
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Guirguis MS, Checka C, Adrada BE, Whitman GJ, Dryden MJ, Sun J, Ding QQ, Le-Petross H, Rauch GM, Clemens M, Moseley T. Bracketing with Multiple Radioactive Seeds to Achieve Negative Margins in Breast Conservation Surgery: Multiple Seeds in Breast Surgery. Clin Breast Cancer 2022; 22:e158-e166. [PMID: 34187752 PMCID: PMC8639835 DOI: 10.1016/j.clbc.2021.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Breast conservation surgery (BCS) is the treatment of choice for unifocal, early-stage breast cancer. The ability to offer BCS to a wider subset of patients, including those with multifocal/multicentric cancer as well as extensive ductal carcinoma in situ, has emerged over time, especially in those undergoing joint oncoplastic reconstruction and those treated with neoadjuvant therapy. However, localization techniques using multiple radioactive seeds for bracketing in this patient subset have not been validated. MATERIALS AND METHODS A single-institution retrospective review was conducted of all patients with breast cancer who underwent BCS, guided by multiple bracketed iodine I 125 radioactive seeds between January 2014 and April 2017. RESULTS Bracketing of breast cancer using 2 or more radioactive seeds was performed in 157 breasts in 156 patients. Negative margins were achieved in 124 of 157 (79%) breasts, including 33 cases (21%) that underwent targeted margin reexcision at the time of surgery after intraoperative, multidisciplinary margin assessment. Thirty-three cases (21%) resulted in close or positive margins, of which 11 (7%) and 10 (6.4%) underwent completion mastectomy or repeat lumpectomy, respectively. Twelve patients (7.6%) did not undergo reexcision. En bloc resection was successful in 134 of 157 (85.4%) lumpectomies. Eighty-nine percent of the procedures were coupled with oncoplastic reconstruction. CONCLUSION Bracketing techniques using multiple radioactive seeds expands the indications for breast conservation therapy in patients who would have traditionally required mastectomy. Intraoperative margin assessment improves surgical and pathologic success. Larger defects created by multifocal resection are optimally managed in concert with oncoplastic reconstruction to minimize asymmetries and aesthetic defects.
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Affiliation(s)
| | - Cristina Checka
- University of Texas MD Anderson Cancer Center, Breast Surgical Oncology
| | | | - Gary J. Whitman
- University of Texas MD Anderson Cancer Center, Breast Imaging
| | - Mark J. Dryden
- University of Texas MD Anderson Cancer Center, Breast Imaging
| | - Jia Sun
- University of Texas MD Anderson Cancer Center, Biostatistics
| | - Qing-Qing Ding
- University of Texas MD Anderson Cancer Center, Anatomical Pathology
| | | | - Gaiane M. Rauch
- University of Texas MD Anderson Cancer Center, Abdominal Imaging
| | - Mark Clemens
- University of Texas MD Anderson Cancer Center, Plastic Surgery
| | - Tanya Moseley
- University of Texas MD Anderson Cancer Center, Breast Imaging
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Nanda A, Hu J, Hodgkinson S, Ali S, Rainsbury R, Roy PG. Oncoplastic breast-conserving surgery for women with primary breast cancer. Cochrane Database Syst Rev 2021; 10:CD013658. [PMID: 34713449 PMCID: PMC8554646 DOI: 10.1002/14651858.cd013658.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques. OBJECTIVES Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions. SELECTION CRITERIA We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer. DATA COLLECTION AND ANALYSIS Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures. MAIN RESULTS We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation. AUTHORS' CONCLUSIONS The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.
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Affiliation(s)
- Akriti Nanda
- Department of Breast Surgery, Oxford University Hospitals, Oxford, UK
| | - Jesse Hu
- Division of Breast Surgery, National University Health System, Singapore, Singapore
| | - Sarah Hodgkinson
- Editorial & Methods Department, Cochrane Central Executive, London, UK
| | - Sanah Ali
- Medical School, Oxford University, Oxford, UK
| | | | - Pankaj G Roy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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11
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Siegel JB, Mukherjee R, Park Y, Cluver AR, Chung C, Cole DJ, Lockett MA, Klauber-DeMore N, Abbott AM. Prognostic factors for residual occult disease in shave margins during partial mastectomy. Breast Cancer Res Treat 2021; 189:471-481. [PMID: 34132936 DOI: 10.1007/s10549-021-06282-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins. METHODS Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors. RESULTS 166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28 months (9-50 months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS. CONCLUSION Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA.
