Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction

The efficacy of breast-conserving surgery for the local control of early breast cancer has been repeatedly evidenced. Although immediate reconstruction following breast-conserving surgery has been described, little information is available regarding surgical management in reoperative settings due to positive margins. We studied the influence of intraoperatively assessed and postoperatively controlled surgical margin status on the type of breast-conserving surgery and report our results regarding complications in a reoperative breast reconstruction scenario. All patients were seen by a multidisciplinary team who recommended breast-conserving surgery. According to the breast volume, ptosis and tumor size/location, the patients were also evaluated by a plastic surgeon, who recommended reconstruction with the appropriate technique. Intraoperative assessment of surgical margins was determined by histological examination of frozen sections. The mean follow-up time was 48 months. Two hundred and eighteen patients (88.5%) underwent breast-conserving surgery and immediate reconstruction. Twelve (5.5%) patients had a positive tumor margin after review of the permanent section. All patients underwent re-exploration. In 1.3%, a second reconstructive technique was indicated and in 2.2% a skin-sparing mastectomy with total reconstruction was performed. Our findings support the important role of the intraoperative assessment of surgical margins and its interference in the selection of reconstruction techniques and negative margins; however, it will not guarantee complete excision of the tumor. Success depends on coordinated planning with the oncologic surgeon and careful intraoperative management.

Papillomas of the breast: factors associated with underestimation

The distinction between benign and malignant papilloma of the breast through percutaneous needle biopsy can be difficult because of limited samples; the underestimation rate can be up to 25%. The aim of this study is to identify clinical and histological factors associated with underestimation, invasive ductal carcinoma, or ductal in-situ carcinoma (DCIS) of the breast found in surgical specimens from papillary lesions. This may contribute toward selection of patients for a follow-up strategy without the need for surgical excision. From a database of 3563 patients, we identified 85 with intraductal papilloma between 2007 and 2013 who had undergone breast-imaging studies, percutaneous needle biopsy, and surgical resection of the lesion. Central papillomas normally present with a palpable mass, whereas peripheral papillomas generally do not have clinical manifestations (microcalcifications); both central and peripheral papillomas were related to atypical lesions, 13.5 and 15.4%, respectively. Among the 59 cases of central papillomas, there were four cases of underestimation, three DCIS and one invasive ductal carcinoma (6.8%). Among the 26 cases of peripheral papillomas, there was one case of DCIS (3.8%), with a total underestimation rate of 5.8%; all underestimated lesions measured more than 1 cm. The median size was 11 mm at mammography and 19 mm at ultrasound. Our data suggest that lesions less than 1 cm in size, without atypia and concordant imaging and clinical findings, may not require surgical resection.

Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer

INTRODUCTION

In this prospective ex vivo study, we propose a new technique for the intraoperative examination of retroareolar tissue and describe both surgical excision and pathological methods. We performed a nipple-sparing mastectomy simulation in patients selected to total mastectomy, in order to evaluate the accuracy of these new technique.

MATERIALS AND METHODS

A total of 158 total mastectomy specimens from patients affected by ductal carcinoma in situ (n = 15) or invasive ductal carcinoma (stages I, II, or IIIA) (n = 143) were examined. To obtain the entire sample area, the terminal retroareolar milk duct bunch was isolated. Fragments approximately 1.5 cm in length were excised and sectioned in parallel at the base of the nipple using a cold bistoury. Three transverse histological sections (4 μm each) at 200 μm intervals that included the entire isolated fragments were subjected to frozen section examination. The sections were stained with hematoxylin-eosin and were evaluated. The remainder of each fragment was embedded in paraffin and 4 μm sections were subsequently stained with hematoxylin-eosin and examined.

RESULTS

There were two false-negative (1.3%) and five false-positive (3.1%) findings among the frozen and paraffin sections analyzed. A statistical analysis of the frozen section examinations showed a sensitivity of 92.0%, a specificity of 96.2%, a positive predictive value of 82.1%, a negative predictive value of 98.4%, and an accuracy of 95.4%.

CONCLUSION

The frozen section examination technique described here detected nipple involvement in breast cancer with greater accuracy than the frozen section usually performed by most surgeons.

