Low-Cost Radio-Opaque Tumor Marking Techniques for Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: a Systematic Review

Current standard of care localization techniques used in breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) are expensive and may not be available in LMICs (lower-middle income countries). This review evaluated the efficacy of radio-opaque low-cost tumor markers. A systematic search was conducted as per PRISMA guidelines through November 30, 2022, for all studies using non-commercial radio-opaque tumor markers for patients undergoing BCS post NACT. Rate of unsatisfactory margin on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. After screening, 07 studies were included for data synthesis. For marking, four studies used LIGA clips, two used 5-mm cut pieces of K-wire, and one used cut pieces of 25-G needle. Incidence of unsatisfactory margins (positive/close) ranged from 0 to 11%. All studies found these low-cost markers to be feasible, with 100% pre-surgery visibility and 100% retrieval rate. Low-cost radio-opaque tumor markers (LIGA clips, 5-mm cut pieces of K-wire and 25-G needle) are effective methods of tumor localization especially for LMICs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01845-2.

Evaluation of the accuracy of an augmented reality-based tumor-targeting guide for breast-conserving surgery

BACKGROUND AND OBJECTIVES

Although magnetic resonance imaging (MRI) is commonly used for breast tumor detection, significant challenges remain in determining and presenting the three-dimensional (3D) morphology of tumors to guide breast-conserving surgery. To address this challenge, we have developed the augmented reality-breast surgery guide (AR-BSG) and compared its performance with that of a traditional 3D-printed breast surgical guide (3DP-BSG).

METHODS

Based on the MRI results of a breast cancer patient, a breast phantom made of skin, body, and tumor was fabricated through 3D printing and silicone-casting. AR-BSG and 3DP-BSG were executed using surgical plans based on the breast phantom's computed tomography scan images. Three operators independently inserted a catheter into the phantom using each guide. Their targeting accuracy was then evaluated using Bland-Altman analysis with limits of agreement (LoA). Differences between the users of each guide were evaluated using the intraclass correlation coefficient (ICC).

RESULTS

The entry and end point errors associated with AR-BSG were -0.34±0.68 mm (LoA: -1.71-1.01 mm) and 0.81±1.88 mm (LoA: -4.60-3.00 mm), respectively, whereas 3DP-BSG was associated with entry and end point errors of -0.28±0.70 mm (LoA: -1.69-1.11 mm) and -0.62±1.24 mm (LoA: -3.00-1.80 mm), respectively. The AR-BSG's entry and end point ICC values were 0.99 and 0.97, respectively, whereas 3DP-BSG was associated with entry and end point ICC values of 0.99 and 0.99, respectively.

CONCLUSIONS

AR-BSG can consistently and accurately localize tumor margins for surgeons without inferior guiding accuracy AR-BSG can consistently and accurately localize tumor margins for surgeons without inferior guiding accuracy compared to 3DP-BSG. Additionally, when compared with 3DP-BSG, AR-BSG can offer better spatial perception and visualization, lower costs, and a shorter setup time.

Patient Perspectives After Surgery-Related Complications Among Breast Cancer Patients from a LMIC

Long-term quality of life in breast cancer patients has been studied and published regularly. However, the lived experiences of patients who develop complications after surgery are not well understood. Determining this experience of patients is challenging in most low- and middle-income countries where the majority of patients belong to poor strata of society and are uneducated. We aimed to explore the thoughts, feelings, and experiences of patients with surgery-related complications after breast cancer surgery. Purposive sampling was used to identify patients who developed any postoperative complication, and semi-structured interviews were conducted. Common patterns of patient experiences were identified and analyzed using descriptive thematic analysis. Twenty-eight patients out of 210 developing complications postoperatively were identified. The median age was 48 years (range 32-65 years). The majority (n = 26) were housewives, educated below the primary level (n = 11) and below the poverty line (n = 13). Complications included seroma (n = 17), flap necrosis and infection (n = 5), and hematoma (n = 1). Seven domains emerged from the interviews-knowledge of complications, psychological impact, burden, disruptiveness, social impact, relationship with the surgical team, and suggestions to improve the experience. The themes identified in the present study provide insights into the lived experiences and can inform the future development of patient-reported outcome measures and quality improvement programs, including more effective pre-operative counseling and consent.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01721-z.

Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study

Background and Aims

Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery.

Material and Methods

This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block.

Results

The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable.

Conclusion

Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.

An Audit of Breast Conservation Surgery for Breast Cancer - a 7-Year Experience from Southern India

To audit the use of breast conservation surgery for breast cancer treatment in a tertiary care centre over a 7-year period, and also to chart the clinical, demographic and pathological characteristics of breast cancer patients treated in the setting of a referral centre in a middle income (MDI) group country. A retrospective analysis of the case records of all patients of invasive breast cancer treated at our institute between January 2014 and December 2020 was done after obtaining approval from the Institute Ethics Committee (IEC). The number of patients seen, age, parity, menopausal status, family history of cancer, laterality, site of tumour in the breast, the symptomatology, clinical stage and presence or absence of metastases was the clinical parameters examined. The pathological stage and grade of the tumour, receptor status, treatment offered according to stage and the patterns of failure with respect to the surgery performed were recorded. Statistical analysis was a direct head to head comparison of the percentage proportions of the different variables. A total of 685 patients of breast cancer were treated between January 2014 and December 2020. A total of 53% of the cohort was more than 45 years old and 56.7% were post menopausal. A total of 58.8% of the patients presented with a cancer in the left breast and in the upper outer quadrant. Nearly 41% of the tumours were more than 4 cm in size. The most common receptor profile in our patient population was ER positive, PR positive and HER 2 negative. A total of 27.7% of the patients were offered neo-adjuvant chemotherapy and 63.06% underwent upfront surgery. A total of 19.7% of all surgeries performed (overall) were breast conservation surgeries (BCS). The use of BCS showed an increasing trend over the 7 years studied rising from 16.79 to 25% (annually). The local failure rate for BCS was 11.8% but the incidence of distant metastases was not significantly different compared to the patients who underwent a mastectomy. Breast conservation is safe and feasible in a referral setting even in a middle income nation with multi-disciplinary treatment planning and needs to be adopted widely to preserve the body image and self esteem of patients with breast cancer.

Limberg Flap in Breast Oncoplasty for Carcinoma Breast Revisited-a Tertiary Cancer Centre Experience

Limberg flap is currently not commonly used in breast oncoplasty. We present our experience with Limberg flap reconstruction in breast cancer patients who underwent breast conservation surgery. This study was conducted at a tertiary cancer centre in Kerala, India. We reviewed the records of patients with breast cancer who underwent Limberg flap reconstruction with breast conservation surgery from 1st January 2020 to 31st October 2021. Data collected included age, quadrant of tumour, side of tumour, T and N stage, status at surgery (primary or post neoadjuvant therapy), type of surgery, flap complications following surgery and breast deformity following surgery. Seventeen patients underwent Limberg flap reconstruction during the study period. The median age of the patients was 51 years. The commonest stage was cT1N0M0. Twelve patients underwent primary surgery and 5 post neoadjuvant chemotherapy. No patient had postoperative flap complications or breast deformity. Limberg flap is simple, versatile and robust and should be a part of the armamentarium of breast surgeons.

Excellent long term oncological outcome in a patient with rare glycogen rich clear cell carcinoma of breast following breast conservation surgery

INTRODUCTION

We present a case report of excellent oncological outcome after 7-year follow up in a female Indian patient with pT2N3aM0 rare GRCC of the breast following breast conservation surgery and appropriate adjuvant treatment. Glycogen rich cell carcinoma (GRCC) is a rare subtype of primary malignant neoplasm of the breast which is not commonly discussed. Only approximately 288 cases have been reported since its first description globally with reports of varying prognosis. Even less (4 patients), which have been reported from India have described only clinic pathological features. This is first case report of patient from India discussing long term oncological outcome of a patient with rare GRCC (pT2N3aMO) of the breast following breast conservation surgery and appropriate adjuvant treatment. A 41-year-old lady presented to us with history of 2 × 2 cm right breast lump for 2 weeks. A BIRAD IV hypo echoic lesion with slightly irregular margins in the upper outer quadrant of the right breast and right axillary lymphadenopathy was reported in mammogram. PET CT showed metabolically active lesion 2.3 × 1.3 cm enhancing nodule with spiculated margins at the same site (SUV-10.8) with metabolically active right axillary metastatic lymphadenopathy (SUV-11) with no distant metastases. Core biopsy indicated Ductal carcinoma. Patient underwent right breast conservation surgery (Wide local excision and oncoplasty with axillary clearance) uneventfully followed by appropriate adjuvant treatment (Chemotherapy, Targeted treatment, Radiotherapy). The final pathological stage was Glycogen rich clear cell carcinoma, pT2N3a M0 with Her2 positive but negative for ER and PR with Ki 67-50 %. The patient had excellent outcome and was alive and cancer free even after 7 years follow up.