| | - Rupak Mukherjee
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Yeonhee Park
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Abbie R Cluver
- Department of Radiology and Radiologic Science, Medical University of South Carolina, Charleston, SC, USA
| | - Catherine Chung
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - David J Cole
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Mark A Lockett
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Nancy Klauber-DeMore
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
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12
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Mukhtar RA, Hoskin TL, Habermann EB, Day CN, Boughey JC. Changes in Management Strategy and Impact of Neoadjuvant Therapy on Extent of Surgery in Invasive Lobular Carcinoma of the Breast: Analysis of the National Cancer Database (NCDB). Ann Surg Oncol 2021; 28:5867-5877. [PMID: 33687613 PMCID: PMC8460506 DOI: 10.1245/s10434-021-09715-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Abstract
Background Given reports of low response rates to neoadjuvant chemotherapy (NAC) in invasive lobular carcinoma (ILC), we evaluated whether use of alternative strategies such as neoadjuvant endocrine therapy (NET) is increasing. Additionally, we investigated whether NET is associated with more breast conservation surgery (BCS) and less extensive axillary surgery in those with ILC. Patients and Methods We queried the NCDB from 2010 to 2016 and identified all women with stage I–III hormone receptor positive, human epidermal growth factor receptor-2 negative (HR+/HER2−) ILC who underwent surgery. We used Cochrane–Armitage tests to evaluate trends in utilization of the following treatment strategies: NAC, short-course NET, long-course NET, and primary surgery. We compared rates of BCS and extent of axillary surgery stratified by clinical stage and tumor receptor subtype for each treatment strategy. Results Among 69,312 cases of HR+/HER2− ILC, NAC use decreased slightly (from 4.7 to 4.2%, p = 0.007), while there was a small but significant increase in long-course NET (from 1.6 to 2.7%, p < 0.001). Long-course NET was significantly associated with increased BCS in patients with cT2–cT4 disease and less extensive axillary surgery in clinically node positive patients with HR+/HER2− tumors. Conclusions Primary surgery remains the most common treatment strategy in patients with ILC. However, NAC use decreased slightly over the study period, while the use of long-course NET had a small increase and was associated with more BCS and less extensive axillary surgery.
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Affiliation(s)
- Rita A Mukhtar
- Department of Surgery, University of California, San Francisco, CA, USA.
| | - Tanya L Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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13
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Crown A, Handy N, Weed C, Laskin R, Rocha FG, Grumley J. Oncoplastic Breast-Conserving Surgery: Can We Reduce Rates of Mastectomy and Chemotherapy Use in Patients with Traditional Indications for Mastectomy? Ann Surg Oncol 2020; 28:2199-2209. [PMID: 32989659 DOI: 10.1245/s10434-020-09044-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/03/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Traditional indications for mastectomy include multiple ipsilateral lesions and/or disease spanning ≥ 5 cm. Neoadjuvant chemotherapy increases breast conservation but does not improve survival. We hypothesized that oncoplastic breast-conserving surgery (OPS) may allow for breast conservation while providing full staging and tumor profiling information to guide systemic therapy decisions, thereby permitting more judicious chemotherapy use. METHODS This was an observational cohort of patients with invasive breast cancer with multiple lesions and/or disease spanning ≥ 5 cm who underwent OPS from 2012 to 2018. Clinicopathologic features, mastectomy rate, chemotherapy use, and recurrence were evaluated. RESULTS Overall, 100 patients were identified. Average disease span was 62.8 ± 20.1 mm, with an average of 2.9 lesions (range 1-13). 'No ink on tumor' was achieved at the index operation in 80 patients; 13 patients underwent completion mastectomy to achieve adequate margins. Eighty-one patients completed radiation therapy. Breast conservation was possible in 50/58 (86%) patients who did not receive chemotherapy. Forty-two patients received chemotherapy (8 neoadjuvant, 34 adjuvant), of whom 37 (88%) achieved breast conservation. Twenty-six patients with high-risk features received adjuvant chemotherapy. Oncotype DX testing demonstrated the need for chemotherapy in an additional eight patients. After a median follow-up of 40 months, four patients had a local recurrence, including two who declined radiation therapy. CONCLUSIONS OPS can facilitate breast conservation in most patients with traditional indications for mastectomy. Additionally, OPS may reduce unnecessary chemotherapy, especially in patients who qualify for Oncotype DX testing. Further study evaluating long-term oncologic and cosmetic outcomes is warranted.
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Affiliation(s)
- Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Breast Surgery, True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | - Nicketti Handy
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Christina Weed
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Ruby Laskin
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Flavio G Rocha
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Janie Grumley
- Margie Peterson Breast Center, John Wayne Cancer Institute, Santa Monica, CA, USA.