Pre-treatment MRI tumor features and post-treatment mammographic findings: may they contribute to refining the prediction of pathologic complete response in post-neoadjuvant breast cancer patients with radiologic complete response on MRI?

PURPOSE

Radiologic complete response (rCR) in breast cancer patients after neoadjuvant chemotherapy (NAC) does not necessarily correlate with pathologic complete response (pCR), a marker traditionally associated with better outcomes. We sought to verify if data extracted from two important steps of the imaging workup (tumor features at pre-treatment MRI and post-treatment mammographic findings) might assist in refining the prediction of pCR in post-NAC patients showing rCR.

METHODS

A total of 115 post-NAC women with rCR on MRI (2010-2016) were retrospectively assessed. Pre-treatment MRI (lesion morphology, size, and distribution) and post-treatment mammographic findings (calcification, asymmetry, mass, architectural distortion) were assessed, as well as clinical and molecular variables. Bivariate and multivariate analyses evaluated correlation between such variables and pCR. Post-NAC mammographic findings and their correlation with ductal in situ carcinoma (DCIS) were evaluated using Pearson's correlation.

RESULTS

Tumor distribution at pre-treatment MRI was the only significant predictive imaging feature on multivariate analysis, with multicentric lesions having lower odds of pCR (p = 0.035). There was no significant association between tumor size and morphology with pCR. Mammographic residual calcifications were associated with DCIS (p = 0.009). The receptor subtype remained as a significant predictor, with HR-HER2 + and triple-negative status demonstrating higher odds of pCR on multivariate analyses.

CONCLUSIONS

Multicentric lesions on pre-NAC MRI were associated with a lower chance of pCR in post-NAC rCR patients. The receptor subtype remained a reliable predictor of pCR. Residual mammographic calcifications correlated with higher odds of malignancy, making the correlation between mammography and MRI essential for surgical planning. Key Points • The presence of a multicentric lesion on pre-NAC MRI, even though the patient reaches a radiologic complete response on MRI, is associated with a lower chance of pCR. • Molecular status of the tumor remained the only significant predictor of pathologic complete response in such patients in the present study. • Post-neoadjuvant residual calcifications found on mammography were related to higher odds of residual malignancy, making the correlation between mammography and MRI essential for surgical planning.

Predictive factors for positive surgical margins in the treatment of breast ductal carcinoma in situ

CONTEXT

Surgery is the main form of treatment for ductal carcinoma in situ (DCIS) of the breast. Among other factors, treatment success requires that the surgical margins are free of disease, to reduce the risk of recurrence.

AIMS

The purpose of this study was to analyze factors that might be associated with positive margins in patients diagnosed with DCIS.

SETTINGS AND DESIGN

A retrospective analysis was performed of hospital databases from the year 2006 to 2014, to identify patients with an initial diagnosis of DCIS made by percutaneous biopsy.

SUBJECTS AND METHODS

Age, the presence of disease symptoms, lesion size on mammogram, and the presence of estrogen receptors, and their relationship to the surgical margins were evaluated in 249 patients.

STATISTICAL ANALYSIS USED

Shapiro and Wilcoxon-Mann-Whitney tests were used to verify that the data were normally distributed. Chi-squared test was used to verify the independence of the variables.

RESULTS

Lesions measuring 1.55 cm or greater had a relative risk of positive margins after conservative surgery of 1.39 (95% confidence interval [95% CI]: 1.02-1.90). The presence of symptoms had a relative risk of positive margins after conservative surgery of 1.54 (95% CI: 1.17-2.02).

CONCLUSION

Lesions measuring 1.55 cm or greater and the presence of symptoms are risk factors for positive margins in the treatment of ductal carcinoma in situ. Therefore, these patients need a better surgical planning in order to reduce the risk of positive margins. There is a clear need for large prospective studies to validate our findings and define other factors that might contribute to the success of surgical resection for ductal carcinoma in situ.