CONCLUSION

The purpose of reporting this case is to increase the knowledge about this rare subtype of breast cancer which underwent organ preservation. This case report reveals that clinical behavior and oncological outcome of GRCC breast can be unexpected, unusual, varied and even good, contrary to recent 2019 SEER data (Zhou Z, Kinslow CJ, Hibshoosh H, et al. Clinical features, survival and prognostic factors of glycogen-rich clear cell carcinoma (GRCC) of the breast in the US population. J Clin Med. 2019; 8: pii: E246).

Receipt of breast conservation over mastectomy in Black women- does breast cancer subtype matter?

BACKGROUND

Breast conservation surgery (BCS) and mastectomy have equivalent survivability. However, perception of surgical benefit may be affected by breast cancer subtypes, impacting procedure choice. We evaluate surgical management among non-Hispanic Black (NHB) and White (NHW) breast cancer patients based on subtypes.

METHODS

Queried the National Cancer Database (NCDB) including BCS eligible women with T1 (<2cm) breast cancer between 2011 and 2016. We selected NHB and NHW women and evaluated differences in sociodemographic variables and treatment including surgery. To determine factors associated with receipt of BCS, a multivariable logistic regression analysis was performed adjusting for age, race, surgery type and breast cancer subtypes.

RESULTS

Analyzed 390,278 women with 89.7% NHW and 10.3% NHB, of mean age 63 years. 55.4% vs. 53.5% of NHW compared to NHB women had BCS (p<.001) as initial cancer therapy. Statistically significant differences between NHB and NHW in surgery were found on univariate analysis in all breast cancer subtypes except Luminal B. NHB women with TNBC and Luminal A subtypes were more likely to undergo BCS on multivariate analysis.

CONCLUSIONS

Significant differences are found in the surgical management of breast cancer with Black women more likely to receive BCS, less likely to undergo mastectomy compared to White counterparts even with TNBC or her-2+ subtypes. Understanding surgical decision making and how knowledge of subtype is applied deserves further study in women of diverse racial and ethnic groups.

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

OBJECTIVE

The objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS).

MATERIALS AND METHODS

We retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 - December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign. Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified.

RESULTS

Of 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05].

CONCLUSION

New calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.

The INTEND 1 randomized controlled trial of duct endoscopy as an indicator of margin excision in breast conservation surgery

PURPOSE

With early detection, breast conservation surgery with adequate surgical margins is the standard of care. The aim of this study was to evaluate the use of pre-operative duct endoscopy (DE) to target surgical resection, improve adequate margins and reduce re-excision operations.

METHODS

Women with DCIS, stage I and II breast cancer suitable for breast conservation were randomized to DE-assisted wide local excision versus standard wide local excision (without DE). The primary endpoint was margin re-excision rates between the two groups. Secondary end points were: (i) volume differences of the surgical specimen; (ii) whether an extensive in situ component (EIC) influenced successful DE-guided resection.

RESULTS

78 women were randomized: 44 patients to no-DE and 34 patients to the DE group. The median age was 59 (49-65) and 56 (48-64) years in the two groups respectively with mean follow-up of 9.1 (4.2-11.1) years. There were 23 positive findings in 17 women in 30 successful DE procedures (17/30 = 56.7%). The surgical specimen volume, no-DE (17 [IQR 10-29] cm³) and DE 20 [IQR 12-28] cm³), did not differ, p = 0.377. The overall re-excision rate was 20/78 (26%), 9 (20%) and 11 (32% in the no-DE and DE groups, respectively, p = 0.233.