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14
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Heeg E, Jensen MB, Hölmich LR, Bodilsen A, Tollenaar RAEM, Laenkholm AV, Offersen BV, Ejlertsen B, Mureau MAM, Christiansen PM. Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study. Br J Surg 2020; 107:1762-1772. [PMID: 32761931 PMCID: PMC7689836 DOI: 10.1002/bjs.11838] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/09/2020] [Accepted: 05/31/2020] [Indexed: 01/17/2023]
Abstract
Background There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting. Methods In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias. Results A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching. Conclusion A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.
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Affiliation(s)
- E Heeg
- Dutch Institute for Clinical Auditing, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M B Jensen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark
| | - L R Hölmich
- Department of Plastic Surgery, Herlev Gentofte Hospital, Herlev, Denmark
| | | | - R A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - A V Laenkholm
- Department of Surgical Pathology, Zealand University Hospital, Slagelse, Denmark
| | | | - B Ejlertsen
- Danish Breast Cancer Cooperative Group, Copenhagen, Denmark.,Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - P M Christiansen
- Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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15
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Evaluating the impact of axillary dissection on recurrence-free survival by extent of nodal disease in invasive lobular carcinoma of the breast. Breast Cancer Res Treat 2020; 183:661-667. [PMID: 32696313 DOI: 10.1007/s10549-020-05794-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Clinical trials have shown that axillary lymph node dissection (ALND) can be avoided for many breast cancer patients with limited nodal involvement. However, whether its omission is safe for those with invasive lobular carcinoma (ILC) is still questioned. We sought to evaluate the impact of ALND on recurrence-free survival (RFS) by extent of nodal disease in patients with ILC. METHODS We performed a retrospective, cross-sectional analysis of ILC patients treated between 1990 and 2019 at our institution. Patients underwent either breast conservation surgery (BCS) or mastectomy. We used univariate and multivariate statistics in Stata 14.2 to evaluate associations between extent of axillary surgery and time to recurrence stratified by nodal burden. RESULTS Of 520 cases, 387 (78.4%) were node negative, 74 (14.9%) had 1-2 positive nodes, and 59 (11.4%) had three or more positive nodes. Most patients (93.3%) had hormone receptor-positive disease, and 94.8% had low or intermediate-grade tumors. The rate of ALND significantly decreased over time (p < 0.002). Using a multivariate model, there was no significant difference in RFS estimates based on receipt of ALND (HR = 0.53, 95% CI 0.17-1.64, p = 0.27), which also held true for patients with 1-2 positive nodes using a test of interaction (HR = 0.91, 95% CI 0.12-6.76, p = 0.92). CONCLUSIONS These findings support the safety of omitting ALND in selected patients with ILC. Further studies of axillary management in ILC and imaging tools to predict nodal involvement and therapeutic response are warranted.
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16
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Abel MK, Brabham CE, Guo R, Fahrner-Scott K, Wong J, Alvarado M, Ewing C, Esserman LJ, Mukhtar RA. Breast conservation therapy versus mastectomy in the surgical management of invasive lobular carcinoma measuring 4 cm or greater. Am J Surg 2020; 221:32-36. [PMID: 32622509 DOI: 10.1016/j.amjsurg.2020.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The safety of breast conservation therapy (BCT) has not been demonstrated in large ILC tumors, potentially contributing to the higher mastectomy rates seen in ILC. METHODS We queried a prospectively maintained database to identify patients with ILC measuring ≥4 cm and evaluated difference in recurrence free survival (RFS) between those treated with BCT versus mastectomy using a multivariate model. RESULTS Of 180 patients, 30 (16.7%) underwent BCT and 150 (83.3%) underwent mastectomy. Patients undergoing mastectomy were younger (56.6 vs. 64.3 years, p = 0.003) and had larger tumors (7.2 vs. 5.4 cm, p < 0.001). While tumor size, nodal stage, receptor subtype, and margin status were significantly associated with RFS, there was no difference in RFS at 5 (p = 0.88) or 10 (p = 0.65) years for individuals undergoing BCT versus mastectomy. CONCLUSIONS For patients with ILC ≥4 cm, BCT provides similar tumor control as mastectomy, provided that negative margins are achieved.