The Apocrine Profile of Triple-negative Breast Carcinomas in Patients Aged 45 Years or Younger: favorable but rare features

Objective Triple-negative breast carcinomas (TNBCs) represent a heterogeneous group of neoplasias, even though they generally exhibit a clinically more aggressive phenotype, and are more prevalent in young women. To date, targeted therapies for this group of tumors have not been defined. The aim of this study was to evaluate the frequency of the apocrine subtype in TBNCs from premenopausal patients as defined by the immunohistochemical expression of the androgen receptor (AR) and its association with: histological type; tumor grade; proliferative activity; epidermal growth factor receptor (EGFR) expression; and a basal-like phenotype. Methods A total of 118 tumor samples from patients aged 45 years or younger were selected and reviewed according to histological type and grade. K_i-67 expression was also evaluated. Immunohistochemical expression of the AR, basal cytokeratin ⅚, and EGFR expression were analyzed in tissue microarrays. The apocrine subset was defined by AR-positive expression. The basal-like phenotype was characterized by cytokeratin ⅚ and/or EGFR expression. Results An apocrine profile was identified in 6/118 (5.1%) cases. This subset of cases also exhibited a lower rate of K_i-67 expression (17.5% versus 70.0%, p = 0.02), and a trend toward a lower histological grade (66.7% versus 27.9%, p = 0.06). Conclusions The apocrine subtype of TNBCs is rare among premenopausal women, and it tends to present as carcinomas of lower grade and lower proliferative activity, suggesting a less aggressive biological phenotype.

Abstract OT2-02-01: Brazilian randomized study - Impact of preoperative magnetic resonance in the evaluation for breast cancer conservative surgery (BREAST-MRI trial)

Background: A precise preoperative evaluation of the tumor is essential to improve breast cancer surgical management. Currently, mammography associated with ultrasound and clinical exam are the standard techniques for evaluating extension and tumor localization. However, approximately one third of the lesions in patients eligible for conservative surgical treatment are misevaluated by these methods. Breast magnetic resonance imaging (MRI) has a high sensitivity (95-100%) in detecting invasive neoplasms, and is able to detect occult tumors, multifocal and/or multicentric disease, and contralateral breast cancer more accurately than mammography and ultrasound. Until now, there are only three randomized trials assessing the role of preoperative MRI. These trials have different designs and contradictory results. Trial design: BREAST-MRI is a randomized, open label, unblinded trial designed to compare the accuracy of breast MRI in the preoperative planning of surgical treatment of breast cancer to standard protocol (clinical exam of the breast, mammography and/or breast ultrasound) and the impact of breast MRI on breast cancer outcome. Patients are randomized on a 1:1 basis, stratified for mammary density, into two groups: 1)MRI group: patients are submitted to MRI and standard protocol 2)Control group: standard protocol. First phase: patient recruitment and data collection up until surgery. Second phase: follow-up for five years or until death. Eligibility criteria: women aged 18 years or older with breast cancer stages I to III candidates for conservative surgery (CC). Specific aims: The aim of this study is to evaluate the ability of MRI in selecting patients for conservative treatment of breast cancer. Primary outcomes are: false positive rates, false negative rates, positive predictive value and negative predictive value of MRI in breast cancer CC. Secondary outcomes are: rates of positive margins on pathological examination; reoperation rates; number of conversions to mastectomy; accuracy of MRI according to mammographic density, immunohistochemical subtype and histopathology of the tumor; rates of multicentricity, multifocality and bilateralality of tumors; disease-free survival after 3 and 5 years; and cost-effectiveness of breast MRI. Statistical methods: The calculated total case number for this trial is 372, assuming a recurrence rate of 10% for CC and 1% for mastectomies. The Shapiro-Whilks test will be used to verify if distribution of the quantitative variables follows normal distribution. The baseline population will be analyzed using the t-Student test, or the Mann-Whitney test when appropriate. To test the existence of a possible association between outcomes and the categorized characteristics, chi-square and Fisher's exact test will be performed. Disease progression will be reassessed at 3 and 5 years follow-up, in order to produce a log-rank Kaplan-Meier curve of survival. Present accrual and target accrual: In June 2017, randomizations are at approximately 90% of the target sample size.

Citation Format: Dória MT, Mota BS, Reis YN, Ricci MD, Piato JRM, Ferreira VCCS, Shimizu C, Barros N, Filassi JR, Baracat EC. Brazilian randomized study - Impact of preoperative magnetic resonance in the evaluation for breast cancer conservative surgery (BREAST-MRI trial) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-02-01.

Abstract P2-12-11: Does conservative surgery treatment for locally advanced breast cancer safe after neoadjuvant treatment?