CONCLUSIONS

This randomized clinical trial was limited by incomplete accrual. DE did not contribute to improved margin excision rates whether a target lesion was visualized or not. The presence of EIC did not improve efficacy of DE.

Transposition flap for the oncoplastic reconstruction of outer quadrant breast defects

Plastic surgical principles are incorporated with breast conservation surgery (BCS) for cancer to improve aesthetic outcomes. In developing countries, average tumour size is larger at presentation resulting in larger resections often, including overlying skin. LD flap has been the workhorse of partial breast reconstruction. We present an easy and effective alternative to LD flap for carefully selected cases of outer quadrant breast tumours. We report 41 cases of local transposition flap from the lateral chest wall for oncoplastic restoration post BCS, performed between January 2016 and February 2020, at our institution. The median age was 49 years (28-63). Twenty-six patients underwent upfront surgery and 15 after neoadjuvant chemotherapy (NACT). The average pathological tumour size was 2.9 cm (median 2.7 and range 1.1-6) and 1.5 cm (median 1.8 and range 0-3.5) for upfront and post-NACT groups, respectively. The median volume of the resected specimen was 277.8 ml and 253.2 ml for upfront and post-NACT groups, respectively. Three patients (7.5%) had a microscopic positive margin requiring margin revision. Three (7.5%) patients had post-operative minor wound complications and were managed conservatively. At a median follow-up of 14 months (1-36), only 2/19 (10.5%) patients had clinical fat necrosis. Local transposition flap from the lateral chest wall based on dermal and subdermal plexus, carefully designed in selected patients, can be used effectively for the reconstruction of outer quadrant breast defects. It is easy to learn, offers good cosmetic outcome, avoids the morbidity and time of LD flap and saves LD flap for future use.

Breast conservation therapy versus mastectomy in the surgical management of invasive lobular carcinoma measuring 4 cm or greater

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.

Breast Anthropometry-Results of a Prospective Study Among Indian Breast Cancer Patients

Breast anthropometry plays an important role in surgical decision-making in the era of breast conservation therapy, oncoplasty and reconstruction. Majority of the currently available breast anthropometry data is from Western countries, and there is a need to evaluate anthropometric data among Indian women to tailor our surgical decision-making and achieve optimum surgical results. Two hundred and thirty-one breast cancer patients were included in this prospective study, and different anthropometric parameters were evaluated to assess and describe the nipple-areola complex, breast shape, size, volume and ptosis. Breast volume was calculated using formula developed by Qiao et al. Outcomes were compared with data available from different countries. Mean breast volume among Indian women was 515 ml. Nearly, 81% of patients had ptosis and up to 40% had grade 3 ptosis. Breast volume among Indian patients can be grouped into three categories based on quartiles (category I-≤ 220 ml, category II-> 220 to ≤ 730 ml, category III-> 730 ml). Overall breast anthropometry data among Indian women was different from the data reported from western studies. Breast anthropometry plays an important role in the surgical decision-making, and results of the study indicate that the anthropometry of Indian women is different from western counterparts.

Does Quality of Life Among Modified Radical Mastectomy and Breast Conservation Surgery Patients Differ? A 5-Year Comparative Study

Breast cancer is the most common cancer among females worldwide, of whom more than 80% survive for more than 5 years. Hence, ensuring a good quality of life (QOL) is essential to achieve holistic approach in treating patients. A cross-sectional study was conducted to compare the QOL in women who underwent modified radical mastectomy (MRM) and breast conservation surgery (BCS) for breast cancer in the last 5 years. QOL was evaluated based on the long-term quality of life-breast cancer (LTQOL-BC) questionnaire. A greater percentage of women who underwent MRM complained of difficulty in completing their house work compared with the BCS group (50% compared with 31%). Twenty-five percent (6) of the women who had undergone MRM reported feeling of being incomplete as women, along with a lack of femininity. However, more than 80% of the women in both groups said that they felt stronger as survivors and derived strength from their experience. There were significant differences in the quality of life of women from both groups in terms of physical function and body image, with the BCS group appearing to have a better QOL.