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Affiliation(s)
- Mary Kathryn Abel
- University of California, San Francisco School of Medicine, San Francisco, CA, USA; Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Case E Brabham
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ruby Guo
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kelly Fahrner-Scott
- University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Jasmine Wong
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Cheryl Ewing
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Rita A Mukhtar
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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17
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Crown A, Rocha FG, Grumley JW. Intraoperative radiation therapy in early-stage breast cancer: Presence of lobular features is not associated with increased rate of requiring additional therapy. Am J Surg 2019; 220:161-164. [PMID: 31839176 DOI: 10.1016/j.amjsurg.2019.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/25/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a paucity of data regarding the application of IORT to the treatment of carcinomas with lobular features. METHODS This study includes women with invasive breast cancer who underwent breast conservation in combination with IORT from February 2011 to October 2016. Patients whose final pathology did not satisfy inclusion criteria or had inadequate margins were recommended to undergo additional therapy (AT) with WBRT as well as re-excision of inadequate margins. RESULTS 243 invasive breast cancers were treated with IORT. The lobular features (LF) group comprised 62 patients and the invasive ductal carcinoma (IDCA) group consisted of 172 patients. Rate of AT was similar between groups (LF 19 patients, 30.6%, vs IDCA 56 patients, 32.6%, p = 0.87) groups. Lobular histology was not associated with a need for AT. Local recurrence rate for the cohort was 1.2% with a median follow up of 46 months. There was no difference in recurrence or survival after 46 months of follow-up. CONCLUSIONS IORT is an effective treatment option for well-selected patients with early breast cancer and can be considered for patients with lobular histology.
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Affiliation(s)
- Angelena Crown
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
| | - Flavio G Rocha
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
| | - Janie W Grumley
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
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18
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Tan M, Silva E. If not now, when? The case for a target rate of re-excision for breast-conserving surgery as a standard of care quality measure. Breast J 2019; 25:1306-1307. [PMID: 31502313 DOI: 10.1111/tbj.13467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Mona Tan
- MammoCare - Breast Oncology, Singapore, Singapore
| | - Edibaldo Silva
- Division of Surgical Oncology, Department of Surgery, Nebraska Medical Center, Omaha, Nebraska
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19
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Piper ML, Wong J, Fahrner-Scott K, Ewing C, Alvarado M, Esserman LJ, Mukhtar RA. Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast. NPJ Breast Cancer 2019; 5:29. [PMID: 31508489 PMCID: PMC6731236 DOI: 10.1038/s41523-019-0125-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/19/2019] [Indexed: 11/09/2022] Open
Abstract
Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15-13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p < 0.001), and completion mastectomies (27.7% versus 4.5%, p < 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS.
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Affiliation(s)
- Merisa L. Piper
- Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, CA USA
| | - Jasmine Wong
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Kelly Fahrner-Scott
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Cheryl Ewing
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Michael Alvarado
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Laura J. Esserman
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Rita A. Mukhtar
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
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20
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Silva E, Tan M. The Impact of Margin Status on Breast Conservation Rates. Ann Surg Oncol 2019; 26:3931-3938. [PMID: 31482391 DOI: 10.1245/s10434-019-07641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes. METHODS A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes. DISCUSSION Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.
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Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
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21
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Mamtani A, Zabor EC, Rosenberger LH, Stempel M, Gemignani ML, Morrow M. Was Reexcision Less Frequent for Patients with Lobular Breast Cancer After Publication of the SSO-ASTRO Margin Guidelines? Ann Surg Oncol 2019; 26:3856-3862. [PMID: 31456094 DOI: 10.1245/s10434-019-07751-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Society of Surgical Oncology and American Society for Radiation Oncology consensus guidelines defined a negative margin for breast-conserving surgery (BCS) as no ink on tumor, and implementation has reduced rates of additional surgery for patients with invasive ductal cancer (IDC). The outcomes for invasive lobular cancer (ILC) patients are uncertain. METHODS This study identified patients who had stage 1 or 2 ILC treated with BCS from January 2010 to February 2018. The guidelines were adopted 1 January 2014. Clinicopathologic characteristics, margin status, and reexcisions were compared before and after adoption of the guidelines and with those of IDC patients treated from May 2013 to February 2015. RESULTS Among 745 early-stage ILC patients undergoing BCT, 312 (42%) were treated before the guidelines and 433 (58%) after the