BACKGROUND:

The aim of this study was to assess the oncological efficacy of breast conserving surgery (BCS) after neoadjuvant chemotherapy in patients with local advanced breast cancer.

PATIENTS AND METHODS:

A retrospective cohort study was conducted with locally advanced breast cancer invasive (Stage IIb to III) treated at ICESP, an oncologic referral center between 2008 and 2016. Endpoints were disease free survival (DFS), local disease free survival (LDFS) and overall survival (OS). Multivariable analyses were performed using Cox proportional hazards models.

RESULTS:

530 patients were included, 26% (138) were stage IIB, 41.9% (222) IIIA, 29.6% (157) IIIB and 2.5% (13) IIIA. 88.8% (470) were invasive ductal carcinoma. The mean age was 51.5(23-95). 95.5% and 4.5% were submitted Neoadjuvant Chemotherapy and Hormone therapy, respectively. The BCS were performed in 24.5% (130) patients versus 75.5% (400) of mastectomies. The mean follow up was 36.4(0.16-80.2) months. There were no differences in local disease free-survival 59 (95%CI 58-61) versus 60 (95%CI 57-60); p=0.4 and overall survival 56.2 (95%CI 52-60) versus 59.3(95%CI 53-65); p= 0.24 for mastectomy and BCS. The disease free survival was lower at mastectomy group 51.4 (95%CI 49-53) versus 56,8 (95%CI 53-59); p=0.01. Logistic regression models were significant only for cancer stage both patterns, although the results were better for masses, particularly when kinetic assessments were included (LR 12.8; p = 0.005)

CONCLUSION:

In our population, the BCS does not affect the overall and local disease-free survival rates, which seems to be safe to perform in patients who desire to conserve the breast after neoadjuvant treatment.

Citation Format: Boufelli G, Mota BS, Franca FC, Doria MT, Maesaka JY, Ricci MD, Piato JRM, Rocha FBC, Giribela AHG, Gonçalves R, Masili-Oku S, Mano MS, Chala LF, Thompson BM, Baracat EC, Filassi JR. Does conservative surgery treatment for locally advanced breast cancer safe after neoadjuvant treatment? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-11.

Abstract P4-12-04: Cost-effectiveness analysis of locally advanced estrogen receptor-positive, HER-2 negative breast cancer care using a tailored treatment approach in Brazil

Introduction: Breast cancer is the most common cancer in women worldwide, and 70% of breast cancer deaths occur in women from low-income and middle-income countries. In Brazil there were 14388 deaths due to this disease in 2013 and an estimate of over 58000 new cases in 2016. Neoadjuvant endocrine therapy (NET) is an attractive alternative to Neoadjuvant chemotherapy (NAC) for Hormone Receptor-positive tumors and could be a resources-saving strategy of treatment.

Methods: We built a decision analysis model of breast cancer treatment to compare a NET schema, with response based on the evaluation of Ki-67, against the surgery followed by adjuvant chemotherapy (AC) and radiation therapy (RT) standard-of-care as two competing approaches to breast cancer management. Our objective is to determine whether tailoring chemotherapy treatment based on response to neoadjuvant endocrine therapy is a cost-effective approach. The NET schema is based on the ACOSOG Z1031B trial, in which post-menopausal women with estrogen receptor-positive, HER-2 negative disease would receive 4 weeks of NET followed by a core-needle biopsy for Ki-67 evaluation. If Ki-67 were lower than 10%, patients would continue in NET for 16-18 weeks followed by surgery and RT according to international guidelines. The indication of AC in these patients would be based on the preoperative endocrine prognostic index (PEPI). Patients with a PEPI score equal to zero would be spared from AC. If Ki-67>10%, patients would be triaged to NAC or surgery. The cost-effectiveness analysis was conducted using a Markov model from the provider's perspective, in this case the Brazilian Health ministry. Healthcare costs, in the form of charges from the hospitals to the health ministry, were obtained from cost tables available at the federal government's webpage. In the Markov model, possible health states were disease-free, local relapse, metastatic disease and death.Transition probabilities and mortality rates were extracted from randomized studies. Our assumptions were that both treatment strategies have similar clinical outcomes and that Ki-67 is a reliable method to triage patients to NAC or surgery. We performed one-way sensitivity analysis to assess the impact of the failure of the Ki-67 test on cost-effectiveness.