Digital Breast Tomosynthesis as a Tool in Confirming Negative Surgical Margins in Non-palpable Breast Lesions

Breast cancer is one of the leading killers among women the world over. Widespread mammographic screening programs have led to almost 20% of breast cancers being detected when they are radiologically visible but clinically impalpable. For the localization of these cancers before surgical excision, the Kopan hook wire is the standard technique, but the extent of margins excised still needs to be determined. In this study, we have evaluated the accuracy of specimen mammogram (SM) with digital breast tomosynthesis (DBT) for margin assessment by comparing it to the excised margins as measured in final histopathology. This is a prospective observational study of patients with radiologically suspicious impalpable breast lesions. The patients underwent ultrasound-guided hook wire placement followed by excision of the lesion, subjected to digital tomosynthesis mammogram, and margins were revised on table when indicated. These findings were correlated with final histopathological margin. Our study included 30 patients and out of the 6 lesions, which showed positive margins on specimen mammography, 4 were histologically confirmed to have tumour at the surgical margin and 2 were confirmed to be tumour free. All DBT-positive margins were re-excised at the time of primary surgery. Individual comparison of the margins revealed a good agreement and high level of correlation between DBT and histopathology margins. None of the cases required a second surgery for margin revision. It can be concluded that specimen mammogram with DBT can be used as a reliable tool for intraoperative surgical margin assessment in non-palpable breast lesions to reduce rate of margin revision as well as reduce the volume of breast excised without compromising the oncological safety of the procedure.

Comparative analysis of margin status in breast conservation surgery and its correlation with subsequent re-excision findings

Purpose

Breast-conservation surgery (BCS) has become a standard treatment option for invasive breast carcinoma (IBC) and ductal carcinoma in situ (DCIS). The strongest predictor of local recurrence remains the surgical margin status. We evaluated the margin positivity by quantifying the tumor on positive margins and analyzing the histologic factors including type and extent in determining the likelihood of residual disease upon re-excision.

Method

Retrospective analysis of 210 BCS performed at Mount Sinai Medical Center from the period of January 2011 - December 2017 revealed that 58 had IBC, DCIS, or both, with positive margins that were followed by re-excision.

Result

The margins had IBC in 18 (31%), DCIS in 32 (55.2%) and both in 8 (13%) cases. Thirty-eight cases (65.5%) were free of carcinoma on re-excision. Of 40 cases with margins positive for DCIS, 16 (40%) had residual DCIS. Of 26 cases with IBC at the margins, and 5 had residual disease (19%). This difference was statistically significant (p = 0.002). Of 21 cases with extensive DCIS, 12 had residual disease (p = 0.02) as compared to only 4 out of 19 without extensive DCIS. None of the cases with clinging/micro-papillary DCIS had residual disease, while 51% of the other types (solid, cribriform, come-do) had residual disease (p = 0.02). The area of DCIS as measured on the involved margin correlated with the amount of residual disease on re-excision (p = 0.03).

Conclusion

Margins positive for DCIS are more likely to have residual disease on re-excision in comparison to margins positive for only IBC. The type and extent of DCIS appears to influence the likelihood of residual disease.

Oncoplastic Breast Reconstruction in Breast Conservation Surgery: Improving the Oncological and Aesthetic Outcomes

Breast conservation surgery (BCS) is now the standard of care for patients with early breast cancer. The main contraindications for BCS besides the presence of multicentricity and diffuse microcalcifications are inadequate tumour size to breast size ratio. With the advent of oncoplastic techniques, the indications of BCS may be further extended to patient with larger tumour size and or small volume breast. We prospectively assessed 42 patients undergoing oncoplastic breast conservation surgery for cosmetic and oncologic outcomes. Cosmetic outcome assessment was done by comparison of operated breast to contralateral breast by an independent surgeon, nurse and patient's attendant at 6 months post-surgery. Risk factors for compromised oncologic outcomes included grades II/III tumours and non-ductal histology. Intraoperative margin assessment with frozen section analysis proved to be important in order to achieve negative surgical margins on final histopathology. By univariate analysis, tumours located in central quadrant and medial half of the breast had similar cosmetic outcomes comparable to tumours located in other quadrants. Majority of our patients (90%) had overall good to excellent cosmetic outcomes on Harvard scale. Oncoplastic breast conservation surgery techniques allow for larger parenchymal resections without compromising oncologic and cosmetic results. It further allows extension of BCS to patients otherwise denied for the same based on earlier recommendations for mastectomy. Oncoplastic techniques and intraoperative margin assessment with frozen section are vital in attaining adequate margins and also decrease chance of local recurrence and revision surgery for positive margins.