guidelines. Most clinicopathologic characteristics were similar between the two groups, with differences in lobular carcinoma in situ, lymphovascular invasion, and node-positivity rates. The overall rates of additional surgery declined significantly after the guidelines (31.4 to 23.1%; p = 0.01), but the difference did not reach significance for reexcisions (19.9 to 15.2%; p = 0.12) or conversions to mastectomy (11.5 to 7.9%; p = 0.099) individually. Between eras, no difference in incidence or number of tumor on ink or ≤ 2 mm margins was observed (all p = 0.2). Larger tumors, younger age, and pre-guideline era were independently associated with additional surgery. Only younger age was predictive of mastectomy. Among 431 pre-guideline and 601 post-guideline IDC patients, reexcisions declined from 21.3 to 14.8% (p = 0.008), and conversion to mastectomy was rare (0.6%). The magnitude of reduction in any additional surgery (interaction, p = 0.92) and reexcisions (interaction, p = 0.56) was similar between ILC and IDC. CONCLUSIONS Despite differences in growth pattern and conspicuity, guideline adoption significantly reduced additional surgery among ILC patients, with a magnitude of benefit similar to that among IDC patients.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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22
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Lombardi A, Pastore E, Maggi S, Stanzani G, Vitale V, Romano C, Bersigotti L, Vecchione A, Amanti C. Positive margins (R1) risk factors in breast cancer conservative surgery. BREAST CANCER-TARGETS AND THERAPY 2019; 11:243-248. [PMID: 31440079 PMCID: PMC6668245 DOI: 10.2147/bctt.s210788] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/12/2019] [Indexed: 12/02/2022]
Abstract
Background The primary goal in conservative breast cancer surgery is the complete excision of the tumor, but at the same time attempting to obtain a satisfactory postoperative esthetic result. The notion of “No Ink on Tumor” that indicates exclusively the presence of tumor cells on the inked surface of the surgical specimen is now the gold standard; however, the problem of the free margin is still a fundamental topic of debate that has not yet found a definitive solution. Methods Our retrospective analysis takes into account 1440 patients undergoing breast conservative surgery, from October 2004 to November 2018, all treated at the breast unit of our institution. Results Positive margins (R1) rate was 10.2% (147 cases out of 1440). Overall survival was 95% at 5 years and 89% at 10 years. No differences in mortality and local recurrence rate between R0 and R1 patients were found. Half of the R1 patients underwent secondary surgery with enlargement of margins, while in the other half we performed direct mastectomy. Among the analyzed variables, age, histological size, histological type, grading, multifocality, lympho-vascular invasion and lymph node status were significantly correlated with the R1 status. The multivariate analysis shows the association of age and surgical technique (oncoplastic) with R1 status. Conclusion Further studies will allow the creation of a statistical model, for better pre-operative prediction of patients with higher risk of R1 and better selection of patients to be candidates for conservative surgery.
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Affiliation(s)
- Augusto Lombardi
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Elena Pastore
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Stefano Maggi
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | | | | | - Camilla Romano
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Laura Bersigotti
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Andrea Vecchione
- Department of Pathology, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Claudio Amanti
- Breast Surgery, Università La Sapienza, Ospedale Sant'Andrea, Rome, Italy
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Chatterjee A, Gass J, Patel K, Holmes D, Kopkash K, Peiris L, Peled A, Ryan J, El-Tamer M, Reiland J. A Consensus Definition and Classification System of Oncoplastic Surgery Developed by the American Society of Breast Surgeons. Ann Surg Oncol 2019; 26:3436-3444. [DOI: 10.1245/s10434-019-07345-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 01/07/2023]
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Park KU, Kuerer HM, Rauch GM, Leung JWT, Sahin AA, Wei W, Li Y, Black DM. Digital Breast Tomosynthesis for Intraoperative Margin Assessment during Breast-Conserving Surgery. Ann Surg Oncol 2019; 26:1720-1728. [DOI: 10.1245/s10434-019-07226-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 11/18/2022]
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Crown A, Laskin R, Rocha FG, Grumley J. Extreme oncoplasty: Expanding indications for breast conservation. Am J Surg 2019; 217:851-856. [PMID: 30771865 DOI: 10.1016/j.amjsurg.2019.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/07/2018] [Accepted: 01/07/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Presence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described. METHODS This is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated. RESULTS One hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ± 23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50-160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy. CONCLUSION EOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.
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Affiliation(s)
| | - Ruby Laskin
- Virginia Mason Medical Center, Seattle, WA, USA
| | | | - Janie Grumley
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA.
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Mukhtar RA. ASO Author Reflections: Breast Conservation and Negative Margins in Invasive Lobular Carcinoma: The Impact of Oncoplastic Surgery and Shave Margins in 358 Patients. Ann Surg Oncol 2018; 25:622-623. [PMID: 30151561 DOI: 10.1245/s10434-018-6716-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Rita A Mukhtar
- Division of General Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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