Results: Our model shows that the NET schema dominates the standard-of-care strategy. Costs were R$ 47799.89 per patient for the NET strategy and R$79809.24 for the standard-of-care strategy. There was an incremental cost saving of R$32009.36 per patient for the NET strategy compared to the standard-of-care strategy. Cost-effectiveness of the NET strategy was R$2612.63 and R$4369.11 for the standard-of-care. Considering the willingness-to-pay of R$ 85494.00, defined by the World Health Organization as three times the gross domestic product per capita, the standard-of-care strategy would only be more cost-effective in the scenario of a Ki-67 test that misclassifies patients more than 9.1% of the time.

Conclusion: The use of response to neoadjuvant endocrine treatment based on Ki-67 analysis as a way to tailor locally advanced breast cancer treatment is a cost-saving strategy in the presence of robust biomarkers.

Citation Format: Goncalves R, Reinert T, Ellis MJ, Sarian LO, Filassi JR. Cost-effectiveness analysis of locally advanced estrogen receptor-positive, HER-2 negative breast cancer care using a tailored treatment approach in Brazil [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-04.

Treatment of carcinoma in situ of the cervix experience at the Faculty of Medicine, University of São Paulo

The authors studied a total of 334 cases of carcinoma in situ of the cervix (1975-1990). The patients were 19 to 61 years old (mean age, 36.6 years). The following procedures were performed: cervical amputation in 54.5% of cases, cervical enlarged amputation with resection of the adjacent vaginal mucosa in 23.3%, abdominal hysterectomy in 15.3%, electrocauterization in 3.6%, simple conization in 2.4%, and vaginal hysterectomy in 0.9%. Recurrence rates were: 9.8% after cervical amputation, 1.3% after cervical enlarged amputation, 25% after simple conization, 5.8% after abdominal hysterectomy, and 33% after electrocauterization. Recurrences were detected before the 18th month after treatment and none of them was of the invasive type. The treatment procedure with the highest rate of complications was cervical enlarged amputation (16%), followed by simple conization (12%), total abdominal hysterectomy (3.9%), and cervical amputation (2.9%). The authors conclude that, although cervical enlarged amputation was followed by the lowest recurrence rate, it was also the treatment followed by the largest number of complications. On this basis, they recommend cervical amputation or hysterectomy. For young women who wish to have children, simple conization is recommended.

Abstract P4-02-04: Magnetic resonance imaging to predict nipple involvement in breast cancer patients

Introduction. The implementation of Nipple-Sparing Mastectomy (NSM) as a treatment option for selected cases of breast cancer has risen great interest among breast surgeons. The preservation of the nipple-areola complex (NAC) can lead to extremely favorable psychological effects in breast cancer patients treated with this type of procedure. However, to ensure the oncologic safety of this technique it is of utmost importance to evaluate the likelihood of NAC involvement pre-operatively. In this study we evaluate the contribution of Breast Magnetic Resonance Imaging (MRI) in predicting the involvement in the NAC in breast cancer patients. Materials and Methods: We studied 170 mastectomy specimens from 165 breast cancer patients (five patients had bilateral disease) affected by Ductal Carcinoma in situ (DCIS)(n=19) or Invasive Ductal Carcinoma (n=151), stages I, II or IIIA. Every patient was pre-operatively studied using a 1.5 Tesla, 4-channel in vivo dedicated surface breast coil MRI. The parameters we investigated were: type of index lesion enhancement pattern (nodular or non-nodular), size of the index lesion, enhancement between the index lesion and the NAC, enhancement of the nipple, thickening of the areola, nipple retraction and size of the nipple in comparison with the contra-lateral nipple. The retro-areolar area and papilla were evaluated in histological sections of 4μm to identify DCIS and Invasive Ductal or Lobular carcinomas. One radiologist, blinded to the result of the histological evaluation of the papillae, performed the evaluation of the MRIs. Results. In univariate analysis, type of lesion enhancement in MRI, enhancement between index lesion and the papilla, distance between the index lesion and the papilla, enhancement of the papilla and nipple retraction had a statistically significant correlation with neoplastic involvement of the NAC (p<0.05). Using multivariate analysis, among the previously mentioned parameters, enhancement between the index lesion and the NAC, and nipple retraction remained as statistically significant predictors of nipple involvement in breast cancer patients (p < 0,001 e 0,010, respectively). The Negative Predictive Value of the combination of these two variables was 89.5%. According to this model that used the combination of those two variables, the probability of neoplastic involvement of the NAC was 73.9% in the presence of enhancement between the index lesion and the papilla combined with nipple retraction; 46% in the presence of enhancement between the index lesion and the papilla without nipple retraction in the MRI; 26.9% if there is only nipple retraction in the MRI; and 9.9% in the absence of these two characteristics. The sensibility of this model composed by those 2 variables to identify neoplastic involvement of the NAC was 29.7% (CI95%: 15.9% - 47%), specificity was 97.7% (CI95%: 93,5% - 99,5%), positive predictive value was 78,6% (CI95%: 49,2% - 95,3%) and negative predictive value was 83,3% (CI95%: 76,5% - 88,8%).