Management of Ductal Carcinoma In Situ (DCIS) of the Breast: Present Approaches and Future Directions

PURPOSE OF REVIEW

Ductal carcinoma in situ (DCIS; intraductal carcinoma) of the breast is commonly found in an asymptomatic woman on routine screening mammography. The purpose of this review is to describe current approaches to the management of DCIS as well as areas for future investigation.

RECENT FINDINGS

Randomized trials have demonstrated that adding radiation treatment after breast conservation surgery (lumpectomy; surgical excision) reduces the rate of ipsilateral local recurrence by about half, and that adding hormonal therapy reduces the rate of all breast cancer events (ipsilateral plus contralateral). Early clinical studies attempted to stratify the risk of recurrence using conventional clinical and pathologic features. More recent clinical studies have attempted to define prospectively patients with lower risk DCIS for whom omission of radiation treatment after lumpectomy is a reasonable option. Molecular profiling is a newer approach to define risk stratification for DCIS. Combining molecular profiling with clinical and pathologic features appears to be more accurate in defining and stratifying the risk of recurrence after lumpectomy. After lumpectomy for DCIS, risk stratification using clinical and pathologic characteristics, and more recently molecular profiling, can help guide clinical decision-making for the use of radiation treatment and hormonal therapy. Ongoing studies are evaluating the possibility of de-escalating therapy, and in some studies, even using core biopsy alone, without surgical excision.

Surgical trends in breast cancer: a rise in novel operative treatment options over a 12 year analysis

PURPOSE

Breast cancer surgical techniques are evolving. Few studies have analyzed national trends for the multitude of surgical options that include partial mastectomy (PM), mastectomy without reconstruction (M), mastectomy with reconstruction (M+R), and PM with oncoplastic reconstruction (OS). We hypothesize that the use of M is declining and likely correlates with the rise of surgery with reconstructive options (M+R, OS).

METHODS

A retrospective cohort analysis was conducted using the ACS-NSQIP database from 2005 to 2016 and ICD codes for IBC and DCIS. Patients were then grouped together based on current procedural terminology (CPT) codes for PM, M, M+R, and OS. In each group, categories were sorted again based on additional reconstructive procedures. Data analysis was conducted via Pearson's chi-squared test for demographics, linear regression, and a non-parametric Mann- Kendall test to assess a temporal trend.

RESULTS

The patient cohort consisted of 256,398 patients from the NSQIP data base; 197,387 meet inclusion criteria diagnosed with IBC or DCIS. Annual breast surgery trends changed as follows: PM 46.3-46.1% (p = 0.21), M 35.8-26.4% (p = 0.001), M+R 15.9-23.0% (p = 0.03), and OS 1.8-4.42% (p = 0.001). Analyzing the patient cohort who underwent breast conservation, categorical analysis showed a decreased use of PM alone (96-91%) with an increased use of OS (4-9%). For the patient cohort undergoing mastectomy, M alone decreased (69-53%); M+R with muscular flap decreased (9-2%); and M+R with implant placement increased (20-40%)-all three trends p < 0.0001.

CONCLUSION

The modern era of breast surgery is identified by the increasing use of reconstruction for patients undergoing breast conservation (in the form of OS) and mastectomy (in the form of M+R). Our study provides data showing significant trends that will impact the future of both breast cancer surgery and breast training programs.

Imaging of the treated breast post breast conservation surgery/oncoplasty: Pictorial review

Mammographic appearance of the normal breast is altered in the post-operative setting. It is essential to be aware of the normal findings as well as to identify features of recurrent disease with particular emphasis on radiological-pathological concordance. Digital breast tomosynthesis and volumetric breast density add incremental value in this clinical setting. We present a pictorial review of various cases to illustrate normal post-operative findings as well as mammographic features suspicious for recurrent disease.

Pre-operative assessment of residual disease in locally advanced breast cancer patients: A sequential study by quantitative diffusion weighted MRI as a function of therapy

PURPOSE

The potential of diffusion weighted imaging (DWI) in assessing pathologic response and surgical margins in locally advanced breast cancer patients (n=38) undergoing neoadjuvant chemotherapy was investigated.

METHODS

DWI was performed at pre-therapy (Tp0), after I (Tp1) and III (Tp3) NACT at 1.5T. Apparent diffusion coefficient (ADC) of whole tumor (ADC_WT), solid tumor (ADC_ST), intra-tumoral necrosis (ADC_Nec) was determined. Further, ADC of 6 consecutive shells (5mm thickness each) including tumor margin to outside tumor margins (OM1 to OM5) was calculated and the data analyzed to define surgical margins.

RESULTS

Of 38 patients, 6 were pathological complete responders (pCR), 19 partial responders (pPR) and 13 were non-responders (pNR). Significant increase was observed in ADC_ST and ADC_WT in pCR and pPR following therapy. Pre-therapy ADC was significantly lower in pCR compared to pPR and pNR indicating the heterogeneous nature of tumor which may affect drug perfusion and consequently the response. ADC of outside margins (OM1, OM2, and OM3) was significantly different among pCR, pPR and pNR at Tp3 which may serve as response predictive parameter. Further, at Tp3, ADC of outside margins (OM1, OM2, and OM3) was significantly lower compared to that seen at Tp0 in pCR, indicating the presence of residual disease in these shells.

CONCLUSION

Pre-surgery information may serve as a guide to define cancer free margins and the extent of residual disease which may be useful in planning breast conservation surgery.

Oncological Safety of Breast Conservation Surgery in Young Females

Breast conservation surgery (BCS) is the standard of care in early breast cancer. The oncological safety of this procedure has been proven beyond doubt in several randomised control trials. But there are concerns regarding the safety of this procedure in young females. The concern is regarding increased risk of local recurrence. This issue has not been addressed in any major trial. In this prospective study we intend to look into the oncological safety of BCS in young patients who are less than forty years of age.

Triple Negative Breast Cancer versus Non-Triple Negative Breast Cancer Treated with Breast Conservation Surgery Followed by Radiotherapy: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this study was to compare the efficacy of breast conservation surgery (BCS) followed by radiotherapy (RT) in triple negative breast cancer (TNBC) versus non-TNBC.

METHODS

We searched the MEDLINE and EMBASE databases from inception through March 31, 2014, using search terms related to TNBC, BCS, and RT. Studies comparing the efficacy of BCS followed by RT in TNBC versus non-TNBC were reviewed.

RESULTS

5 studies including 2,922 non-TNBC and 510 TNBC cases were selected. The overall quality of included studies was deemed moderate to high. Compared with non-TNBC, the pooled relative risk of 5-year local relapse-free survival was 1.315 (95% confidence interval (CI) 0.967-1.789; p = 0.008) for TNBC, and that of 5-year overall survival, regional relapse-free survival, and distant metastasis-free survival was 1.929 (95% CI 1.392-2.674; p = 0.000), 3.052 (95% CI 1.629-5.715; p = 0.000), and 2.407 (95% CI 1.910-3.034; p = 0.000), respectively.

CONCLUSION

The local control rate of TNBC treated with BCS plus RT is similar to that of non-TNBC.

A pre-pubertal girl with giant juvenile fibroadenoma: A rare case report

INTRODUCTION

Fibroadenomas are benign neoplasms usually arising between the ages of 15-25 years. Approximately 0.4% fibroadenomas arise in juvenile age group. Usually the diagnosis is straightforward by clinical examination and FNAC. But sometimes rapid growth and giant size may pose difficulty in clinical approach.