Conclusion. We can conclude that the probability of the NAC being cancer-free is around 90% when there is no enhancement between the index lesion and the nipple, and there is no retraction of the nipple in the pre-operative MRI study of the breast.

Citation Format: Piato JR, Chala LF, Alves-Jales RD, Dória MT, Mota BS, Messias AP, Goncalves R, Mano MS, Soares JM, de Barros N, Filassi JR, Baracat EC. Magnetic resonance imaging to predict nipple involvement in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-04.

Abstract PS1-22: The oncological safety of lipofilling after breast cancer surgery: A meta-analysis

INTRODUCTION Autologous fat grafting (AFG) for the purpose of breast reconstruction presents difficulties during follow-up radiological exams and the oncological potential of grafted fat is uncertain. Coleman et al in 2007 confirmed that, provided a rigorous protocol is respected, the fatty tissue could be transferred under good conditions and would not interfere with mammographic follow-up, although the issue remains controversial about the oncological safety. This study aims to analyze the oncological safety of lipofilling through a meta-analysis of the current literature. METHODS We conducted a meta-analysis to evaluate the oncological safety of AFG after breast cancer (BC) surgery. We reviewed the literature published until 07/05/2020. The outcomes were overall survival (OS), disease free-survival (DFS) and local recurrence (LR). We included RCTs, cohort studies, case-control studies that evaluated women with BC diagnosis who undergone surgery followed by reconstruction with AFG. This review was performed in accordance with the PRISMA guidelines and we searched the electronic databases of Medline, EMBASE and LILACS, using the MeSH terms for AFG and BC. There was no language restriction. Methodological quality was assessed using the Downs and Black instrument and evidence quality by GRADE. We synthesized data using the inverse variance method on the log-HR scale for time-to-event outcomes using RevMan. We assessed the presence of statistical heterogeneity using the Chi2 statistic and we investigated its extension by the use of I2 statistic. RESULTS We identified 624 references. Of these, 16 studies fulfilled our eligibility criteria and were included. Funnel plot analysis revealed no publication bias. There were 8667 patients included and their mean age was 49 years. The breast surgery indications were invasive breast carcinoma (66.1%), carcinoma in situ (18.4%) and prophylactic reasons (15,5%). Ten out of 16 studies described the technique used to perform the AFG as Coleman’s. In 9 out 16 studies there was no difference in adjuvant treatment between groups, two studies do not mention if there was any difference and in 4 studies there were different adjuvant treatments in control and intervention arms. Quality assessment resulted in 11 studies being considered ‘good’, 4 studies were considered ‘fair’ and 1 study was considered poor. The HR could be extracted from four studies and an increase of OS for lipofilling group was detected with high heterogeneity (HR 0.47, 95% CI 0.32 to 0.7, p=0.0002, 2331 patients, I2= 84%, high certainty evidence). Funnel plot analysis indicated a high risk of publication bias from one study, Krastev et al, which included 587 patients. The analysis excluding this article found no difference in OS between lipofilling group and control and publication bias was not detected (HR 0.9, 95% CI 0.53 to 1.54, p=0.71, 1744 patients, I2= 58%, high certainty evidence). The HR for DFS could be extracted from six studies and no difference was found between lipofilling group and control (HR 1.01, 95% CI 0.73 to 1.38, p=0.96, 2755 patients, I2= 0%, high certainty evidence). The HR for LR could be extracted from ten studies and no difference was found between lipofilling group and control (HR 0.86, 95% CI 0.66 to 1.12, p=0.43,6839 patients, I2= 1%, moderate certainty evidence). Funnel plot analysis indicated a publication bias from one study (Petit et al) that included only DCIS tumors. The analysis excluding this article did not demonstrate difference in results. (HR 0.8, 95% CI 0.61 to 1.05, p=0.94, 6662 patients, I2= 0%, moderate certainty evidence) CONCLUSION Based on published data, AFG is a safe technique of breast reconstruction for patients that undergone BC surgery. According to our findings, AFG did not affect OS, DFS or LR. These data have moderate to high certainty and additional studies probably will not change the current evidence.