CASE PRESENTATION

In this paper we are presenting a rare case of giant juvenile fibroadenoma in a 10 years old girl which was diagnosed by FNAC and treated by excision. Diagnosis was confirmed by histopathology.

DISCUSSION

Giant juvenile fibroadenomas are over 5cm in diameter and tend to show rapid growth mimicking a carcinoma. But histological features are similar to smaller fibroadenomas and can be enucleated.

CONCLUSION

Through this case we want to emphasize that these giant benign neoplasms should be suspected in any pre-pubertal girl with breast lump and should always be treated with breast conserving surgery.

Challenges in Diagnosis and Management of Paget's Disease of the Breast-a Retrospective Study

Paget's disease of the breast is uncommon and patients may present with nipple discharge, eczema, plaque or nipple destruction with or without a lump. The aim of the present study was to evaluate the presentation, clinicopathological features and treatment given for patients presenting with Paget's disease of the breast. We performed a retrospective analysis of medical records of patients who were treated at our centre for Paget's disease of the breast from 2006-2011. Twenty patients were treated in this period. Twelve patients had associated lump and eight patients did not have a lump in the breast. Two patients did not have a lump or any detected abnormality in mammography. Multicentricity was present in five patients. Diagnosis of malignancy was made by fine-needle aspiration cytology for patients with palpable lump and nipple wedge biopsy for patients with no lump. Modified radical mastectomy was done in 10 patients: 2 patients underwent total mastectomy and sentinel lymph node biopsy and 8 patients underwent central quadrantectomy and sentinel lymph node biopsy. Eleven patients had invasive ductal carcinoma, one patient had ductal carcinoma in situ with foci of invasion and eight patients had ductal carcinoma in situ. Seven patients had lymph node metastases. Three patients had recurrence, one had local recurrence and two had distant recurrences. The mean follow up period was 28 months (range 15-64 months). Paget's disease of the breast is a rare entity and one needs imaging and biopsy to diagnose these patients as they have associated cancer. They can be considered for breast conservation surgery with good cosmetic and oncological results.

Safety of partial breast reconstruction in extended indications for conservative surgery in breast cancer

Breast conservation surgery after large volume excisions for women with relatively larger or multicentric operable breast cancer (OBC) and in some locally advanced breast cancers (LABC) post neo-adjuvant chemotherapy (NACT), is known to be a feasible option using a latissimus dorsi flap. However, the oncological safety of such a procedure is not well reported in literature. Two hundred and twenty one women with breast cancer (148-OBC, 73-LABC) underwent BCT plus LD during March 1998 to August 2009. One hundred and forty six women (72-LABC, 66-OBC) received prior NACT for downstaging, followed by completion of adjuvant therapy in all, including postoperative radiotherapy and hormone therapy where indicated. Women aged 20-62 years, with tumors 1.5-15 cm (median 5.0 cm), underwent volume replacement surgery with LD flap. All positive cut margins (total-4.9%, gross positive-1.3%) were re-excised to ensure negative margins. The mean surgical time for excision of primary with axillary clearance followed by volume replacement by LD was 5 h and mean hospital stay 6 days. Donor site morbidity was seen in 11 patients and 3 had minor recipient site infection. At a median follow up of 36 months, ten of 221 patients (4.5%) had failed locally (7-OBC, 3-LABC). The determinants of local recurrence were presence of lymphatic vascular invasion (p = 0.016) and axillary metastasis (p = 0.003). BCT plus LD flap is an oncologically safe, technically quick procedure with minimal morbidity, and should be offered to all eligible women as an extended breast conservation procedure.

Reduction mammaplasty in conjunction with breast conservation

Breast conservation therapy, consisting of lumpectomy or segmental mastectomy with negative margins followed by breast irradiation, has become a standard and safe alternative to mastectomy in selected patients with early-stage breast cancer. As the inclusion criteria for breast conservation therapy have continued to evolve to include lower quadrant tumors, very large breasts, and central tumors, the potential for significant disfigurement after breast conservation therapy has increased. Bilateral reduction mammaplasty in conjunction with tumor-directed partial mastectomy is a surgical approach that can benefit these patients by creating symmetric, aesthetically pleasing breasts in a single-stage operation.