Citation Format: Rodrigo Goncalves, Bruna S Mota, Bruno Sobreiro-Lima, Marcos D Ricci, José M Soares, Jr, Edmund C Baracat, José R Filassi. The oncological safety of lipofilling after breast cancer surgery: A meta-analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-22.

Abstract P3-13-09: Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer

Introduction: Development of the nipple-sparing mastectomy (NSM) technique has constituted a significant advance in the surgical treatment of selected cases of breast cancer. The most important aspect of areolar complex preservation is the exclusion of carcinoma involving the nipple. The retroareolar surgical margin is usually sampled and subjected to an intraoperative evaluation by frozen section examination in order to avoid a second procedure. However, this method is not standardized resulting in variable rates of false-negative results. Here, a new technique is proposed for the intraoperative study of the retroareolar margin. This ex vivo study was conducted by performing a simulated NSM procedure for patients undergoing total mastectomy to assess the impact of these measures on the accuracy of retroareolar frozen section examination. Materials and Methods: Between September 2012 and April 2014, we studied 158 mastectomy specimens from patients undergoing total mastectomy for breast cancer at the Cancer Institute of the State of São Paulo. Inclusion criteria were stage Tis-T3 tumors, multifocal and multicentric breast carcinoma, unicentric carcinoma not suitable to quadrantectomy. Patients submitted to neoadjuvant chemotherapy were also included. To obtain the entire sample area, the terminal retroareolar milk duct bunch was isolated. Fragments approximately 1.5 cm in length were excised and sectioned in parallel at the base of the nipple using a cold bistoury. Three transverse histological sections (4 μm each) at 200 μm intervals that included the entire isolated fragments were subjected to frozen section examination. The sections were stained with hematoxylin-eosin (H&E) and were evaluated. The remainder of each fragment was embedded in paraffin and 4 μm sections were subsequently stained with H&E and examined. Results: A total of 158 mastectomy specimens involving mammary carcinoma of no special type were examined. These included 15 (9.5%) in situ stage tumors, 36 (22.8%) stage I tumors, 71 (44.9%) stage II tumors, and 36 (22.8%) stage IIIA tumors. Paraffin examinations identified 25 retroareolar fragments compromised by carcinoma, resulting in 16.1% prevalence. Of the frozen sections examined, 2/158 (1.3%) had false-negative results and 5/158 (3.1%) had false-positive results. For the former two cases, the corresponding paraffin examinations detected low-grade carcinoma in situ and a residual cell cluster with a diameter less than 1 mm. The latter was found in a mastectomy specimen from a patient that underwent neoadjuvant chemotherapy. For the three cases involving false-positive results, the corresponding paraffin examinations revealed no atypical ductal hyperplasia present, one sclerosing intraductal papilloma and one nipple syringomatous adenoma. Statistical analysis revealed that the frozen section examinations performed had a sensitivity rate of 92.0% and a specificity rate of 96.2%. In addition, the positive predictive value (PPV) was 82.1%, the negative predictive value (NPV) was 98.4%, and the accuracy was 95.4%. Conclusion: The frozen section examination technique described here detected nipple involvement in breast cancer with greater accuracy than the frozen section usually performed by most surgeons.

Citation Format: Piato JR, Aguiar FN, Mota BS, Dória MT, Alves-Jales RD, Messias AP, Goncalves R, Mano MS, Soares JM, Ricci MD, Filassi JR, Baracat EC. Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-09.